Lateral Tarsoconjunctival Onlay Flap Lower Eyelid Suspension in Facial Nerve Paresis

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To evaluate the efficacy of a lateral tarsoconjunctival flap suspension procedure to improve paralytic eyelid malposition.


Retrospective chart review (with photograph and videographic data) of consecutive patients between 2008 and 2013 with permanent unilateral paralytic eyelid malposition treated with a far lateral tarsoconjunctival flap lower eyelid suspension alone or in conjunction with lateral canthoplasty. Upper and lower eyelid position, lagophthalmos, ocular surface disease, patient satisfaction, and cosmesis were recorded before and after intervention. Postoperative complications and subsequent management were also recorded.


A total of 110 patients were identified. Lagophthalmos, ocular surface exposure, exposure keratopathy, and eyelid retraction (both upper and lower) improved in all cases. All patients described an improvement in eye irritation, epiphora, and cosmesis. Patients with a good Bell’s reflex exhibited some dynamic function to the lower eyelid on videography. Three (2.7%) eyelids had flap dehiscence that was successfully treated with repeat suturing. Seven (6.4%) patients had symptomatic temporal peripheral vision requiring partial flap takedown. Five (4.5%) patients had pyogenic granulomas excised. Seven (6.4%) patients later had a supplemental medial tarsorrhaphy for medial lagophthalmos.


The lateral tarsoconjunctival flap suspension was highly effective in this series of patients with paralytic eyelid malposition. Improved eyelid position and cosmesis were universal although some patients benefitted from an additional medial tarsorrhaphy. Return of natural upward lower eyelid movement upon eyelid closure was a further benefit in some patients. Temporal vision obstruction was an infrequent side effect and flap dehiscence and granulomas were rare complications.

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