Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 1 • A. Sagittal craniosynostosis. The
anatomic anterior incision (Ant) is designed dorsal to
the anterior fontanelle, and the dorsal incision (Dor) is
designed anterior to the posterior fontanelle. B. The
incision for metopic craniosynostosis is designed
dorsal to the hairline (H) and anterior to the fontanelle
(F). C. The incision placement for coronal
craniosynostosis is perpendicular to the affected
suture and lateral to the anterior fontanelle. If
visualization of the suture is difficult, a second smaller
incision may be made caudally to facilitate
visualization and suturectomy. D,E. The incision for
lambdoid synostosis is made perpendicular to the
suture with the cephalically oriented incision (1)
placed just caudal to the posterior fontanelle. The
second smaller incision (2) may also be made to
confirm the complete removal of the suture.

■ Craniectomy
■ Regardless of the affected suture, the procedure for craniectomy is similar.
■ Handheld Senn retractors are used to expose the underlying calvarium.
■ A high-speed pneumatic drill with attachment is used to perform a small
craniotomy (TECH FIG 2A).
■ Avoid penetrating the dura covering the brain. The dura is stripped from the
overlying calvarium and a Kerison punch forceps is used to complete a
troughlike craniectomy by avoiding damage to the underlying venous sinuses
that may be present along the surgical path (TECH FIG 2B).
■ The width of the craniectomy will encompass the synostosis.
■ A similar trough is made under the second incision (if indicated) to serve as
the destination for completion of the endoscopic dissection.
■ With the surrounding dura stripped from the overlying calvarium, a handheld
suction catheter is placed through the incision, followed by an endoscope.
■ The endoscope is surrounded by an irrigating sheath to promote
visualization.
■ Under direct visualization, the suction and endoscope are advanced to
slowly peel the dura from the overlying calvarium (TECH FIG 2C).
■ At this point, the craniosynostosis can be viewed and confirmed.
■ Suction-monopolar cauterization is used to isolate and coagulate vessels
that may connect the dura to the calvarium.
■ The dissection is continued to the second craniectomy trough (when used).
■ Lateral dissection of the dura from the calvarium is confirmed under direct
visualization to ensure adequate space for insertion of instruments.
■ Bone-cutting scissors are introduced under direct visualization with a lit
retractor (TECH FIG 2D).
■ Cuts are made on both sides parallel to the affected suture and carried from
trough to trough.
■ The bone can then be removed with forceps or may require further cutting
to remove through a small incision.
■ When a single incision is used (coronal, lambdoidal, metopic), a Kerrison
punch or Takahashi bone-cutting forceps are used to ensure the complete
removal of the affected suture.
■ After bone removal, an endoscopic retractor is introduced to protect the dura
and provide visualization of the bone edges.

■ Using suction-monopolar cauterization, the bone edges are cauterized
(TECH FIG 2E). Thermal injury to the dura must be avoided.
■ After confirmation that bleeding is controlled, the area is reinspected and
irrigated.

TECH FIG 2 • A. A craniotomy is developed to permit
separation of the dura from the calvarium. B. The
initial craniotomy is expanded to permit dural
dissection and insertion of instruments. C. An
endoscope with an irrigating sheath is inserted,
followed by a suction dissector, to separate the dura
from the overlying calvarium. D. Bone-cutting scissors
are inserted under direct visualization and the fused
suture is removed. E. The endoscopic retractor is
inserted to allow visualization of the bone edges. A
suction-monopolar cautery is introduced and used to
obtain hemostasis.
■ Closure
■ After hemostasis is achieved, the skin is closed in layers with simple, buried
dissolvable sutures (4-0 Vicryl).
■ A superficial, running, dissolvable suture is then used to coapt the skin edges
(4-0 Rapide).
■ Our practice is to apply a thin layer of Dermabond to the incision followed
by another occlusive dressing (Tegaderm).

