Long-Term Photogrammetric- and Panel Assessment-Based Outcome Study of Staged Reconstructive Approach for Hypertelorism Correction

BACKGROUND

The surgical management of hypertelorism is challenging for plastic surgeons, and limited long-term outcome data are available. The purpose of this long-term study was to report a single-surgeon experience with a staged reconstructive protocol for hypertelorism correction.

METHODS

This retrospective study reviewed the records of patients with hypertelorism who were surgically managed by a single surgeon between 1978 and 2000. Bone (orbital box osteotomy and orthognathic surgery) and soft tissue (rhinoplasty and epicanthoplasty) surgeries were performed based on a patient-specific surgical protocol. Included patients were divided into a childhood group and an adolescence or adulthood group according to their age at orbital repositioning (≤12 and >12 years, respectively). Patients were invited for clinical interviews in February 2020 to evaluate whether requests for revision surgery had been made. The photogrammetric analysis-based hypertelorism index was calculated at preoperative and long-term postoperative times. Satisfaction with the long-term outcome was judged by both surgical professionals and laypeople.

RESULTS

In total, 14 patients with hypertelorism of different etiologies were included, with no request for revision surgery during an average follow-up of 29 years. The preoperative hypertelorism index was higher than the long-term postoperative evaluation (all, P < 0.05) for both childhood and adolescence or adulthood groups. Intergroup comparison revealed no significant difference for the hypertelorism index and panel assessment-based satisfaction with long-term outcome analysis (all, P > 0.05).

CONCLUSIONS

Considering the complexity and wide spectrum of clinical presentation of soft tissue and bone deformities in hypertelorism and current outcomes, the surgical approach to these patients should be staged and individualized for achievement of a balanced result between functional (orbital, occlusion, and psychosocial) and aesthetic parameters.

Multidisciplinary eyelid reconstruction in Barber-Say syndrome: A case report

Barber-Say syndrome is an unusual dysplasia caused by the mutation of the TWIST2 gene (2q37.3), which encodes a protein that acts at an epigenetic level. The case is presented of a 2-day-old male child in whom ectropion, hypertelorism, hypertrichosis and other dysmorphic features led to the clinical diagnosis of Barber-Say syndrome, which was later confirmed with genetic tests. Around 20 cases have been reported on this syndrome, of which less than half have described the surgical technique, as it represents a surgical challenge. The approach in this case included a lateral tarsorrhaphy and skin grafts taken from the volar surface of the forearm, retroauricular area and supraclavicular fossa, as well as autologous lipografts from the inner side of both thighs for palpebral reconstruction. This is the first case of Barber-Say syndrome in which the use of skin grafts are taken from supraclavicular fossa and forearms.

Horizontal eye position in thyroid eye disease: a retrospective comparison with normal individuals and changes after orbital decompression surgery

Objective

To compare horizontal eye positions between proptotic thyroid eye disease patients and normal individuals, and to examine positional changes after orbital decompression surgery in thyroid eye disease patients.

Methods

The present case-controlled and retrospective comparative study included 78 proptotic thyroid eye disease patients who underwent bilateral orbital decompression surgery [lateral orbital wall decompression (Group L), 47 patients; medial orbital wall decompression (Group M), 9 patients; and balanced orbital decompression (Group B), 22 patients] and 143 age-matched healthy volunteers as controls. The interpupillary distance was measured to determine horizontal eye positions before and 3 months after surgery in thyroid eye disease patients and was also examined in control eyes. Horizontal eye shifts were calculated by subtracting postoperative from preoperative interpupillary distances.

Results

Preoperative interpupillary distances in thyroid eye disease patients were significantly larger than in controls. The interpupillary distances were significantly decreased postoperatively in Groups M and B, but were significantly increased in Group L. The order of the magnitude of the horizontal shifts was Groups M>B>L.

Conclusions

Proptotic thyroid eye disease patients preoperatively showed laterally displaced eyes in comparison with controls. However, the eyes shifted medially after the medial orbital wall decompression and the balanced orbital decompression, although the former showed more shift. Medial orbital wall or balanced orbital decompression can be used to correct both lateral and anterior displacement of the eyes.

[Modified technique for correction of the orbital hypertelorism]

OBJECTIVE

To explore the possibility of para-orbital soft-tissue expansion, before orbital osteotomy and medial translocation procedures with a combined intracranial-extracranial approach.

METHODS

Tissue expansion in the region of the zygomatic and temporal has been undergone for 3 weeks before the traditional intracranial-extracranial approach for orbital osteotomy and medial translocation in two patients. The healing between the orbital bone was studied with measurement of interorbital distance and three-dimensional CT.

RESULTS

The inter-orbital distance of the two patients decreased from 4.4 cm and 3.2 cm to 2.0 cm and 1.4 cm. The intercanthal distance decreased from 6.7 cm and 4.8 cm to 5.0 cm and 3.8 cm.

CONCLUSIONS

The para-orbital soft-tissue expansion technique may be an effective technique for the stability of the corrected interorbital distance in orbital hypertelorism.

Frontoethmoidal encephalomeningocoele with colpocephaly: case report and clinical review

Frontoethmoidal encephalomeningocoele is a rare congenital disease in which an intracranial mass protrudes through a midline defect from the anterior cranial fossa into the facial skeleton. The condition affects patients in South East Asian countries, such as Thailand, Burma, Malaysia and Indonesia, with frequency of 1 in 5000. The pathogenesis of encephalocoeles may be regarded as a 'late' neurulation defect during the fourth gestational week. We present a case of frontoethmoidal encephalomeningocoele with corpus callosal agenesis and colpocephaly; this may well be the first report of this combination. The patient had a bulging mass in the middle frontonasal area, with broadening of the nasal bridge and hypertelorism. Computed tomography scans delineated the skull defect and associated brain anomalies. A one-stage, combined transfacial-transcranial approach, correctional procedure was performed. We present here a discussion of the findings, with special reference to the condition's pathogenesis, morphological classification and evolving surgical treatments. Early diagnosis and referral, involving multidisciplinary teamwork, are of paramount importance because of the distorting influence of the extruding mass on facial growth.

