Temporalis Muscle Transfer for the Treatment of Lagophthalmos in Patients With Leprosy: Refinement in Surgical Techniques to Prevent Postoperative Ptosis.

Facial paralysis resulting from leprosy has a serious impact on the entire face especially in the areas innervated by the facial nerves. In particular, lagophthalmos in patients with leprosy causes exposure keratitis, corneal, and conjunctival dryness, which can progress to blindness and disfigurement. Recently, we conducted 4 different temporalis muscle transfer (TMT) methods over the last 4 years to reduce ptosis. The methods used included Brown-McDowell, McCord-Codner, modified Gillies-Anderson, and modified Gillies. Seventy-five TMT operations in 60 patients were performed between 2011 and 2014. The mean age was 70.1. Fifteen patients had bilateral TMT procedures. As a result, ptosis appeared in 14(18.7%) of 75 TMT procedures for 4 years. To prevent or correct this complication, the following 4 technical refinements have simplified the surgery and yield better surgical outcomes. First, an increase in the length of the temporalis muscle flap to approximately 8 cm with a parallel course to the lateral canthus will reduce oblique pull. Second, the width of the fascia sling in the upper eyelid is narrowed (3-4 mm) to reduce weight on the eyelid. Third, the fascia sling in the upper lid should not be located along the full length of the upper lid but terminate 3.5 cm medial to lateral canthal tendon and in other words, should not be tied at the medial canthal tendon to reduce tension and weight. Lastly, the fascia sling in the eyelid should be located shallow (probably in subdermal layer) and as near as possible to the lid margin to prevent any functional disturbance in levator aponeurosis.

Efficacy of temporalis muscle transfer for correction of lagophthalmos in leprosy.

OBJECTIVES: Temporalis Muscle Transfer (TMT) is a surgical technique used to correct lagophthalmos in leprosy patients. We have evaluated the degree of success of TMT in achieving full lid closure, which is important in preventing damage to the cornea. SUBJECTS AND METHODS: A retrospective study was carried out on 69 patients who had TMT done, at one centre, on 101 eyes during the period of 1998-2009. Lid gaps on direct gaze and with both gentle and forced closure, as well as voluntary muscle testing of eye lid closure, were assessed using standard measuring techniques by a qualified physiotherapist. Associated problems due to lagophthalmos were recorded both pre- and post- operatively. Data were abstracted on to a special proforma and subjected to statistical analysis using SPSS. RESULTS: On completion of post-operative physiotherapy, 85% of the eyes could achieve full lid closure with no measurable gap. The mean (SD) lid gap on forced closure was 48 (2.8) mm pre-operatively and 0.2 (0.5) mm at the end of the in-patient stay. The mean (SD) lid gap on gentle closure was 7.9 (2.6) mm preoperatively and 2.4 (1.8) mm post-operatively. The mean (SD) vertical inter-palpebral distance, during straight gaze, was reduced from 12.6 (1.6) pre-operatively to 9.8 (1.2) postoperatively. Exposure keratitis cleared in 16 of 27 eyes (60%) and Epiphora cleared or improved in 31 eyes. CONCLUSIONS: It is concluded that the TMT is a successful option (cosmetically and functionally) for correction of lagophthalmos.

[Long-term results of two temporalis muscle transfer procedures in correction of paralytic lagophthalmos].