PEARLS AND PITFALLS
Physical
findings
■ Physical examination is generally reliable for diagnosis, but a CT
scan is recommended to document the affected suture.3
Technique
■ Incisions are concealed within and behind the hairline. This is of
particular importance for patients with metopic craniosynostosis. If
the hairline is difficult to visualize, loupe magnification is
indicated to avoid placement of the incision on the forehead.
■ The incision should be as small as possible to ensure an excellent
cosmetic outcome.
■ Stripping the dura from the overlying calvarium should be done
cautiously to avoid bleeding from an underlying venous sinus.
■ Thermal injury to the dura should be avoided to prevent
cerebrospinal fluid leak. All CSF leaks must be repaired
immediately.
Postoperative
■ Helmet therapy is initiated after surgery, typically within 1 wk.
■ The infant is seen every 3 mo to check helmet fit and head shape
improvement.
■ Helmet therapy is generally discontinued 1 y from the time of
surgery.
■ Frequent communication between patients, surgeons, and
helmeting personnel should take place to ensure proper helmet fit
and function.
■ Helmet care should be encouraged including frequent washing
protocols to maintain a clean environment for the healing
incisions.
■ Helmets should be worn according to an established schedule to
avoid starting and stopping helmet therapy. Re-establishing helmet
wear after prolonged periods of disuse can be difficult for children
to tolerate.
POSTOPERATIVE CARE
■ Incision care is initiated after the occlusive dressing is removed on
postoperative day 2.
■ Care includes gently washing the incision with warm water and soap.
■ Skin glue and dissolvable sutures are not removed.
■ Molding helmet therapy is initiated within 1 week of the operation.

■ The child is seen in clinic postoperatively at 2 weeks, followed by 3-month
intervals until 1 year has elapsed from the time of surgery.
■ Head shape correction is monitored via laser scans when the patient presents
for helmet adjustments to the orthotic provider.
■ Molding helmet therapy is discontinued 1 year from the time of surgery.
OUTCOMES
■ Outcomes from minimally invasive endoscopic-assisted suturectomy are
excellent.
■ This approach results in decreased operative time, blood loss, length of
hospital stay, and the use of extensive and costly hospital resources.
■ Less than 10% of patients require a blood transfusion, and this figure can be
considerably lower with surgical experience and careful postoperative
monitoring.2
■ Frequently a child may avoid admission to an intensive postsurgical unit. This
can be facilitated if appropriate protocols are in place for checking blood
volume status postoperatively.
COMPLICATIONS
■ Widened scar formation due to hair follicle injury caused by rough tissue
handling and thermal injury from electrocautery
■ Inadvertent incision placement on the forehead
■ Incomplete resection of the fused suture
■ Need for secondary surgery to increase intracranial volume or improve
cosmesis
■ Bleeding, infection, and CSF leakage
■ Helmet-related complications: poor compliance, pressure ulcer formation, and
alopecia
REFERENCES
1. Jimenez DF, Barone CM. Early treatment of anterior calvarial
craniosynostosis using endoscopic-assisted minimally invasive techniques.
Childs Nerv Syst. 2007;23:1411-1419.
2. Vogel TW, Patel AW, Kane K, et al. A comparison of costs associated with
endoscope-assisted strip craniectomy and open cranial repair for infants with
sagittal synostosis. J Neurosurg. 2014;13:324-331.
3. Fearon JA, Singh DJ, Beals SP, Yu JC. The diagnosis and treatment of single-

sutural synostoses: are computed tomographic scans necessary? Plast Reconstr
Surg. 2007;120:1327-1331.
4. Fearon JA. Evidence-based medicine: craniosynostosis. Plast Reconstr Surg.
2014;133(5):1261-1275.

16
CHAPTER
Section II: Orbital
Dystopias
Box and U-Shaped
Osteotomies
Sunil Tholpady, Robert J. Havlik, and Barry E. Eppley
DEFINITION
■ Orbital dystopia is used to describe a vertical or horizontal displacement of the
entire orbit and its contents.
■ The most common dystopia encountered is orbital hypertelorism.
ANATOMY
■ Hypertelorism is an abnormal interorbital distance and should not be confused
with telecanthus, which is lateral displacement of the medial canthi without
normal bony architecture (FIG 1).

