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Editor,—The paper by Olver1describes nine consecutive patients suffering from sagging of the lower eyelid due to facial palsy, in whom lifting of the suborbicularis oculi fat (SOOF) was added to the usual treatment with the lateral tarsal strip procedure and, if indicated, medical canthal tightening. Based on observation of her results, the author concludes that SOOF lifting both supports the elevation of the lower eyelid and enhances the cosmetic results. However, the study offers no clear data on postoperative lower eyelid height or any comparison of her results with reported data on the tarsal strip procedure alone. Therefore, I feel that the study offers insufficient evidence to support these conclusions.
Since the addition of SOOF lifting to a relatively straightforward lateral tarsal strip procedure is likely to enhance its morbidity (more conjunctival chemosis, as stated by the author, possible damage to the infraorbital nerve, more bleeding and infection) I would suggest that routinely adding a SOOF lift to the tarsal strip procedure should be postponed until the advantage of this addition has been demonstrated more clearly, preferably in a randomised prospective series that quantifies the lower eyelid position and that uses an independent observer for qualitative comparison.
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Editor,—I thank Van den Bosch for his interest in my paper on the role of the suborbicularis oculi fat (SOOF) lift in the rehabilitation of patients with chronic facial palsy. The aim of my paper was to describe the lateral tarsal strip (LTS) in conjunction with a SOOF lift in the correction of lower eyelid “sag” or paralytic ectropion. The use of this procedure was confined to patients in whom, preoperatively, there was coexistent mid-face ptosis which could be elevated digitally, mimicking the anticipated surgical outcome. My paper did not suggest that the combination of LTS and SOOF should be used routinely for all cases of paralytic ectropion. Probably only one in four patients with chronic facial palsy would be suitable for this procedure.
Measurement of palpebral aperture and lagophthalmos used in this study provides data relating to the lower eyelid raising but not the mid-face raising. I found that the SOOF lift was best in longstanding facial palsy, such as congenital or childhood onset, where the cheek tissue was slightly atrophic and the mid-face lift sustained.
A LTS alone does not always adequately reduce lagophthalmos in facial palsy, therefore other techniques and variations of LTS are sought. Direct comparison with other series is often difficult as patient selection may differ and other confounding influences may be present. A randomised prospective trial is a counsel of perfection. It is probably inappropriate at this stage in the development of the technique, when patient selection and optimal techniques are yet to be fully determined. In practice, it is unlikely that sufficient numbers of patients would consent to take part in such a study. For a randomised study to produce accurate results both patient selection and operative technique need to be unchanged for a large number of patients.