OBJECTIVE: To compare the long-term results and possible complications of a modified temporalis muscle transfer (TMT) with the Johnson's procedure in correction of paralytic lagophthalmos. METHODS: From September 1997 to March 2000, paralytic lagophthalmos due to leprosy in 92 patients were corrected with TMT. The 89 cases (127 to eyes including 51 unilateral and 38 bilateral) followed up 3 years after operation were analyzed. There were 69 males and 20 females with ages ranging from 18 to 65 years (52 years on average). The duration of lagophthalmos was 1-22 years with an average of 8.2 years. And 36 eyes were complicated with lower eyelid ectropion. Sixty-five eyes were corrected with Johnson's procedure (Johnson's TMT group), 62 with the modified TMT procedure (modified TMT group). The modifications were as follows: (1) omitting the fascial strip in the lower eyelid to avoid postoperative ectropion. (2) fixing the fascial strip of the upper eyelid to the middle or inner margin of the tarsal palate depending on the degree of the lagophthalmos to avoid possible ptosis of the upper eyelid. RESULTS: In Johnson's TMT group, the mean lid gap on light closure was reduced to 3.1 mm postoperatively from 7.7 mm preoperatively; and the mean lid gap on tight closure was reduced to 0.5 mm postoperatively from 6.1 mm preoperatively. The symptoms of redness (73.7%) and tearing (63.7%) disappeared or were improved postoperatively. However, ectropion and ptosis occurred in 24 eyes and 9 eyes respectively. The overall excellent and good rate was 58.5%. In the modified TMT group, the mean lid gap on light closure was reduced to 3.3 mm postoperatively from 7.5 mm preoperatively; and the mean lid gap on tight closure was reduced to 0. 6 mm postoperatively from 6. 3 mm preoperatively. The symptoms of redness (90.9%) and tearing (71.0%) disappeared or were improved postoperatively, and no ectropion or ptosis was found except one ectropion. The overall excellent and good rate was 87.1%, which was significantly higher than that of Johnson's group (P < 0.01). CONCLUSION: The modified TMT is an efficiency and simple procedure with very few complications, and thus is strongly recommended for use when TMT is an indication.

[Long-term results after the correction of the paralytic ectropion caused with leprosy in 115 eyes].

OBJECTIVE: To analyze the long-term results after the correction of the paralytic ectropion in leprosy. METHODS: Seventy-four patients with 115 paralytic ectropion eyes after leprosy were treated with the surgical procedures included medial canthoplasty, medial canthal tendon plication, lateral tarsal strip, medial canthal resection, lateral canthoplasty, and lid shortening. The results were evaluated with the follow-ups from 2 to 4 years. RESULTS: The eye-redness was reduced from 93 to 40 while the epiphora from 107 eyes (24 mild, 36 moderate and 47 severe) to 90 (40 mild, 32 moderate and 18 severe). The mean lid gap in mild eye closure was reduced from 6.8 mm to 5.3 mm and the cornea lesion was reduced from 53 to 36. The results were excellent in 18 eyes (15.7%), good in 45 eyes (39.1%), fair in 41 eyes (35.7%) and poor in 11 eyes (9.6%). However, the mean visual acuity remained same pre- and postoperatively. CONCLUSIONS: Surgical correction of ectropion is helpful for cornea protection and could improve the signs and symptoms of the eyes such as epiphora and red [abstract truncated].

Location of the extracranial extent of leprous facial nerve pathology may allow leprous facial palsy to be reanimated by free muscle transfer.

Leprosy is a mycobacterial nerve and skin infection, which can be eradicated by antibiotics. Some patients affected by leprosy, once cured, have residual nerve impairment with paralysis and sensory neuropathy. A series of patients with facial nerve paralysis, investigated using clinical, histological and electrophysiological techniques, demonstrated that the nerve pathology was distal to the section of main trunk prior to its bifurcation. Facial reanimation was achieved with a free gracilis-muscle transfer, coapting its motor nerve to the ipsilateral facial nerve trunk proximal to the site of the leprosy pathology, with a moderate clinical result.

Location of the extracranial extent of leprous facial nerve pathology may allow leprous facial palsy to be reanimated by free muscle transfer

Leprosy is a mycobacterial nerve and skin infection, which can be eradicated by antibiotics. Some patients affected by leprosy, once cured, have residual nerve impairment with paralysis and sensory neuropathy. A series of patients with facial nerve paralysis, investigated using clinical, histological and electrophysiological techniques, demonstrated that the nerve pathology was distal to the section of main trunk prior to its bifurcation. Facial reanimation was achieved with a free gracilis-muscle transfer, coapting its motor nerve to the ipsilateral facial nerve trunk proximal to the site of the leprosy pathology, with a moderate clinical result.

