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Background:Paralytic ectropion patients suffer from impairment of function and appearance of the lower eyelid and are at high risk of developing an exposure keratitis. A canthoplasty procedure can reduce the horizontal eyelid laxity and elevate the lower eyelid. We used a periosteal flap from the outer orbit to create a new canthal ligament. This study investigates the long-term outcomes of this technique.Methods:Cross-sectional outcome study in which 30 cases of paralytic ectropion are treated with a lateral periosteal flap canthoplasty after adequate eyelid shortening. At the desired canthal height, a periosteal flap from the outer temporal orbital rim is mobilized around the rim and sutured in a double-breasted fashion to a tarsal strip. Effect of the operation is measured by comparing preoperative and postoperative photographs for signs of ectropion. For this purpose, a new photograph-based scoring method [the Ectropion Severity Score (ESS)] was developed and evaluated.Results:The ESS proved to be reliable and sensitive to the presence of ectropion. Significant improvement of the ectropion sequelae was measured after a mean follow-up period of 2 years. In 3 cases (13%), a revision procedure was necessary because of relapse of lower eyelid sagging after a mean time of 1.9 years. In these cases, the periosteal flap could be reused.Conclusions:The ESS is a useful instrument to score the severity of paralytic ectropion. The periosteal flap canthoplasty is an effective procedure, with durable results in paralytic ectropion patients. The same periosteal flap can be used in a revision procedure.
Dear Editor,We compliment dr. De Lima Resende and dr. Weber with their interesting article entitled: 'Peripheral Facial Palsy in the Past. Contributions from Avicenna, Nicolaus Friedreich and Charles Bell' 1 . In it, they state that "Charles Bell […] himself had right peripheral facial paralysis".To support their statement the authors refer to a review on the history of facial nerve surgery by Jongkees (1979) 2 , who indeed made the same remark. Jongkees in turn concluded this from a book chapter written by 3 , who started the chapter with the following quotation by Sir Charles Bell (1774-1842): "…When the paralysis was complete, I began to feel pain in the temple, and there was oedematous swelling in the part. During the course of this complaint I have experienced two circumstances which may lead to the detection of the facial nerve becoming affected…".Thereafter Zülch wrote: "We consider it apt to preface our description of 'idiopathic' facial paralysis with this excellent piece of self-observation, quoted by Sir Charles Bell in his well-known publication (1829) of his physiological and pathological research on the nervous system. It was a letter written by Professor Roux of Paris to his colleague Descot, in which he described his own symptoms" 3 . Thus, Zülch did not mention that Bell was affected by facial paralysis. Instead it seems to have been Roux, whose self-observation was reported by Bell in 1827 4 . Neither Bell's own work nor the extensive biography on Bell written by Gordon Taylor and Walls (1958) 5 gives us indications that Bell himself was affected by facial paralysis.Unfortunately, Jongkees seems to have introduced the error that Bell himself was affected by facial paralysis. To prevent perpetuation of reporting historical errors in the literature, a critical and scientific attitude regarding the use of historical data is necessary. We should always beware of secondary literature, and we should always check the primary sources concerned. Already in 1916, Frank Place advised us: "Take no reference for granted. Verify the reference that your best friend gives you. Verify the reference that your revered chief gives you. Verify most of all, the reference that you yourself found and jotted down. To err is human, to verify is necessary" 6 .
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