FIG 1 • Differences between telecanthus and
hypertelorism.

■ Ethmoid sinuses are often overexpanded with excess medial soft and hard
tissue.
■ Severe hypertelorism can be associated with inferior displacement of the
cribriform plate.
■ The interorbital distance (dacryon to dacryon) is used to diagnose and classify
hypertelorism. (The intercanthal distance is 4 to 6 mm greater than the
interorbital distance due to soft tissue.)
■ Normal is 25 mm in women and 28 mm in men.
■ First degree: 30 to 34 mm
■ Second degree: 34 to 40 mm
■ Third degree: greater than 40 mm1
PATHOGENESIS
■ Orbital dystopias are a heterogeneous group of disorders that usually arise as a
consequence of congenital or traumatic conditions:
■ Craniofrontonasal dysplasia
■ Apert or Crouzon syndrome
■ Encephaloceles or craniofacial clefts
■ Frontal sinus mucocele
■ Neurofibromatosis
■ Fibrous dysplasia
■ Craniofacial trauma
■ Orbital positioning will at best be maintained and may worsen with time and
growth.
■ Traumatic dystopias can occur at any age.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Symmetric hypertelorism with wide set brows
■ Vertical malposition of the orbit
■ Epicanthal folds
■ Wide nasal dorsum
■ Amblyopia or strabismus
■ Inferolaterally positioned zygomas
■ High-arched palate
IMAGING
■ Neurosurgical consultation is appropriate for intracranial exposure.

■ Ophthalmologic consultation for amblyopia, strabismus, or extraocular
dysfunction and postoperative visual changes
■ Three-dimensional computed tomographic reconstruction of the face and skull
is necessary.
■ Three-dimensional printed models may be useful for visualizing and teaching
surgery.
SURGICAL MANAGEMENT
■ Most surgical corrections of hypertelorism in the pediatric population are
performed between the ages of 4 and 8.
■ Psychosocially, this is a period of development during early school years.
■ The cranium has had a period of explosive growth, and the interzygomatic
distance is nearly adult-sized by age 6.
■ The sinuses have not yet pneumatized.
■ Most stable results are obtained in adults, and there may be a need for
revision when the procedure is performed in the pediatric population.
■ There are no absolute contraindications, but patients with a high-arched palate,
narrowed midface, inferolaterally displaced orbits, or very severe cases may
benefit from a facial bipartition procedure to correct these concerns.
■ Box osteotomies can be used to correct both horizontal and vertical dystopias.
An intracranial approach is preferable with significant (greater than 40 mm
deformity), as this provides access to the central ethmoidosphenoidal area.
Orbits are sectioned in a 360-degree fashion (FIG 2A).2
■ U-shaped osteotomies may be used when the interorbital distance is less than
40 mm and a smaller movement performed in a completely subcranial fashion
is desired. Orbits are sectioned in a 180-degree fashion (FIG 2B).2,3
Preoperative Planning
■ Medical models of the skull abnormalities enable preoperative knowledge of
osteotomy positions and predicted movements (FIG 3).

FIG 2 • Medical modeling with proposed osteotomies
and final result. A. Demonstrates box osteotomies and
(B) demonstrates U-shaped osteotomies.

FIG 3 • Proposed cuts for a box osteotomy (A) or a U-
shaped osteotomy (B).
Positioning
■ The patient is placed in the supine position on a Mayfield headrest.
■ An oral RAE tube is ligated to the lower central incisors with 26-gauge steel
wire.
■ Corneal protectors are placed with ophthalmic ointment, and the lids are
sutured together with a single stitch.
■ Afrin-soaked pledgets are placed in the nose.
T E C H N I Q U E S
■ Exposure
■ A standard coronal approach is used to raise the scalp in the subperiosteal
plane.
■ The shape of the incision and choice of hemostasis (cautery, Raney clips) are
entirely dependent on surgeon preference.
■ At the superior orbital level, the supraorbital nerves are spared as they exit
their foramina. The periorbital tissue is released circumferentially, including
the lateral third of the floor.