Single stage craniofacial reconstruction for fronto-nasal encephalocele and hypertelorism in an adult

The fronto-nasal type of fronto-ethmoidal encephalocele is one of the more common subtype of anterior encephaloceles. We discuss different aspects and difficulties in the management of fronto-nasal encephalocele in a 30-year-old woman. Fronto-nasal encephaloceles present a difficult scenario in adults, mainly due to large gliotic herniating brain tissue, large bony and dural defect, increase in the size of paranasal sinuses, and scars from previous surgeries. However, all difficulties can be overcome after applying the principles of craniofacial reconstructions, i.e. correction of bone defect with autologus split calvarial graft, dural closure with autologous pericranial graft and correction of hypertelorism.

Mucocele of the paranasal sinuses as a cause of acquired orbital hypertelorism: the second case

BACKGROUND

Orbital hypertelorism is defined as a lateralization of the total orbit. This condition is associated almost always with congenital abnormalities. An acquired total displacement of the orbit is almost impossible once the bony pillars of the craniofacial complex are established. The aim of this article was to discuss a case of a young man with paranasal sinus mucocele, who developed OHT.

CASE DESCRIPTION

A 20-year-old man was admitted to us with orbital hypertelorism in 1993. The patient's examination revealed marked orbital hypertelorism, and no other abnormal finding was noted, and he had no congenital defect at birth. Hypertelorism was corrected by surgery, and we find that this condition was acquired secondary to paranasal sinus mucocele.

CONCLUSION

This is the second case of an acquired OHT secondary to paranasal sinus mucocele and the first in which the condition was corrected by surgery in late years of life. We found excellent correction of orbital hypertelorism 13 years after surgery. The authors discuss the possible link between mucocele and possible mechanism for the development of orbital hypertelorism and emphasize the need for early surgery and long-term follow-up.

What is the Incidence of Hypertelorism in Filipino Frontonasal Encephalocele Patients?

It is unclear whether Filipinos with sincipital encephaloceles have true orbital hypertelorism or just telecanthus. Knowing this determines whether orbital osteotomies or medial canthoplasty are more appropriate corrective procedures. To evaluate this, 56 sequential Filipino sincipital encephalocele patients (28 female and 28 male, average age 66.6 months, age range 4 days to 21.8 years) were evaluated for orbital width. Soft tissue measurements of inner and outer canthal position and CT measurements of medial and lateral orbital wall position were obtained. Normative data curves by age and sex for orbital bony and soft tissue distances in normal Filipino children were developed. Data was plotted on these curves and analyzed to determine if encephaloceles were associated with medial widening alone or true hypertelorism. Inner canthal measurements for male were approximately +2.8 standard deviation (SD) and female +2.3 SD wider than average. Medial orbital wall dimensions were wider for male +1.5 SD and female +1.4 SD. Lateral orbital measurements for both male and female clustered around the normative mean (males -0.5 SD and females -0.8 SD). Female outer canthal measurements also clustered around the normative mean (+0.6 SD wider) while male outer canthal measurements averaged approximately +1.1 SD wider than mean. As expected, measurements were wider medially when compared to normative data. However, lateral bony and soft tissue widening was minimal or approached normative averages. This suggests the problem is medial widening only and less invasive procedures such as medial canthoplasty or nasal bony contouring may be the most appropriate surgical management.

Craniofacial surgery for orbital malformations

Paediatric craniofacial surgery is a highly specialised field requiring a multidisciplinary team input. Orbital and ocular involvement is relatively common in craniofacial patients. This is more in syndromic patients. In nonsyndromic patients, orbital involvement is common in frontal plagiocephaly and trigonocephaly. The management of these conditions requires close working between the craniofacial surgeon and ophthalmologist. An outline of the management of these deformities is discussed.

[Establishment of rabbit orbital hypertelorism model and evaluation of effects of surgical correction]

OBJECTIVE

To establish a rabbit model of orbital hypertelorism for plastic and reconstructive surgery and evaluate the surgical effects.

METHODS

Orbital osteotomies and medial translocation was performed in 16 New Zealand rabbits (4 to 6 months old) by combined intracranial-extracranial approach. The interorbital distance (IOD) and bone healing between the orbits were evaluated with gross measurement. X-ray and histological examinations were performed immediately and 12 weeks after the operation.

RESULTS

The average IOD of the rabbits was 0.74 cm after completion of the operation, but increased to 0.96 cm 12 weeks after the operation, showing significant relapse of orbital hypertelorism (P<0.01).

CONCLUSION

The IOD can be decreased successfully in this rabbit model.

Clinical Experience With a New Fast-Resorbing Polymer for Bone Stabilization in Craniofacial Surgery

Polylactic acid (PLA) and polyglycolic acid have been successfully used as suture material during the past 30 years and have been successfully used in various orthopedic and craniofacial applications, with increasing frequency during the past 15 years. To eliminate some of the problems seen with the longer-lasting Macropore PLA product and other longer-lasting resorbable systems, a new fast-resorbing polymer (FRP) was manufactured by Macropore-Medtronic Neurologic Technologies, Inc. from commercially available 85:15 poly(D,L-lactide-co-glycolide) raw material using traditional melt-processing techniques. The delivery system is easily used and uses essentially the same instrumentation. One hundred and sixty eight patients who had implantation of the FRP were studied. Detailed clinical evaluation was completed after surgery and at each postoperative visit. Overall, there was a 2.1% implant-related complication rate, which compared favorably to the 8.5% implant-related complication rate associated with the longer-lasting PLA product. All patients who received FRP implants have had maintenance of stable bony fixation, followed by bony healing and satisfactory or excellent cosmetic results. The results from the FRP study indicate that the FRP material and implants are safe and effective in craniomaxillofacial applications.

