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Lateral Tarsoconjunctival Onlay Flap Lower Eyelid Suspension in Facial Nerve Paresis

Tao, Jeremiah P. M.D., F.A.C.S.*; Vemuri, Swapna M.D.*; Patel, Amy D. M.D.*; Compton, Chris M.D.; Nunery, William R. M.D., F.A.C.S.

Ophthalmic Plastic and Reconstructive Surgery: July/August 2014 - Volume 30 - Issue 4 - p 342–345
doi: 10.1097/IOP.0000000000000175
Surgical Techniques

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

Methods: 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.

Results: 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.

Conclusions: 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.

A lateral tarsoconjunctival flap improves paralytic eyelid malposition.Supplemental Digital Content is available in the text.

*Gavin Herbert Eye Institute, University of California–Irvine, Irvine, California, U.S.A.; and University of Louisville, Louisville, Kentucky, U.S.A.

Accepted for publication March 9, 2014.

Gavin Herbert Eye Institute is a recipient of an institution Research to Prevent Blindness grant.

The authors have no other financial or conflicts of interest to disclose.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (

Address correspondence and reprint requests to Amy D. Patel, M.D., Department of Ophthalmology, Gavin Herbert Eye Institute, University of California, Irvine, 850 Health Sciences Road, Irvine, CA 92697. E-mail:

© 2014 by The American Society of Ophthalmic Plastic and Reconstructive Surgery, Inc., All rights reserved.