■ Dissection proceeds above the deep temporal fascia. When the zygomatic
arch is palpated, incision is placed on the bone. Any attachment of temporalis
to the lateral orbital wall is released.
TECH FIG 1 • A,B. Incisions and exposure.
■ The nasal dorsum and medial orbital wall are meticulously exposed,
maintaining the medial canthal attachments to bone.
■ A maxillary vestibular incision is performed from first molar to first molar.
Subperiosteal dissection exposes the bony nasal aperture, the bilateral
zygoma, and the remainder of the orbital floor.
■ Neurosurgical assistance with the frontal bone flap reveals the orbital roof,
sphenoid, and cribriform plate (TECH FIG 1).
■ Osteotomies

■ Superior orbital osteotomies are not performed for U-shaped osteotomies but
are performed for box osteotomies.2,3
■ Malleable retractors are used to protect the brain and orbital contents.
■ Orbital cuts should be made posterior to the equator of the orbit to capture
the functional orbital volume.
■ Superiorly, a reciprocating saw is used to create osteotomies in the superior
orbit extending laterally to the posterior portion of the lateral third of the
orbital floor, as well as the zygoma (TECH FIG 2A,B).
■ Medial orbital osteotomies are performed with a 3-mm osteotome to
complete the posterior orbital cut.
■ The maxilla is osteotomized with a reciprocating saw to connect the piriform
aperture to the zygomatic eminence. This is performed through an upper
gingivobuccal sulcus or eyelid incision.
■ A rectangular piece of bone is removed from the nasal bones extending
posteriorly to the crista galli (TECH FIG 2C).
■ A septal osteotomy anterior to the cribriform plate will be necessary if this
is considered.
■ Alternatively, a central portion of the nasal bones may be left with bilateral
paramedian excisions of the nasal bone and posterior tissue.
■ Ethmoid sinuses are exenterated to assist with translocation.
■ Bone is stored for later bone grafting at the lateral orbital rims.

- Malleable retractors expose crista gala and protect brain The supraorbital and the upper third of the medial orbit osteotomies are performed transcranially Cribiform plate Crista gala V-shaped ostectomy is performed in the midline anterior to crista gala The lateral orbital wall, lateral third of orbit floor, and zygoma are cut with reciprocating saw V-shaped midline osteotomy includes frontal bone, ethmoids, midline nasal dorsum, and superior part of bony septum Cribiform plate remains intact

TECH FIG 2 • Cranial (A), orbital (B), and facial (C)
osteotomies.
■ Translocation
■ Smith spreaders are used to gently walk the lateral orbital rim medially.
■ Finger pressure is sufficient to translocate orbits to the midline.
■ A 24-gauge wire is used to ligate orbits temporarily into the correct position.
■ Bony distance at the medial wall is 17 or 18 mm. Because of soft tissue
mechanics, more bony reduction may be necessary in severe hypertelorism.
■ Fixation
■ Rigid fixation is necessary with titanium plates at the midline, zygoma, and
maxilla. Absorbable plates and screws can be considered in the growing
patient.
■ Exposed sinus structures are obliterated and cranialized.
■ An inferiorly based pericranial flap can be elevated from the scalp flap to
separate the brain from these structures, but there should be bony continuity
between the cranial bases after translocation.

TECH FIG 3 • Mobilization (A) and fixation (B).
■ Bone removed from the dorsum is placed laterally to augment the lateral
orbital and zygoma bone movements (TECH FIG 3).
■ Canthal and Nasal Reconstruction
■ The 24-gauge wire temporarily placed is now removed.
■ If the canthal tendons are attached to mobilized bone segments and the soft
tissue repositioning is sufficient, no further treatment may be necessary.
■ If the tendons have been stripped or there is telecanthus, transnasal wiring
can be used to reposition medial canthal tendons.
■ Nasal dorsal tissues can be plicated to enhance projection. A cranial bone
graft can also be used to enhance nasal projection as a cantilevered bone
graft.
■ If nasal projection is insufficient and a bone graft will be placed at a later
time, nasal soft tissue should not be excised to allow for a larger envelope

