Upper Eyelid Gold Weight Implantation in the Asian

Upper Eyelid Gold Weight Implantation in
the Asian Patient with Facial Paralysis
Phillip H. Choo, M.D., Susan R. Carter, M.D., and Stuart R. Seiff, M.D.
Sacramento and San Francisco, Calif.
Patients with facial paralysis may develop ophthalmic
complications. Poor eyelid closure and lagophthalmos
place the patient at increased risk for the development of
corneal problems such as epithelial defects, stromal thinning, bacterial infection, and even perforation. Initial
treatment should be conservative and include the use of
ocular lubricants, moisture chambers, and taping of the
lower eyelid into proper position. Surgical intervention
may be required in patients who have failed medical therapy or in whom the facial paralysis is not expected to
improve. Gold weight implantation in the upper eyelid
has become a popular procedure to correct upper eyelid
retraction and to improve corneal coverage. Previous descriptions of gold weight placement in the upper eyelid
have focused on Caucasian eyelid anatomy. However,
there are distinct anatomic differences between the Caucasian and Asian eyelids, which dictate the overlying aesthetic differences. We describe our technique for placement of a gold weight in the Asian upper lid, with
attention to the maintenance of symmetric eyelid creases.
We reviewed the charts of six Asian patients with facial
paralysis who underwent gold weight placement in the
upper eyelid for the correction of lid retraction. All patients did well functionally and aesthetically, and none
developed an extrusion of the implant with this approach.
(Plast. Reconstr. Surg. 105: 855, 2000.)
patients continue to have signs of corneal exposure even on maximal medical therapy. Others are stable on maximal medical therapy, but
the facial paralysis fails to improve, and they
are subsequently faced with the tedious work of
continually lubricating the exposed cornea.
These two categories of patients are candidates
for surgical correction of lagophthalmos.2
Gold weight implantation in the upper eyelid is an effective procedure to correct upper
eyelid retraction in patients with facial paralysis
and corneal compromise.3–5 Previous descriptions of gold weight placement in the upper
eyelid have focused on Caucasian eyelid anatomy.6 However, there are distinct anatomic differences between the Caucasian and Asian eyelids, which are responsible for the overlying
aesthetic differences.7–9 Inferior descent of the
brow fat pad or submuscular fibroadipose layer
in the Asian eyelid, in combination with a low
insertion point for the orbital septum, results
in a low or indistinct eyelid crease and a fullappearing eyelid.10 –12 To maintain symmetry
and the natural Asian appearance, these anatomic differences must be considered when a
gold weight is implanted into an Asian upper
eyelid. We describe our technique and review
the results of Asian patients who have undergone this procedure.
Patients with facial paralysis can have numerous ophthalmic manifestations including upper eyelid retraction, lower eyelid ectropion,
poor eyelid closure or lagophthalmos, and decreased tear production. Patients with these
findings are at increased risk for developing
complications secondary to corneal exposure,
such as epithelial defects, stromal thinning,
bacterial infection, and perforation. Initial
treatment includes the use of ocular lubricants,
moisture chambers, and taping of the lower
eyelid into proper position.1,2 However, some
METHODS
Preoperative Assessment
The presence or absence of a crease is noted
in both upper eyelids, and the height of the
crease from the eyelid margin is measured.
From the Ophthalmic Plastic and Reconstructive Surgery Service, Department of Ophthalmology at the University of California Davis, and
the Division of Ophthalmic Plastic and Reconstructive Surgery at the Beckman Vision Center and Department of Ophthalmology, University of
California San Francisco. Received for publication April 26, 1999; revised July 22, 1999.
None of the above authors has any commercial association with the MedDev Corporation.
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PLASTIC AND RECONSTRUCTIVE SURGERY,
March 2000
The proper size gold weight is then selected for
implantation by taping a progressively larger
weight onto the skin of the retracted upper
eyelid until lagophthalmos resolves. However,
the weight should not be so heavy that it creates a significant ptosis. If further corneal coverage is necessary, a lower eyelid tightening
procedure may be necessary at the same time
as the gold weight placement.