Hypertelorism: the importance of three-dimensional imaging and trends in the surgical correction by facial bipartition

BACKGROUND

The technique of facial bipartition has been considered a great advance in achieving a more natural appearance in hypertelorism correction.

METHODS

Fourteen patients who had undergone hypertelorism correction by facial bipartition were retrospectively studied to analyze the role of three-dimensional computed tomographic reconstruction in the evaluation of the deformity and preoperative planning. The procedure and surgical details that can improve the outcome were described. A reproducible set of three-dimensional measurements that can help in preoperative patient evaluation was determined based on information obtained using the Analyze/AVW 3.1 system (Biomedical Imaging Resource, Mayo Foundation, Rochester, Minn.).

RESULTS

In this series, the most common diagnosis was frontonasal dysplasia (64.3 percent). Five patients had second-degree (35.7 percent) and nine had third-degree hypertelorism (64.3 percent). The three-dimensional scans were shown to be highly accurate in predicting the degree of deformity. There was a significant difference in the preoperative and postoperative interdacryon distance and midface height (p < 0.05) but not in the bitemporal distance (p = 0.08). The simulation correlated significantly with the postoperative result when interdacryon distance and midface height were analyzed (0.736 and 0.999).

CONCLUSIONS

Facial bipartition provided a three-dimensional correction of hypertelorism. Three-dimensional imaging can definitely be considered an extra tool for accurate surgical planning and helping the family understand the surgical procedure and the end result.

Repair of proboscis lateralis

We report an 8-year-old girl presented with a proboscis on the right nasal nostril, right heminasal hypoplasia, hypertelorism, and cleft lip and palate on the other side. After repair of the cleft lip and palate and the hypertelorism, we successfully reconstructed the heminose with a V-Y advancement flap containing the proboscis tube.

Multidisciplinary management of Opitz G BBB syndrome

Opitz G BBB syndrome is a rare condition characterized by the 3 major anomalies of hypertelorism, cleft lip and palate, and hypospadias, although there may be other associated anomalies. The underlying genetic causes are complex and consist of both X-linked recessive and autosomal dominant forms of the disorder. Previously, there have been publications on the underlying genetics and case reports, but there have been few reports regarding the long-term outcome. The aim in this study was to review the range of clinical presentation and evaluate outcomes of the multidisciplinary management of a cohort of patients with Opitz G BBB syndrome. In a 25-year period, 7 patients with Opitz G BBB syndrome were managed by the Australian Craniofacial Unit (ACFU), 5 male and 2 female. Most of the patients are now reaching skeletal maturity. Each one presented with a range of severity in the triad of hypertelorism, cleft lip and palate, and hypospadias anomalies. The males all exhibited the triad of anomalies, while the females both had hypertelorism, only 1 had isolated cleft palate, and neither had any genitourinary anomalies. Each patient underwent multidisciplinary assessment to make a treatment plan for staged management of different anomalies. Plan for surgical corrections of facial anomalies were performed according to the unit's protocol management of both hypertelorism and cleft lip and palate, but the presence of these coexisting anomalies required adjustment of the standard protocol of management of cleft lip and palate. In conclusion, we recommend that patients with Opitz G BBB syndrome require careful evaluation, and management of the anomalies should be in a coordinated manner by a multidisciplinary team.

The K Stitch for Hypertelorbitism: Improved Soft Tissue Correction With Glabellar Width Reduction

After correction of moderate to severe hypertelorbitism (greater than 40 mm interdacryon distance) with facial bipartition or orbital box osteotomy, excess glabellar soft tissue and brow width should be addressed. Traditional methods described used a midline excision down the forehead and nasal dorsum, and left an unsightly scar. With a series of 12 patients, the authors document the K stitch technique with no external vertical scar. A mean 38.8% reduction of interbrow distance was noted using this technique. Two patients underwent revisions, and two patients had temporary eyelid ptosis. All patients reported satisfaction once the skin contracture was completed.

Surgical correction of orbital and periorbital deformities using lamella and complex osteotomies in both orbital rim and wall

PURPOSE

For dealing with the problems in orbital and periorbital deformities.

METHODS

In orbital deformities such as hypertelorism, orbital dystopia, radiated orbit, and secondary deformities of traumatic orbit, the authors used lamella osteotomies of either orbital rim and wall or complex osteotomies in both adjacent orbital rims and walls with bicoronal incision and galea aponeurotica dissection. In most of the cases, the fragments of complex osteotomies were repositioned with rigid fixation.

RESULTS

Best results with nearly normal orbital volumes, better contour of orbit and midface, and improved eyelids and vision were achieved in 44 cases. There were 5 cases of supraorbital osteotomy (intracranial routine), 8 cases of medial orbital osteotomy, 3 cases of inferior orbital osteotomy, and 28 cases of both lateral and inferior orbital osteotomy in the series. No complications occurred. Clinical measurement was achieved in both pre- and postoperative osteotomies. According to comparative recordings, such as cephalometric measurement of the interorbital distance, exophthalmic measurement with Hertel exophthalmometer, the angle between orbital horizontal level and bilateral tragus linkage, and the linear distance between lateral canthus and tragus, the gap difference between pre- and postoperative data were achieved. The orbital and midface appearance has improved significantly.

CONCLUSIONS

Lamella and complex osteotomies of orbital rim and wall were proved to be save and effective for correction of most deformities of the orbital and periorbital region.