Resultados da correçäo cirúrgica do lagoftalmo (técnica de Gillies) em doentes de hanseníase / Results of surgical correction of lagophthalmos (Gillies technique) in leprosy patients

Foram analisados os resultados de 51 cirurgias de transferência do músculo temporal (Técnica de Gillies), realizadas em 34 pacientes com lagoftalmo. O principal objetivo foi avaliar a extensao e o tempo para recuperaçao da oclusao palpebral voluntária e o efeito estático da técnica sobre a pálpebra inferior, nos casos com ectrópio parcial e epífora. Em 34 (66.67 por cento) olhos houve recuperaçao completa e duradoura da oclusao palpebral voluntária. As medianas dos tempos para obtençao de fendapalpebral zero, ao morder, foram de 8 dias (l - 120) nos casos do grupo excelente e de 14 dias (l - 120) nos casos do grupo bom. A correçao do ectrópio parcial e epífora foi constatada em 15 (83,33 por cento) olhos. A recuperaçao da oclusao palpebral voluntária e a reposiçao da pálpebra inferior, observada na maioria dos casos, confirmam a efetividade da técnica de Gillies para correçao do lagoftalmo.

Facial palsy--a leprosy surgeon's viewpoint.

Facial palsy is cosmetically unacceptable, whether affecting eyes or mouth. It endangers the vision. Both upper and lower facial paralysis can be surgically dealt with, using the temporal muscle and fascia. This produces satisfactory results in a relatively short period of time.

Traitement chirurgical de la paralysie faciale chez le lépreux en Iran / Surgical treatment of leprous facial paralysis in Iran

Leprous facial paralysis appears more frequent in Iran than in other countries. The damaged branch is more often the upper one inducing lagophtalmos and, sometimes, associated with a trigeminal anesthesia. The ocular risk is great. When the lower branch is struck down, it gives an inesthetic deformity and speaking difficulty. As a consequence, surgical treatment is necessary and directed: --against lagophtalmos, with static or dynamic methods, --against the ptosis of commissura labiorum with several techniques available.

[Surgical treatment of leprous facial paralysis in Iran (author's transl)]. / Traitement chirurgical de la paralysie faciale chez le lépreux en Iran.

Leprous facial paralysis appears more frequent in Iran than in other countries. The damaged branch is more often the upper one inducing lagophtalmos and, sometimes, associated with a trigeminal anesthesia. The ocular risk is great. When the lower branch is struck down, it gives an inesthetic deformity and speaking difficulty. As a consequence, surgical treatment is necessary and directed: --against lagophtalmos, with static or dynamic methods, --against the ptosis of commissura labiorum with several techniques available.

Ectropio-lagoftalomo: correcao cirurgica da paralisia hansenica na regiao orbitaria / Ectropion-logoftalmo: surgical correction of the hansenic paralysis of the orbital region

Os autores estudam as alterações funcionais da região orbitária, especificamente o ectrópio e o lagoftalmo em pacientes de hanseníase, corrigindo-se cirurgicamente

Surgical treatment of facial nerve involvement caused by leprosy.

Complete and partial nerve paralysis can result from leprosy. The latter is more prevalent and results in lagophthalmos and corneal hypoesthesia. The former is characterized by loss of facial expression, deviation of the face to the nonparalyzed side, difficulty in chewing, and drooling, in addition to lagophthalmos and corneal hypoesthesia. Affected patients are at risk to develop blindness, as well as suffering social and economic deprivation because of the effects of facial nerve paralysis. Prevention of blindness and amelioration of the latter were successfully achieved by muscle transfer procedures, temporalis transfer to the eyelid, and masseter transfer to the mouth and nasolabial fold in small, minimally equipped hospitals in Africa.

Reconstructive operations for leprous disfigurement of the face

The communication is based on the experience with 380 reconstructive operations in the face fo patients at the residual stage of leprosy. A classification of the sequelae of leprosy in the face, which includes all types of disfigurement and facilitates selection of the most rational method of surgical treatment for each group, has been elaborated. in most patients who have overcome leprosy, a combination of all kinds of deformations and defects in the facecan be observed, which requires a whole complex of plastic operations in order to take off the mask of leprosy. Reconstructive operations in the face are indicated at the stage of deep regression or in residual leprosy. The paper deals with the successful repair of deformations of the nose by means of dividing the subcutaneous scar contractures and of constructing a supporting cartilage scaffolding, of reconstructing the nose and lips with a Filatov pedicle flap, of repairing facila-muscle palsy with a tape of fascia and lagophthalmos with a myofascial-band plasty, of reconstructing the eye browns with arterialized flaps on subcutaneous pedicles, and of other reconstructive and cosmetic operations. The skin wounds have healed well in leprosy patients, and no hypertrophic or kelloid scar formation has been observed.