Frontonasal encephalocele--"long nose hypertelorism"

Two varieties of frontonasal encephalocele are presented, with variations in the surgical technique necessitated by the different anatomical findings. The encephalocele pushes the nasal skeleton posteriorly and caudally and widens the distance between the medial orbital walls. This causes the long nose and the telecanthus. In this variety of frontonasal encephalocele, hypertelorism is uncommon. There may be absence of dura in relation to the encephalocele. The suggested method of correcting the deformity involves a combined intracranial and extracranial approach. The nasal skeleton is mobilized and placed in its correct position and the telecanthus is corrected. All skull defects are bone grafted. Correcting the deformity at an early age is recommended.

Surgery related to the correction of hypertelorism

The importance of skeletal reduction of the interorbital distance in the treatment of patients with teleorbitism is now well recognized. In spite of this, results of surgery are not always as good as one would hope. For this there are two reasons: (1) reduction of the interorbital distance may be followed by deformities such as canthal drift, enophthalmus, pseudoptosis, and so forth; and (2) hypertelorism is frequently associated with a variety of other malformations that become more conspicuous after reduction of the interorbital distance. In this paper attention is focused on the mechanisms responsible for the appearance of new stigmata, on their prevention, and also on the treatment of the associated malformations.

[Craniofacial surgery]

Deformities in the orbital area can also be corrected by craniofacial surgery. Early surgery within the first year of life is indicated in cases with intracranial pressure if permanent damage to the eye is to be avoided. Otherwise, corrective surgery should be performed in early childhood, although it can also be performed on adult patients. More severe strabismus cannot be treated, but disturbance of lid function can be positively influenced. From the esthetic point of view considerable improvement can be achieved. These very protracted operations require intensive interdisciplinary cooperation.

Application of the biological principle of induced osteogenesis for craniofacial defects

Demineralised bone implants were used for cranio-maxillofacial reconstruction and construction in 34 patients, 28 with congenital deformities and 6 with acquired defects. The patients' ages ranged from 15 months to 59 years (mean 18 years). In 33 cases, the implants were obtained from cadaver femurs; in 1 case, the implant was prepared from the patient's own skull. Early healing was assessed by clinical and radiographic examination and, when appropriate, by biopsy. Longer follow-up will be required to determine whether resorption has been avoided. The clinical advantages are rapid union, healing of large defects, avoidance of harvesting procedures, and the potentially unlimited supply of banked material.

Craniofacial surgical techniques for aesthetic results in congenital and acute traumatic deformities

The first case of congenital orbital hypertelorism presented demonstrates that complex investigations, careful planning, and extensive experience combined with meticulous attention to detail can turn a severe congenital deformity into normality in one operation. The second case of trauma shows that an acute injury (even in the face of potential major contamination) can be initially managed by utilizing all the principles of craniofacial surgery, thus achieving optimal results in one operation. The surgeon must be prepared to utilize extensive exposures to visualize exact fracture sites and the degree of displacement. Bone grafts must be used to provide contour and to replace missing segments. Direct wiring performed with mechanical efficiency can produce a completely stable skeleton without the need of external devices. Probably the most important factor is that the surgeon should endeavor to achieve complete correction during initial operation regardless of the time taken. The concept of doing some things at a later date is never satisfactory in terms of the quality of result.

Current surgery of craniofacial anomalies

Craniofacial dysplasia is a term covering all types of skeletal anomalies. Craniofacial surgery has made possible the movement of any bone of the face or skull to correct such deformities. Such surgery is a new and separate subspecialty and should be limited to a few regional centers. There are numerous osteotomies available. The common ones are the Le Fort I, II, and III for advancement of different segments of the midface, orbital hypertelorism correction converting each orbit into a box, which moves medially together with the eyeball, and advancement of the forehead to correct premature coronal synostosis in infancy or forehead recession in Crouzon's or Apert's syndrome. In hemifacial microsomia, the asymmetrical skeleton is rotated about the facial midline to produce symmetry, and the mandibular ascending ramus and temporomandibular joint are constructed if absent. Combinations of the various osteotomies are possible, depending upon the type of deformity as assessed by the craniofacial team. Psychosocial study indicates that surgical correction should be undertaken as early as is technically feasible. The four main complications are death, blindness, brain damage, and infection.