Choanal atresia and rare craniofacial clefts: report of three cases with a review of the literature

OBJECTIVE

This retrospective study reports three cases associating choanal atresia (CA) and rare craniofacial clefts (RCFCs) described in Tessier's classification. Although still discussed, these two malformations could derive from the same embryopathogenic context, with an anomaly of migration of the neural crest cells as a common factor. In two of the three cases presented, the RCFC was diagnosed during the neonatal period, and the third case (case 3) was diagnosed at the age of 12 years. The knowledge of this malformative association must permit the diagnosis of CA as early as the neonatal period or through the thorough and directed examination of the children as part of the follow-up.

Public domain computer-aided surgery (CAS) in orthodontic and maxillofacial surgery

BACKGROUND

Computer-aided virtual three-dimensional (3D) surgical simulation assists the necessary visual understanding of complex pathological situations but has so far been dependent on expensive hardware and software.

METHOD

For the first time a non-commercial, user-orientated application for orthognathic and craniofacial surgical simulation has been introduced, based on freeware NIH Image 1.62 provided by the National Institute of Mental Health (NIMH). Use and limitations are demonstrated here by the example of hypertelorism surgery. The osteotomy lines and the amount of resection for outward positioning of the orbits were determined by the surgeon on a workstation using CT data. Possible movement patterns of the osteotomy fragments were rotations, sagittal and transversal movements or combinations of these. The program then allows the calculation of anatomical distances on the screen in a 1:1 relation. Normative values according to age and pathological anatomy determine the degree of displacement. The program calculates the new position of the osteotomy fragments and transfers the data of the segment movement to the original CT data.

RESULTS

3D visualization of bone and soft tissue contours have been produced with an acceptable quality on a workstation for the demonstration and visual understanding of the surgical plan. Evaluation of a postoperative CT showed that the amount of movement and size of bone resection in the simulation was slightly overestimated rather than underestimated. This was also dependent on the complexity of the pathological anatomy and on how experienced the surgeon was.

CONCLUSION

The use of 3D simulation programs allows a better understanding of the pathological anatomy in all dimensions, and in many cases enables limitations to be recognized in advance. The public domain program makes a major contribution to the quality of orthognathic and craniofacial surgical planning through cost-free usability, and supports continuous development and exchange of experience.

Tacks: a new technique for craniofacial fixation

Biodegradable fixation in craniofacial surgery provides secure fixation while eliminating much of the concern over intracranial migration of metallic plates and screws. One limitation of present biodegradable systems, however, is the need for tapping the drill hole before screw insertion. Herein, a new method of rigid, biodegradable fixation with tacks (Macrapore, Inc., San Diego, CA) is described. The tacks are made of a 70:30 ratio of the L and DL form of polylactic acid (L,DL-PLA). Degradation times range from 18 to 36 months. Newer prototypes are nearly developed for more rapid dissolution times. From April 1999 to February 2000, tack fixation has been applied in 100 patients (51 males, 49 females aged 3 months to 61 years). Indications for operation were craniosynostosis (n = 33); craniofacial trauma or post-traumatic deformities (n = 11); cleft lip and palate (n = 13); craniofacial syndromes (n = 18); other diagnoses (n = 11). Patients underwent fronto-orbital advancement with cranial reshaping; monobloc osteotomy, open reduction-internal fixation of fractures; hypertelorbitism repair; cranioplasty; stabilization of grafts; major cranial reconstruction; zygomatic advancement; alveolar cleft repair; and iliac bone graft donor site protection. Tacks were also used for temporalis muscle and lateral canthal suspension. Follow-up ranged from 16 to 28 months. Complications occurred in 7 patients, 4 of whom had infections and during debridement had biodegradable implants removed. None of the complications appeared to be related to the use of tacks. The tacks are carried in a specially designed holder and may be placed by hand or with the light tap of a mallet on the tack driver. An automatic driver has been developed. Overall, the performance of the tacks has been excellent. They are easily handled by the nursing personnel and rapidly inserted by the surgeon. Stability appears to be excellent. At this time, it is probably preferable to employ tap and screws for orthognathic surgery or other osteotomies with substantial load bearing.

Craniofacial surgery for leaking encephalocele in a newborn baby

A newborn baby with a leaking frontoethmoidal encephalocele is reported. The 1-day-old baby was referred to our center with a swelling on the nose leaking CSF. The child was the third baby of a consanguinous marriage. The baby had a swelling over the nose, 8 cm in diameter. The center of the swelling looked unhealthy, with a small raw area seeping CSF. CT scan showed a swelling containing tissue isodense with normal brain. The bone window and the 3D CT revealed a basal bone defect in front of the crista galii and an outer bone defect at the frontonasal junction over the nasion. The baby was operated on the 5th day after birth. One-stage repair of the encephalocele was performed, along with correction of hypertelorism and bone grafting over the forehead. The baby withstood the surgery well and was discharged from the hospital on the 10th postoperative day.

Rare craniofacial anomaly: Tessier no. 2 cleft

Four cases of facial cleft that fit the anatomic description of the rare Tessier no. 2 cleft, with two patients having the no. 12 cleft extending to the cranium as no. 2 clefts, are presented. In all patients, clinical expressions of the anomaly were different. Thus, diverse surgical procedures were used in all cases. These cases and review of the literature help to define the soft-tissue and bony course of these clefts, and also emphasize the role of three-dimensional computed tomography scan imaging to show the bony cleft route. The diagnosis and treatment plan of the no. 2 cleft as well as its cranial counterpart are discussed in this report.