to later accommodate the cantilevered bone graft.
■ Closure
■ All cranial tissues are copiously irrigated with half-strength peroxide, saline,
and saline containing bacitracin.
■ A drain can be placed to minimize swelling.
■ Nasal soft tissue can be debulked from the inner scalp flap and
reapproximated internally to avoid an external scar.
■ Hypertelorism of greater distances may require external skin removal,
preferably at the junction of the dorsum and sidewall subunits.
■ Scalp is closed in two layers.
■ Maxillary incision is closed last with a single layer of suture.
PEARLS AND PITFALLS
Orbital floor
osteotomies
■ Osteotomies across the orbital floor should be made 8–10 mm
from the sphenoid ridge to obtain translocation of the functional
orbit. Too anteriorly placed osteotomies will not allow adequate
translocation.
Approximation
of orbits
■ Ethmoidal cell exenteration is essential to reapproximate orbits.
Resection of a portion of the middle turbinates may also help with
translocation.
Preservation
of cribiform
■ Olfaction is preserved with preserved continuity of the cribriform
plate with the septum.
Medial canthal
splinting
■ Care should be taken with postoperative splinting as pressure
necrosis at the medial canthus can occur with vigorous splinting
at the medial canthus.
Post-operative
forced duction
test
■ Postoperative strabismus is common, but a forced duction test
should be performed after mobilization to verify that the medial
rectus muscles are not being impinged upon by the bony step-off
from the posterior orbital osteotomy.
POSTOPERATIVE CARE

■ ICU monitoring for one night postoperatively to monitor for increase in
intracranial or intraorbital pressure due to bleeding
■ Use of a drain can increase pressures and periorbital swelling that makes eye
examination difficult.
■ Postoperative steroids and head-of-bed elevation can alleviate swelling.
■ IV antibiotics with coverage of staphylococcal and oral flora are preferred for
24 to 48 hours with continuation of oral antibiotics for 10 days.
■ External nasal splinting can assist with molding soft tissue of the nose.
■ Vasoconstrictor and steroid nasal sprays can alleviate bleeding and nasal
congestion for 1 to 2 weeks.
OUTCOMES
■ Usually good correction is possible (FIG 4).
■ The closer the procedure is performed to skeletal maturity, the more stable the
outcome is.
COMPLICATIONS
■ Infection: May require a return to the OR for drainage. Usually presents as
unilateral swelling and pain 2 to 3 weeks after surgery.
■ Hematoma: Increased brain or eye pressure necessitates return to the OR and
can be identified with serial neurologic and ophthalmologic examinations.
Postoperative CT scan can also serve as a basis for comparison in case of
change in neurologic status after surgery.
■ CSF rhinorrhea: Uncommon but may require a short-term lumbar drain

FIG 4 • Before and after photos of a patient who
underwent box osteotomies for hypertelorism.
■ Visual disturbances: Diplopia is not uncommon and usually resolves
spontaneously. Ophthalmologic evaluation before and after surgery is
necessary to identify extraocular muscle dysfunction.
■ Anosmia: Very uncommon and without treatment options; it is a preoperative
risk of which the patient should be informed.
REFERENCES
1. Converse JM, et al. Ocular hypertelorism and pseudohypertelorism: advances
in surgical treatment. Plast Reconstr Surg. 1970;45:1-13.
2. Converse JM, Wood-Smith D. Craniofacial surgery for ocular hypertelorism
and craniofacial stenosis. Trans Am Acad Ophthalmol Otolaryngol.
1973;77:1352-1367.
3. Tessier P. Orbital hypertelorism. I. Successive surgical attempts. Scand J Plast
Reconstr Surg. 1972;6:135-155.