Nasal correction in hyperteleorbitism. The short and the long nose

The soft tissue deformities associated with hyperteleorbitism often present serious reconstructive problems. Although skeletal correction is the basic preliminary step, the final result depends on the quality of the soft tissue and nasal repair. The patients are not interested in the postoperative intercanthal distance or the appearance of the X-ray film. What they want is a good aesthetic appearance and this is closely related to the shape and size of the nose. The short wide noses of the true hyperteleorbitism must be differentiated from the long noses associated with meningoencephalocele and pseudohypertelorism. For the first group, narrowing of the nose and the use of a forehead flap is indicated according to the severity of the problem. For the second group, shortening of the nose is accomplished by transverse resection of skin via a U shaped incision or skin replacement with a forehead flap. Downward sliding of forehead and brows may be necessary. The indication for each procedure is discussed and the different techniques are described.

The pulley canthopexy for residual telecanthus after hypertelorism repair or facial trauma

The onset of canthal drift after hypertelorism repair can nullify the effectiveness of the repair, despite roentgenographic evidence of normal interorbital distance. The problem of hypertelorism is simply replaced by the problem of telecanthus. An excess of bulky tissue between the orbits contributes to the problem. A procedure is described in which excess soft tissue (fat, nasal muscles, and parts of the orbicularis oculi) are excised. A pulley canthopexy with a figure-of-eight suture of polypropylene is performed to bring the canthal tendons together using a hollow awl with a removable handle. The pulley gives a 4 to 1 mechanical advantage to the suture, adding control and distributing the forces over a wider area. The pulley canthopexy is a valuable tool not only in congenital anomalies but also for correcting long-standing traumatic telecanthus and acute detachment of the canthal ligaments.

Major osteotomies of the cranium, facial bones, and mandible

This paper describes the present status of osteotomies of the facial skeletal framework, including craniofacial surgery, in Japan based on patients seen at the Tokyo Metropolitan Police Hospital. It presents our experience with the correction of craniofacial dysostosis, orbital hypertelorism, orbital hypotelorism, untreated plagiocephaly, craniostenosis, cleft lip deformity, prognathism, and asymmetry of the mandible. There are a few departments skillfully performing such osteotomies in Japan, but it cannot yet be said that the procedures are well developed here. I myself have applied them in almost 100 patients in the past four years; considering the complexity and difficulty of these operations, however, my experience is quite limited and simply follows in the footsteps of previous work done mostly in western countries. Nevertheless, we can now treat most craniofacial and facial skeletal problems ourselves.

Experience with transnasal canthopexy

The results are presented of a series of 14 canthopexies in recent trauma cases, 15 for correction of post-traumatic canthal dystopy, 12 for correction of hypertelorism and 8 in Le Fort III midface advancements. The overall results in traumatic cases are acceptable, in hypertelorism a considerable amount of relapse is noted and in Le Fort III osteotomies intercanthal distance enlarges slightly. The reasons for unsatisfactory results are discussed: Pressure ulcers of the skin, lateral pull of the soft tissues, and exaggerated pull on the ligaments seem to be the main factors. In Le Fort III osteotomies the anatomical situation has to be considered. As a conclusion it is suggested that the canthal ligaments should not be detached whenever possible in cases in which the topographical relationship between ligament and medial orbital wall does not have to be changed.

Improvements in craniofacial reconstruction: methods evolved in 235 consecutive patients

Quality evaluation following craniofacial operative procedures is largely aesthetic and almost impossible to measure. Relapse rates are measurable, and morbidity and mortality can be determined. In our series, infections have decreased from 12.5 to 1.3 percent; operating times have been reduced from a mean of 7 1/2 to 4 hours; and blood loss has been reduced from 86 to 56 percent of the total blood volume. Methods we feel are largely responsible for these improvements are (1) maintaining separation of cranial from oronasal cavities, (2) modification of osteotomies around the orbits, (3) infant surgery and extensive use of craniectomy bone, (4) frequent use of onlay bone grafts, (5) a variety of lesser technical refinements, (6) antibiotic use and anesthetic modifications, and (7) consistent team organization. No deaths or blindness have occurred in any patients in the entire series.

[Correction of post-traumatic hypertelorism (author's transl)]

Following naso-orbital fractures, posttraumatic hypertelorism (or telecanthus) cannot always be avoided, even when prompt surgical treatment is given. For correction of this deformity, attempted remobilisation of the injured nasal skeleton (with or without grafting) is rarely successful. This is so because of two reasons: (1) the lateral nasal wall is thickened by overlapping fragments of fractured bone so that excessive scar tissue cannot be adequately replaced; (2) revision of paranasal sinus drainage is needed in most cases. Three cases are reviewed in order to demonstrate our concept of surgical repair: complete removal of bony fragments and scar tissue between lateral nasal mucosa and periorbita, restoration of the contour of the bony bridge of the nose by cartilage grafting and median canthoplasty, as well as possible pan-sinusectomy with or without dacryocystorhinostomy when needed.