A new technique for the repair and reconstruction of frontoethmoidal encephalomeningoceles by medial orbital composite-unit translocation

A frontoethmoidal encephalomeningocele is a herniation of brain and meninges through a congenital bone defect in the skull at the junction of the frontal and ethmoidal bones. Between 1992 and 1999, we treated 145 cases of frontoethmoidal encephalomeningocele. Before 1993, the operation was performed in two stages. An intracranial repair by neurosurgeons preceded the external extirpation of the mass. In 70 cases that were operated on after 1993, a one-stage closure of the skull defect with a medial orbital composite-unit translocation technique was used. The medial orbital rim on each side, with intact periosteum, medial canthal ligament and lacrimal apparatus, was translocated as a unit to the midline. The advantages of this technique are that it allows convenient access to resect the herniation mass and close the defect, it restores normal interorbital and intercanthal distances and it eliminates the need for a transnasal medial canthopexy. Augmentation rhinoplasty can be avoided in most cases by tilting the composite unit with its preserved blood supply.

Surgical treatment of frontoethmoidal encephalocele: a case report

This study reports a patient affected by congenital frontoethmoidal encephalocele. The cause of this malformation is unknown. A preoperative selective diagnosis evaluation is necessary. The workup should include an accurate clinical examination associated with radiological study (two- and three-dimensional computed tomography, magnetic resonance imaging, etc). The aim of the surgical treatment is to restore the functional brain tissue in the cranial cavity, perform dural repair, correct bone lack and other associated facial malformations (hypertelorism, orbital dystopia, etc.). A multidisciplinary team approach is necessary to resolve the brain herniation and to correct splanchnocranium malformations frequently associated with encephalocele. Cranial flap with orbital osteotomies has been performed; this operation permits correction of the hypertelorism and of the orbital dystopia associated with this malformation. In bone reconstructions, miniplates have been used as fixation devices. In adults we generally use titanium, but resorbable devices are required in children because of growing tissues. A restoration of craniofacial malformations with good aesthetic and functional results is achieved with early surgery.

The use of hydroxyapatite cement in secondary craniofacial reconstruction

Sixty-one patients underwent secondary craniofacial reconstruction for contour defects using hydroxyapatite cement over a 3-year period (20-month mean follow-up). There were 56 children, aged 2.2 to 18 years (mean, 10.7 years), 21 boys and 35 girls. This is the first series of pediatric patients in whom the use of hydroxyapatite cement has been reported. There were five adults aged 21 to 46 years (mean, 32 years), 3 men and 2 women. Thirty-one patients underwent reconstruction for secondary orbitocranial defects after surgery for synostosis, 7 after surgery for hypertelorism, 10 for posttraumatic skull defects, and 13 for a variety of other facial skeletal defects. There were seven complications (11 percent), ranging from a retained drain to postoperative seromas, all of which required reoperation without loss of the contour correction. All of the complications occurred in the first 18 months of our study. There has been excellent retention of implant volume with no recurrence of contour defects to date. We have not found any visible evidence of interference with craniofacial growth over the study period. We conclude that hydroxyapatite cement is a versatile and safe biomaterial when used for the correction of secondary craniofacial contour defects in children and adults. The coupling of antibiotics with this biomaterial may have applications in the treatment of osteomyelitis.

Quantitative assessment of osseous, ocular, and periocular changes after hypertelorism surgery

The purpose of this study was to develop a methodology to quantify osseous, ocular, and periocular fat changes caused by correction of orbital hypertelorism to test the hypothesis that there is a quantitatively predictable relationship between the movement of the osseous orbit and that of the ocular globe. A retrospective review was performed of 10 patients who were status post unilateral or bilateral transcranial medial orbital translocation, for whom there were archival digital data for preoperative and postoperative (mean interval = 30 months) three-dimensional computed tomographic (CT) scans. In addition to standard demographic and surgical data, the clinical preoperative and postoperative interpupillary and intermedial canthal distances were recorded. By using a computer graphics workstation, the CT digital data were registered to four surgically unaltered anatomic fiducial points to allow longitudinal quantitative comparisons. The following three-dimensional measurements were made for each patient preoperatively and postoperatively: interdacryon and interocular centroid distances, and on a standard series of three horizontal and two vertical planes, the position of the medial and lateral orbital walls, and the thickness of the medial and lateral periorbital fat (20 orbits). CT digital distances were compared with similar clinical distances when possible. The age at operation ranged from 4.0 to 12.5 years (mean, 6.6 years). The reduction in interdacryon distance exceeded the reduction in intercentroid distance (mean interdacryon change = -5.3 mm versus mean intercentroid change = -2.7 mm). Although there was a strong correlation between the amount of reduction of the lateral orbital wall and intercentroid distances, there was only a moderate correlation between the reduction in the intercentroid distance and that of the medial orbital wall. Similarly, there was a moderate correlation between the decrease in thickness of the lateral periorbital fat and the reduction of intercentroid distance but not of the medial orbital fat. In conclusion, medial translocation of the orbit does not produce equivalent movement of the ocular globe; neither the intermedial canthal nor the interdacryon distance is a useful predictor of ocular centroid position; and if the goal of hypertelorism operation is reduction of interocular distance, then CT measurement of globe intercentroid distance is essential for outcome assessment.

Management of frontoethmoidal (sincipital) encephalocele

Frontoethmoidal encephaloceles are congenital malformations that cause complex deformities in the frontal, orbital, and nasal regions. As the term implies, with frontoethmoidal encephaloceles, intracranial material has herniated through the dural and skull defect. In this report, 21 patients with frontoethmoidal encephalocele operated by a craniofacial team are presented, and accompanying anomalies, results, and complications are discussed.

Orbital and globe rotation: the role of the periorbita

We hypothesize that excyclorotation of the globe and extraocular muscle cone associated with external orbital rotation around each orbital axis in craniofacial conditions could be at least partially corrected by leaving the anterior periorbita (periosteum lining the orbit) attached to the surgically rotated portion of the orbit. This hypothesis was tested by comparing the degree of rotation of the globe in response to internal rotation of the anterior orbit, leaving the periorbita attached to the rotated portion of the orbit on one (study) side, and stripping the periorbita on the opposite (control) side, in nine fresh cadavers. There was a highly significant difference (P < 0.0001) between the study and control sides. The possible extrapolations of this finding to the clinical situation are discussed.