17
CHAPTERFacial Bipartition
Jessica Ching and Christopher R. Forrest
DEFINITION
■ Orbital hypertelorism, or hypertelorbitism, is increased distance between the
bony orbits and represents true lateralization of the orbits (FIG 1).
■ Interorbital hypertelorism is defined as increased distance between the medial
orbital walls.
■ Telecanthus is an increased distance between the medial canthi with a normal
interorbital distance and associated with a normal interpupillary distance.
■ The severity of hypertelorism may be interpreted according to patient age.
■ The presence of an epicanthal fold can give the illusion of hypertelorism and
may be termed pseudohypertelorism.
■ Hypertelorism is a clinical finding, not a diagnosis, and is etiologically
heterogeneous.
■ It may be surgically corrected through facial bipartition, 360-degree box
orbital osteotomy, segmental orbital osteotomy, or a camouflage rhinoplasty.
■ Facial bipartition is a complex craniofacial osteotomy developed by Paul
Tessier after first being described by van der Meulen.1,2 This technique
separates the frontal-orbital-zygomatic-maxillary complex from the skull base
and removes a segment of bone between the medial nasal-orbital region and
splits the palate down the middle—mobilization allows for a medialization and
rotation of the orbits with lateralization and expansion of the maxillary arch
and lengthening of the midface.
■ It is traditionally performed for less severe cases of hypertelorism.

FIG 1 • A–C. CT scan examples of patients who would
benefit from facial bipartition.
■ Facial bipartition may be performed in conjunction with a frontofacial
monobloc advancement procedure.
■ Facial bipartition can be performed in the young patient, whereas 360-degree
box orbital osteotomies are usually performed in older children when the
maxillary sinuses have developed, tooth buds descended and orbits have near-
completed growth around age 7 years.
ANATOMY
■ The degrees of hypertelorism may be measured using soft tissue and bony
landmarks.
■ The dacryon is the most medial portion of the bony orbit, lying at the
intersection of the frontal, lacrimal, and maxillary bones. This is the most
common landmark for measuring interorbital distance (IOD).
■ Important bony landmarks are used to measure the inner canthal distance
(ICD) between the two medial canthi measured at the level of the posterior
lacrimal crest and the outer canthal distance (OCD) measured between the two
lateral canthi.
■ The interpupillary distance (IPD) between the two midpupillary regions in
front gaze is a useful measure, but taken by itself, increased IPD may not be
indicative of hypertelorism. It may be seen in post-traumatic cases or in cases
of exophoria due to extraocular muscle imbalance.
■ ICD, OCD, and IPD are always increased in cases of true hypertelorism (FIG
2).

■ Hypertelorism exhibits an increased IOD due to intervening excess bone and
soft tissue.
FIG 2 • Graphic representation of orbital measurements
in the normal orbit, telecanthus, and orbital
hypertelorism. ICD, inner canthal distance; OCD, outer
canthal distance; IPD, interpupillary distance; PFL,

palpebral fissure length. (Redrawn from Sharma RK.
Hypertelorism. Indian J Plast Surg. 2014;47(3):284-
292.)
■ IPD will be increased, and orbital aperture dimensions (height and width) are
usually normal.
■ For children, the average interorbital distance increases with age3:
• 1 year old: 18.5 mm
• 2 years old: 20.5 mm
• 3 years old: 21 mm
• 5 years old: 22 mm
• 7 years old: 23 ± 4 mm
• 10 years old: 25 ± 2 mm
• 12 years old: 26 ± 1 mm
■ For adults, average interorbital distance is 25 mm in women and 28 mm in
men.3
■ Degree or severity of hypertelorism is graded in children and adults by the
amount of deviation from the average interorbital distance (Table 1).
PATHOGENESIS
■ During embryologic development, lateral optic placodes move medially during
weeks 5 to 9 and become the orbits and associated ocular structures.
■ A persistent divergence of the orbital axes reflects early developmental arrest.
■ Mechanisms of arrest include the following:
■ Deficient growth affecting the brain and eyes
■ Deficient closure of the rostral neuropore with the development of sincipital
encephaloceles
■ Deficient differentiation of the nasal capsule
■ Compensatory accommodation of the cranial base to the growing brain
■ Hypertelorism may result from syndromic and nonsyndromic etiologies, such
as
■ Encephalocele (nasofrontal, nasoethmoidal, naso-orbital, and combined)
■ Craniofrontonasal dysplasia
■ Median facial clefting or frontonasal dysplasia
■ Syndromic craniofacial dysostoses (ie, Apert, Crouzon, Pfeiffer)

