Extended frontalis orbicularis oculi muscle flap shortening for treating refractory apraxia of eyelid opening associated with blepharospasm

Background: Refractory apraxia of eyelid opening (AEO) is mostly unresponsive to botulinum toxin (BTx) and inevitably leads to functional blindness. To treat this challenging condition, an innovative surgical technique was proposed.Methods: The extended frontalis orbicularis oculi muscle (FOOM) flap shortening consisting of frontalis suspension, partial myectomy, and myotomy in situ of eyelid protractors was applied to treat refractory AEO associated with blepharospasm. The postoperative outcomes and patient satisfaction were evaluated.Results: Seven patients (mean ages 64.1 +/- 3.9 years) of 14 eyelids in total had an average flap shortening distance of 24.4 +/- 1.3 mm. During a mean follow-up of 31.6 +/- 11.4 months, the average BTx dosage reduced from 58.6 +/- 12. 1 units to 30.0 +/- 8.2 units, with a mean injection interval decreasing from 2.3 +/- 0.5 months to 4.1 +/- 0.9 months (p < 0.05). Palpebral fissure height increased from 1.4 +/- 0.5 mm to 7.9 +/- 0.7 mm, and the disability scale decreased from 78.8% +/- 7.2% to 12.6% +/- 7.0% (p < 0.05). The postoperative BTx dosage and frequency were significantly reduced. All patients restored voluntary eyelid opening and reported high postoperative satisfaction (average Likert scale 4.6 +/- 0.5).Conclusion: Extended FOOM flap shortening is an effective treatment to solve refractory AEO associated with blepharospasm.