Eyelid transplantation: Lessons from a total face transplant and the importance of blink

Background: Despite inclusion of periorbital structures in facial transplants, critical assessment of posttransplantation short- and long-term periorbital function has not been reported. The purpose of this article is to report recovery of ocular and periorbital function, with critical appraisal of posttransplant blink in the setting of revision surgery. Methods: Prospective ocular and periorbital functional assessments were completed at multiple time points in a patient undergoing facial transplantation and subsequent revision operations. Function was evaluated using clinical ocular examinations, visual acuity assessments, photography, and video at various intervals from preoperative baseline to 13.5 months after transplantation. During this period, revision operations involving periorbital structures were performed at 6 and 9 months after transplantation. Results: Before transplantation, volitional blink was 100 percent in both eyes. Involuntary blink was 40 percent in the right eye and 90 percent in the left eye, with occasional full closure. Following face transplantation, voluntary blink was preserved, partial skin sensation was present, and involuntary blink improved to 70 percent in the right eye and 100 percent in the left eye. Following revision surgery, visual acuity and voluntary and involuntary blink were impaired. By 7.5 months after revision, improvement comparable to the pretransplantation assessment was observed. Conclusions: Adherence to principles of blink preservation is critical in periorbital transplantation. Involuntary blink is essential for preserving vision, and can be improved after transplantation. Revision surgery may temporarily impair advances made with initial allotransplantation. A comprehensive understanding of ocular biomechanics and function is invaluable to the reconstructive surgeon performing facial transplantation involving periorbital structures and posttransplant revision operations.