[Syndromes 7. Hypertelorism (Greig syndrome)]

Hypertelorism is an increased distance between the orbits. Most evident symptom is the increased intercanthal distance. It can be caused by congenital deformities (facial clefts, encephaloceles, enlarged ethmoïds) and by trauma. Three degrees are differentiated. Grade one and two can be corrected with a small risk for complications. If there is vertical orbital dystopia it has to be corrected by a transcranial procedure, as is necessary in grade 3.

The value of stereolithographic models for preoperative diagnosis of craniofacial deformities and planning of surgical corrections

The purpose of this study was to assess the importance of stereolithographic models (SLMs) for preoperative diagnosis and planning in craniofacial surgery and to examine whether these models offer valuable additional information as compared to normal CT scans and 3D CT images. Craniofacial SLMs of 20 patients with craniomaxillofacial pathology were made. A helical volume CT scan of the anatomic area involved delivered the necessary data for their construction. These were built with an SLA 250 stereolithography apparatus (3D-Systems, Valencia, CA, USA), steered by FORM-IT/DCS software (University of Zurich, Switzerland). The stereolithography models were classified according to pathology, type of surgery and their relevance for surgical planning. Though not objectively measurable, it was beyond doubt that relevant additional information for the surgeon was obtained in cases of hypertelorism, severe asymmetries of the neuro- and viscerocranium, complex cranial synostoses and large skull defects. The value of these models as realistic "duplicates" of complex or rare dysmorphic craniofacial pathology for the purpose of creating a didactic collection should also be emphasized. The models proved to be less useful in cases of consolidated fractures of the periorbital and naso-ethmoidal complex, except where there was major dislocation.

[Results of surgical therapy of orbital abnormalities]

Dystopies of the bony orbit are caused mainly by craniosynostosis, facial clefts and encephaloceles. This article presents the results of the surgical correction of orbital hypertelorism in 24 patients. Using this operation technique, the bony interorbital distance was decreased from an average of 47.6 mm to 22.8 mm. However, the distance between the soft tissues was not reduced by the same amount as the distance between the bony orbits. The intercanthal distance decreased from an average of 58.5 mm to 44.5 mm, whereby an additional refixation of the medial palpebral ligament resulted in a reduction of the intercanthal distance to 40.8 mm. A strabismus divergens was seen preoperatively in 18 patients, postoperatively only in 8 patients. Four of the latter had to undergo operative correction of the diplopia. We conclude that the operative technique is not reserved only for complex cases of hypertelorism because it shows satisfactory functional and aesthetic results with a low complication rate.

[Median craniofacial clefts. Therapy recommendations and late outcome]

Median craniofacial clefts are classified as median facian cleft deformities and are characterized by clefts of the nose involving the skull base. They can be accompanied by hypertelorism and/or encephaloceles. From a total of 22 of our patients with median deformities, three encephaloceles and two severe median nasal clefts with hypertelorism were considered in 2- to-8-year-olds. Two children with severe brain deformities died before the commencement of therapy. The remaining median deformities were corrected as soon as possible, whereby exclusively soft-tissue surgery was performed during the first year of life and in no case later than school admittance. Final corrections on the nasal skeleton were made after the age of 12. No growth disturbances of the middle face or jaw occurred subsequent to craniotomies and corrections of hypertelorism. Plate osteosynthesis has proven to be the most reliable method of stabilization; we removed the osteosynthetic material in all cases. The multiplicity of possible deformities requires that procedures be tailored to the individual case.

[Bone substitute with growth factor. Preliminary clinical cases for cranio- and maxillo-facial indications]

Several biological materials have been analyzed in combination with osteo-inductive growths factors to determine whether such a system can replace bone grafting in surgical practice. Efforts have been aimed at the discovery of the best carriers and delivery systems. We present the results of the surgical treatment of 11 cranio-maxillo-facial defects in 9 patients using a combination of natural coral skeleton (NCS in blocks or granules), human fibrin glue and transforming growth factor beta-1 (TGF-beta 1) as a composite bone substitute. Three patients were initially excluded because of early extrusion of the materials due to a technical error. Clinical and radiological evaluation was performed in all cases, with the patient acting as his own control. Clinical firmness and radiological mineralization occurred in three quarters of cases. New bone formation was confirmed histologically in two of these patients. Clinically the initial results remained stable over a three years follow-up with staged surgical procedures performed on a number of patients. None of the patients suffered any detrimental effect from implantation of the bone substitute. Although the numbers in these series are limited, the association of TGF-beta 1, human fibrin glue and NCS represented an interesting step, although the clinical results could be improved. Important factors in the success of this technique appeared to be stabilisation of the biological materials, quality and asepsis of the surrounding tissue and the dose of growth factor.

A simple procedure for aesthetic correction of the medial epicanthal fold

The author presents a surgical procedure for aesthetic correction of the medial epicanthal fold. The procedure consists of an asymmetrical Z-plasty of the epicanthal fold where a flap is formed from the posterior surface of the epicanthal fold itself. This procedure does not require geometric planning and produces excellent anatomical and functional results, with inconspicuous scars.

A delayed complication with steel wire osteosynthesis

We treated a 6-year-old child for hyperteleorbitism. We performed a facial bipartition steel wire osteosynthesis of the frontal bone. After 7 years we observed two episodes of pneumococcal meningitis, which were treated with intravenous antibiotic, resulting in a prompt recovery. The computed tomographic scan and nuclear magnetic resonance image showed the steel wire included in the frontal sinus and in contact with the dura mater. Removal of the wire and suture of the dura allowed prompt recovery.

