{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,8]],"date-time":"2026-01-08T18:43:59Z","timestamp":1767897839009,"version":"3.49.0"},"reference-count":21,"publisher":"BMJ","funder":[{"DOI":"10.13039\/100001818","name":"Research to Prevent Blindness","doi-asserted-by":"publisher","award":["N\/A (unrestricted grant)"],"award-info":[{"award-number":["N\/A (unrestricted grant)"]}],"id":[{"id":"10.13039\/100001818","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Br J Ophthalmol"],"abstract":"<jats:sec><jats:title>Background\/aims<\/jats:title><jats:p>To present a case series of patients with facial nerve palsy (FNP) undergoing lower eyelid surgery where inadequate horizontal tarsal length was encountered and managed with a periosteal flap.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>A two-centre retrospective, non-comparative case series of all patients with FNP who underwent lower eyelid periosteal flap procedures. Theatre records identified all such procedures performed by, or under the supervision of, one of two surgeons (RM, BCP) between November 2018 and November 2020. Outcome measures, including the Cornea, static Asymmetry, Dynamic function, Synkinesis grading score, were measured preoperatively and postoperatively.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>All 17 patients had undergone medial canthal tendon (MCT) plication. Six had previously undergone MCT plication then were listed for further lower eyelid surgery. In 11 cases, horizontal deficiency was encountered intraoperatively, immediately following MCT plication. Four patients were surgery-na\u00efve. 94% were within the \u2018contraction phase\u2019 of FNP (ie, greater than 1-year duration); eight (45%) had previously undergone lower eyelid shortening procedures (such as lateral tarsal strip procedure, LTS). All patients had improved lower eyelid position postoperatively, although at 1-year postoperation, four patients require redo lower eyelid surgery.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusions<\/jats:title><jats:p>MCT plication and stabilisation appear to be closely linked to the need for lower eyelid lengthening procedures, particularly in patients who have also undergone LTS and\/or those within the \u2018contraction phase\u2019 of FNP. Unnecessary loss of horizontal tarsal length (particularly during LTS procedures) must be avoided in patients with FNP. Surgeons managing such patients should take care to identify inadvertent eyelid shortening early and be prepared to perform a lateral periosteal flap when required.<\/jats:p><\/jats:sec>","DOI":"10.1136\/bjo-2022-322549","type":"journal-article","created":{"date-parts":[[2023,4,18]],"date-time":"2023-04-18T17:20:13Z","timestamp":1681838413000},"page":"bjo-2022-322549","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":2,"title":["Lower eyelid lengthening in facial nerve palsy: when is a periosteal flap required?"],"prefix":"10.1136","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8294-443X","authenticated-orcid":false,"given":"Aaron","family":"Jamison","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bhupendra C","family":"Patel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8566-2094","authenticated-orcid":false,"given":"Samantha","family":"Hunt","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Raman","family":"Malhotra","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2023,4,18]]},"reference":[{"key":"2023041810200470000_bjo-2022-322549v1.1","doi-asserted-by":"crossref","first-page":"713","DOI":"10.1038\/eye.2016.21","article-title":"Occurrence and severity of upper eyelid skin contracture in facial nerve palsy","volume":"30","author":"Ziahosseini","year":"2016","journal-title":"Eye (Lond)"},{"key":"2023041810200470000_bjo-2022-322549v1.2","doi-asserted-by":"crossref","first-page":"358","DOI":"10.1002\/mus.24154","article-title":"Quantitative ultrasonography of facial muscles in patients with chronic facial palsy","volume":"50","author":"Volk","year":"2014","journal-title":"Muscle Nerve"},{"key":"2023041810200470000_bjo-2022-322549v1.3","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1177\/074880680602300303","article-title":"A classification system for facial fat atrophy","volume":"23","author":"Napolez","year":"2006","journal-title":"Am J Cosmet Surg"},{"key":"2023041810200470000_bjo-2022-322549v1.4","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1097\/IOP.0000000000000710","article-title":"Periorbital autologous fat grafting in facial nerve palsy","volume":"33","author":"Siah","year":"2017","journal-title":"Ophthal Plast Reconstr Surg"},{"key":"2023041810200470000_bjo-2022-322549v1.5","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1055\/s-2005-858862","article-title":"Ultrasound of the upper eyelid to evaluate tarsal curvature in facial palsy","volume":"223","author":"Schrom","year":"2006","journal-title":"Klin Monbl Augenheilkd"},{"key":"2023041810200470000_bjo-2022-322549v1.6","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1080\/01676830.2019.1705500","article-title":"Recognising meibomian gland inversion in patients with facial palsy to improve the ocular surface","volume":"40","author":"Ullrich","year":"2021","journal-title":"Orbit"},{"key":"2023041810200470000_bjo-2022-322549v1.7","doi-asserted-by":"publisher","DOI":"10.1136\/bjophthalmol-2015-307167"},{"key":"2023041810200470000_bjo-2022-322549v1.8","first-page":"603","article-title":"The care guidelines: consensus-based clinical case reporting guideline development","volume":"110","author":"Gagnier","year":"2013","journal-title":"Dtsch Arztebl Int"},{"key":"2023041810200470000_bjo-2022-322549v1.9","doi-asserted-by":"publisher","DOI":"10.1136\/jnnp.72.5.665"},{"key":"2023041810200470000_bjo-2022-322549v1.10","first-page":"14","article-title":"Neurologic principles of edema in inactivity","volume":"16","author":"Trettin","year":"1992","journal-title":"Z Lymphol"},{"key":"2023041810200470000_bjo-2022-322549v1.11","doi-asserted-by":"crossref","unstructured":"Korteweg SFS , Stenekes MW , van Zyl FE , et al . 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