Surgical Procedure
A preexisting eyelid crease is marked with a
fine-tip marking pen just slightly wider than
the width of the gold weight chosen for implantation. If no crease is present in either of
the upper eyelids, an incision approximately 3
to 4 mm from the upper eyelid margin is
marked. The medial extent of the incision
should not extend past the superior punctum
or into an epicanthal fold because of the risk
for medial canthal webbing. An additional
mark is placed at the margin in line with the
center of the pupil in primary gaze. The upper
eyelid is then injected with anesthetic solution,
and the surgical field is prepared and draped
under sterile conditions.
A 4-0 silk traction suture is placed through
the upper eyelid margin to retract the lid inferiorly. An incision through skin and pretarsal
orbicularis oculi muscle is made. Dissection is
carried down to the anterior surface of the
tarsal plate. If either the submuscular fibroadipose layer or the preaponeurotic fat pads are
encountered, care should be taken not to excise these structures. Instead, they should be
retracted away from the field with a Desmarres
retractor to increase visualization.
Once dissection has been made to the anterior surface of the tarsal plate, a pocket to
house the gold weight is made anterior to both
the levator fibers and the tarsal plate. The
pocket should be somewhat larger than the
actual size of the gold weight and displaced
slightly medial to the center of the pupil in
primary position (Fig. 1, above). During the
dissection and creation of the pocket, the attachments of the levator aponeurosis to the
anterior surface of the tarsal plate should not
be disinserted. Although a limited levator recession may be helpful in correcting the upper
eyelid retraction, one may cause an iatrogenic
ptosis. In addition, if facial nerve function improves and the weight is removed, the patient
may be left with a residual ptosis. Instead, the
gold weight should be placed anterior to the
FIG. 1. (Above) Dissection has been made to the anterior
surface of the tarsal plate, and a pocket for the gold weight
has been created. Note the low crease incision and the preservation of the submuscular fibroadipose layer. (Center) Gold
weight is secured in place with sutures placed through the
positioning holes and into partial-thickness tarsal plate. The
fibroadipose layer is then brought over the implant before
closure. (Below) Immediate postoperative appearance of the
right upper eyelid.
fibers of the levator aponeurosis as well as the
tarsal plate (see Fig. 3).
Interrupted sutures are then placed through
each of the three positioning holes of the gold
weight and attached to the tarsal plate with
partial-thickness bites. The eyelid must be
everted and checked for full-thickness suture
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UPPER EYELID GOLD WEIGHT IMPLANTATION
passes. Full-thickness passes may lead to corneal abrasions or ulcers, which are extremely
difficult to treat in facial palsy patients. The
three sutures are then tied sequentially, applying only light pressure. This prevents buckling
of the tarsal plate if there is uneven placement
of the sutures in relation to the positioning
holes. Once the gold weight is secured in
place, the preaponeurotic fat pads and the
submuscular fibroadipose layer are brought
over the gold weight (Fig. 1, center). The orbicularis muscle layer and skin are then closed as
separate layers (Fig. 1, below).
RESULTS
The charts of six Asian patients with facial
paralysis who underwent placement of a gold
upper eyelid weight (MedDev, Palo Alto, Calif.) were reviewed (Fig. 2). Four women and
two men, ranging in age from 38 to 82, had
unilateral facial palsies and corneal exposure.
Etiology of the facial palsy was idiopathic in two
patients and occurred following intracranial
FIG. 2. (Above) Same patient 3 months after gold weight
implantation in the right upper eyelid. Note the preservation
of the single upper eyelid crease and the epicanthal fold to
maintain the Asian appearance of this patient. (Below) Same
patient on attempted eyelid closure.
tumor resection in four patients. The range of
gold weights used was 1.2 to 1.6 g. Follow-up
ranged from 12 to 60 months, with a mean of
26.5 months. All patients experienced an improvement in corneal epithelial defects and
lagophthalmos after placement of the gold
weight. Infection, inflammation, migration,
and extrusion were not observed in any of the
patients.
DISCUSSION
The Asian upper eyelid crease has received
much attention in the plastic surgery literature.13–25 This interest has been promoted by
the popularity of the Asian blepharoplasty or
double eyelid surgery. In the past, some authors have focused on achieving a “westernized” or Caucasian appearance.26,27 In our experience, most of the Asian patients whom we
have consulted for an upper blepharoplasty
have wanted to maintain their Asian appearance.