Titanium mesh and bone dust calvarial patch during cranioplasty

A technique of filling calvarial defects using bone dust reinforced with titanium Micro Mesh (Leibinger) was investigated using plain x-ray films and computed tomography (CT) in seven consecutive patients (age range, 7-21 years). The aim of our study was to assess whether, in the presence of the titanium, bone dust harvested with a power burr promotes persistent ossification that is comparable with adjacent bone. The mesh was localized by standard skull plain x-ray films, and orthogonal CT scans were obtained at between 9 and 18 months post-operatively. An ultrahigh-resolution algorithm was used to detect neoossification on either side of the Micro Mesh (1-mm collimation, 330-mA and 120 KV(p) at the center of 400 HU, and window width of 2000 Hu). The mesh induced minimal streak artifact. Virtually no new bone formation was seen. It appears that bone dust was completely reabsorbed in this patient group even in the presence of semi-rigid fixation.

Surgical planning and correction of medial craniofacial cleft

In the framework of malformations that concerns the craniofacial area, the orbit is often involved because it represents the border structure between the neurocranium and the splanchnocranium. In these malformations it is very easy to find hypertelorism. Tessier classified clefts rising from the anterior skullbase and involving the maxilla and the alveolar process, as medial or 0 = 14 clefts. We report on a 2-year-old patient, treated with cranial decompression at an early age, suffering from this kind of malformation. To correct it, the surgical technique of facial bipartition was used. This technique, used for the first time by Tessier and then modified by Stricker and colleagues, allows the simultaneous correction of the orbits and maxilla. It is very important to make a correct diagnosis, to plan for surgery carefully for patients suffering from this kind of pathology, and to prescribe the most effective therapy. A computerized analysis system, based on the study of teleradiographic images and on three-dimensional computed tomography, to quantify the extent of the malformation and to define surgical planning was developed.

Craniofrontonasal dysplasia

A series of 10 patients with craniofrontonasal dysplasia presenting to the Oxford Craniofacial Unit since 1983 is presented. In addition to the well-described combination of coronal synostosis and frontonasal dysplasia, 9 patients had very characteristic dry, curly or frizzy hair. All the patients were female. Recognition of the syndrome is important for genetic counselling, although the precise mode of genetic transmission is unclear with females predominating and males being less severely affected. Surgical correction was in two stages: early frontal advancement followed by correction of hypertelorism when the child became aware of the deformity. Four patients had their craniosynostosis treated in the Oxford Craniofacial Unit. Three patients had previously had frontal remodelling elsewhere. Nine patients had surgery for hypertelorism. The preferred technique for hypertelorism correction was facial bipartition. Following hypertelorism correction, the excess skin was allowed to redrape and subsequently dealt with by medial canthoplasties, thus avoiding a midline scar. Careful attention to the primary frontal advancement procedure is important to avoid complications following difficult dissection of the frontal bone flap at the time of hypertelorism correction.

Late results of hypertelorism correction

The late results of patients who were operated on for the correction of hypertelorism were evaluated. Follow-up ranged between 1 and 11 years (mean, 4.3 years). The mean interorbital distance was 32.9 mm preoperatively and 26.7 mm postoperatively. The significant decrease in the interorbital distance and the absence of serious postoperative complications revealed that craniofacial surgery for the correction of hypertelorism was an effective and reliable procedure.

Early and late surgical treatment of orbital dystopia in craniofacial malformation

Orbital dystopia is one of the most frequent clinical signs of craniofacial malformation. The term dystopia indicates the mono- and bilateral asymmetry of the orbits at least in one of the three-dimensional planes. The diagnosis is based on the clinical test of the patient with the support of diagnostic instruments such as teleradiography in both standard projections, axial computed tomographic (CT) scans at a rate of 1:1 through the neuro-orbital plan, and the three-dimensional CT. Good results of the surgical treatment depend on the patient's age and on adequate programming, which should consider the anomalies in the three spatial planes. The VTO is obtained through a protocol of analysis on cephalometric graphics of the teleradiographics on the CT at a rate of 1:1. The surgical treatment of orbital dystopia is different depending on the age of the patient and the cause of the orbital anomaly. In the case of growing patients, it is preferable to use the fronto-orbital bandeau technique so as not to damage the dental buds, whereas in grown patients Tessier's orbital quadrant technique is used. Even the fixation is quite different between patients who are growing and those who are already grown. In still-growing patients, rigid internal fixation is used only in some cases to avoid the interference with the growth mechanisms.

Maxillary growth in children after early facial bipartition

Facial osteotomies performed in young children are frequently associated with growth deficiencies, especially at the middle third of the face. This problem may be more severe when the initial deformity is associated with alveolar and palatal clefts. Orbital hypertelorism is a major congenital malformation requiring early correction. The resection of the ethmoid tissues located between the orbit and the medialization of the orbital skeleton through the intracranial approach modifies the exaggerated interorbital distance but does not correct the vertical shortness at the midline of the face. Also this procedure interferes with the sagittal growth of the maxilla possibly resulting from the horizontal osteotomy across the maxillae. The medial rotation of the two halves of the face performed by the intracranial approach or the subcranial approach simultaneously corrects the orbital hypertelorism and elongates the nose and the central segment of the face. Our experience with this procedure in infants and young children is analyzed. A series of nine patients with orbital hypertelorism associated with median and paramedian clefts underwent correction by hemifacial rotation. All patients were monitored from 6 to 10 years (mean, 7 years) and demonstrated normal sagittal growth of the maxillae.

Monobloc and facial bipartition osteotomies for reconstruction of craniofacial malformations: a study of extradural dead space and morbidity

This study evaluated the presence of extradural dead space following a monobloc or facial bipartition osteotomy and examined its natural history and relationship to postoperative infection and the presence of a ventriculoperitoneal shunt at the time of osteotomy in a consecutive series of patients with craniofacial dysostosis, frontonasal dysplasia, midline cranio-orbital clefts, and orbital hypertelorism. Only patients followed for at least 1 year were included in the study (range 1.3 to 5.5 years). The 23 patients studied were divided into three groups: 10 patients (mean age 9 years) underwent a monobloc osteotomy with advancement, 7 (mean age 8 years) a facial bipartition osteotomy with advancement, and 6 (mean age 7 years) a facial bipartition osteotomy without advancement. Standard craniofacial computed tomographic (CT) scans were obtained for each patient early after surgery (within 2 weeks in 13 patients and at 6 to 8 weeks in 10 patients) and again 1 year after surgery in every case. The extradural dead space was measured from a reproducible axial CT scan slice for each patient at each postoperative interval. An initial dead space was documented in the retrofrontal region of the anterior cranial fossa when the reconstruction incorporated forward projection of the osteotomy parts. This space was found to be obliterated by the expanded brain by 6 to 8 weeks in the patients examined by CT scan slice for each patient at each postoperative in all patients. Perioperative complications also were documented. The presence of a ventriculoperitoneal shunt at the time of osteotomy (7 of 23 patients) did not increase the risk of complications or alter the pattern of dead space closure after operation. Two patients developed infectious complications that were managed without long-term consequences.

Study and planning of the surgical procedure for the orbital district in patients affected by craniofacial malformations

Orbital surgery is of critical importance within the framework of craniofacial surgery. The conical conformation of orbits requires analysis and surgical procedure planning methods involving all three dimensions. We present our protocol for the analysis and our three-dimensional surgical procedure plan to treat orbital malformations using teleradiography and two- and three-dimensional computed tomographic imaging. A number of clinical cases treated according to this approach are also presented.

"Piggyback" osteotomies in craniomaxillofacial surgery

The total correction of severe skeletal dysplasias in patients with craniofacial anomalies can often be limited by the use of standard osteotomy designs. In this report, we emphasize the concept of the "piggyback" osteotomy for the correction of severe skeletal dysplasias. The piggyback approach, which uses the tiering or stacking of one osteotomy segment on another, allows the reconstructive surgical team to address multiple skeletal problems in one operative setting adequately. The use of this approach throughout the entire craniomaxillofacial skeleton is illustrated with several clinical examples. The conceptual importance of the piggyback principal and the rationale behind its application are discussed.

Internal brain herniation in a patient with Apert's syndrome

Patients with Apert's syndrome typically exhibit craniosynostosis, exorbitism, midface hypoplasia, and symmetric syndactyly. There have also been occasional descriptions of the variable dysmorphology of the inner surface of the calvarium. We present a patient with Apert's syndrome who had an intracranial herniation of a portion of the frontal lobe through a ridge of ossified dura. The ridge and the gliotic cortical tissue were removed when the patient underwent repair of the hypertelorism at age six. Bone grafts for this repair were fashioned in part from the resected ridge. We believe this finding may be the result of a small dural tear that occurred during prior surgery.

Monobloc and facial bipartition osteotomies: quantitative assessment of presenting deformity and surgical results based on computed tomography scans

PURPOSE

The results of monobloc (MB) or facial bipartition (FB) osteotomies on 23 consecutive patients operated on between 1987 and 1991 were evaluated.

PATIENTS AND METHODS

A previously described method of clinically relevant linear measurements taken from preoperative and postoperative computed tomographic scans of these patients was used to document their presenting dysmorphology and the results of surgical correction initially and 1 year after operation. These data were compared with control values, and a percentage of normal for each measurement was derived for each patient.

RESULTS

In the patients with craniofacial dysostosis undergoing an MB osteotomy, the initial cranial vault length (87% of normal), medial orbital wall length (87%), zygomatic arch length (84%), and extent of globe protrusion (134%) all indicated horizontal (anterior-posterior) deficiency of the upper and middle face. After surgery, these measurements moved closer to age-matched control values. At the 1-year interval a minor degree of relapse was evident. In the patients with craniofacial dysostosis who were believed to need an FB osteotomy, the globe protrusion (142% of normal), medial orbital wall length (85%), and zygomatic arch lengths (83%) all indicated horizontal (anterior-posterior) deficiency in the upper and middle face. In addition, the anterior interorbital distance (123% of normal), mid-interorbital distance (122%), and intertemporal distance (126%) all indicated upper face hypertelorism. As a result of the FB osteotomy, anterior bony projection was achieved, and the hypertelorism was improved, but fell short of age-matched normal values. In the patients with frontonasal dysplasia, cranio-orbital clefting, and isolated orbital hypertelorism who underwent an FB osteotomy, preoperative measurements showed a distinct widening of the whole upper midface with forward projection of the medial relative to the lateral orbital walls. The orbital measurements revealed a substantially widened anterior interorbital distance (175% of normal), increased mid-interorbital distance (123%), and an increased distance between the lateral orbital walls (106%). After the surgical procedure, these measurements were improved and relatively stable but not completely normalized.

CONCLUSION

The use of quantitative measurements in the initial evaluation, intraoperative skeletal reshaping, and assessment of early and late reconstructive results provides useful benchmarks.

Neurosurgical considerations on the anatomy of the medial canthus in children

Craniofacial surgery and anterior skull base surgical techniques require an intimate knowledge of periorbital structures. The medial orbital anatomy is especially important for midline approaches to nasion encephalocele, midline trauma, surgery for hypertelorism as well as midline approaches to anterior skull base lesions. The medial canthal tendon is of primary importance in anchoring the eyelid medially in a cosmetic and functional fashion. This review will summarize the anatomic features of the medial canthus and its surrounding structures, including vascular and muscular components. The intimate relationship of the three components of the medial canthal tendon to the nasal lacrimal apparatus is emphasized. Techniques to prevent injury as well as to repair abnormalities in this area will be discussed.