The difference between the Asian and the
Caucasian upper eyelid crease is dictated by
the difference in the underlying anatomy. The
upper eyelid crease forms at the highest point
of attachment of the levator aponeurosis to the
subcutaneous tissue. In Caucasians, the orbital
septum inserts onto the anterior surface of the
levator aponeurosis above the superior border
of the tarsal plate and holds the preaponeurotic fat pads in place. This allows the anterior
fibers of the levator aponeurosis to extend to
the subcutaneous tissue at or above the superior border of the tarsal plate and to create a
high upper eyelid crease.
In Asians, the brow fat often descends inferiorly as the submuscular fibroadipose layer
(Fig. 3). This layer provides fullness to the
upper eyelid, acts as a barrier between the
anterior fibers of the levator aponeurosis and
the subcutaneous tissue, and prevents the formation of a high eyelid crease. Furthermore, in
Asians the insertion site of the orbital septum
onto the anterior surface of the levator aponeurosis is variable. In this area, the septum
becomes diffuse and less prominent, allowing
for the inferior descent of the preaponeurotic
fat pads. It is this combination of a prominent
submuscular fibroadipose layer, weak inferior
septum, and the inferior descent of the
preaponeurotic fat pads that can either prevent the formation of an eyelid crease (single
eyelid) or create a low crease (double eyelid).
These anatomic differences need to be con-
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PLASTIC AND RECONSTRUCTIVE SURGERY,
March 2000
FIG. 3. This diagram illustrates some of the differences between the Caucasian and Asian
upper eyelids. Both the preaponeurotic fat pads (P) and the fibroadipose layer (F) descend more
inferiorly in the Asian upper eyelid. The white arrows point to recommended incision sites for gold
weight implantation. Notice that the incision should be made lower in the Asian eyelid. In
addition, the gold weight (white rectangle) may be placed slightly lower on the tarsal plate in the
Asian eyelid. In both cases, however, the gold weight is placed anterior to both the tarsal plate
and the inferior fibers of the levator aponeurosis, which insert onto the surface of the tarsal plate.
sidered when planning gold weight placement
in the Asian patient. One should focus on
maintaining symmetry with the unaffected side
and take special steps during the procedure to
maintain a low or single eyelid crease. First,
one should avoid a high incision (generally 8
to 10 mm from the lash margin in the Caucasian eyelid), which may promote a bifid or a
“westernized” crease. Instead, the incision
should be kept low (3 to 4 mm from the lash
margin) or at a preexisting crease if present
(Fig. 3).
Furthermore, one may encounter brow fat
(submuscular fibroadipose layer) as well as the
preaponeurotic fat pads during dissection toward the anterior surface of the tarsal plate. If
this occurs, the brow fat and the preaponeurotic fat pads should be preserved. These layers
act as a barrier between the anterior fibers of
the levator aponeurosis and the overlying dermis and prevent the formation of an unwanted
eyelid crease above the incision. In addition,
these layers help to prevent an anterior extrusion of the gold weight implant and counteract
upper eyelid retraction by providing an extra
weight load. Another difference in technique
between the Asian and Caucasian eyelids is the
location of the gold weight implantation. In
Caucasian eyelids, some surgeons prefer to
place the gold weight high in the lid to reduce
visibility of the weight. However, the weight in
the Asian eyelid can be placed lower because it
is camouflaged by both the preaponeurotic fat
pads and the fibroadipose layer (Fig. 3).
One criticism of the above technique may be
the low incision. Catalano et al.28 stated the
importance of not overlapping any portion of
the implant to prevent an extrusion. In our
series, none of the patients has developed an
extrusion. However, this is a serious concern,
and we try to prevent this by covering part if
not all of the implant with the submuscular
fibroadipose layer and the preaponeurotic fat
pads. Next, we advocate meticulous closure of
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UPPER EYELID GOLD WEIGHT IMPLANTATION
the orbicularis muscle and the overlying skin in
two separate layers. In conclusion, with careful
attention to the anatomic differences between
Asian and Caucasian eyelid anatomy, one can
implant a gold weight in the Asian upper eyelid
to improve function while preserving the natural appearance of the Asian patient.
Phillip H. Choo, M.D.
University of California Davis Medical Center
Department of Ophthalmology
4860 Y. Street, Suite 2400
Sacramento, Calif. 95817
[email protected]
ACKNOWLEDGMENT
This work was funded in part by the Research to Prevent
Blindness Foundation.
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