■ Tumors
■ Vascular malformations
Table 1 Severity of Hypertelorism Defined in Children and Adults
Degree of
Hypertelorism
Childrena
Adultsb (Gunther’s
Classification)4
First
2–4 mm
30–34 mm
Second
4.1–8 mm
35–40 mm
Third
>8 mm
>40 mm
aReported as distance of deviation from average interorbital distance by age.
bReported as absolute interorbital distance.
NATURAL HISTORY
■ Hypertelorism may remain stable or worsen with growth, depending on the
etiology, but it does not improve over time.
■ Relapse is common when surgery is performed in young children (under 8
years of age).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation includes assessment of prenatal and birth history,
general development, medical diagnoses, genetic findings, family history of
similar conditions, the level of patient’s and parents’ concern regarding the
hypertelorism, psychosocial issues, and eagerness to undergo surgical
correction for hypertelorism.
■ A history of sleep disordered breathing may suggest the need for a frontofacial
advancement to increase the size of the airway.
■ Previous intracranial surgical history is important to document including
cranio-orbital reshaping and insertion of a VP shunt.
■ Physical examination: a basic examination of the head and neck is mandated
with specific attention paid toward the cranio-orbital and midface region.
■ Soft tissue measurements including ICD, OCD, and IPD are documented
recognizing that soft tissue intercanthal measurements can be increased greater
than 10 mm over underlying bone measurements.5
■ Presence or absence of midface and zygomatic hypoplasia
■ Nasal appearance recognizing that hypertelorism may be masked by surgical

augmentation of a depressed nasal dorsum
■ Other contributors to the appearance of hypertelorism should also be assessed,
such as exotropia, dystopia canthorum, epicanthal folds, narrow palpebral
fissures, and widely spaced eyebrows.
■ Extraocular muscle function, gross vision, presence of exorbitism, and degree
of corneal protection should be noted.
■ Evaluate for soft tissue excess that may be present or be created by
medialization of the orbits.
■ In assessing the need to correct hypertelorism, a technique to obscure the naso-
orbital region can help determine whether the lateral orbital wall distances are
abnormal and if so, would necessitate either facial bipartition or box
osteotomies. If not, then medial wall osteotomies or camouflage rhinoplasty
procedures would be effective (FIG 3).
■ The cranial shape and fontanelle patency should be assessed for associated
craniosynostosis in cases of craniofrontonasal dysplasia and craniofacial
dysostoses, which may alter surgical planning.
■ Further examination should identify other findings suggestive of an underlying
syndromic diagnosis, which may influence treatment planning and timing such
as midface retrusion, severe exorbitism, and indications of elevated intracranial
pressure.
■ Preoperative consultations are routinely obtained from ophthalmology,
neurosurgery, and anesthesia.

FIG 3 • A technique to determine whether a camouflage
or medial wall procedure would be of benefit. Placing
the hand in front of the medial naso-orbital region
highlights the discordance of the lateral orbital regions.
A,B. This patient looks abnormal with the hand
obscuring the midorbital region and would benefit from
a true orbital hypertelorism correction. C,D. This patient
would benefit from nasal reconstruction alone.
IMAGING
■ Preoperative imaging with computed tomography (CT) scans (axial, sagittal,
and coronal) of the craniofacial skeleton should be obtained, preferably with a
low-dose, bone-only window radiation protocol to obtain a 3D reconstruction

for full visualization of the craniofacial region.
■ MRI is indicated for assessment of midline tumors and encephaloceles and to
assess the hypothalamic-pituitary system in specific cases.
■ Vascular studies (CT angiogram/venogram, MR angiogram). A CT arteriogram
and venogram of the head and neck, or comparable vascular study, may be
indicated in select cases for the purpose of identifying cerebral venous drainage
anomalies commonly found in these patients as well as the vascular pathways
in cases of encephaloceles.
■ Printing of 3D surgical models from CT scans is of great benefit in surgical
planning and mock surgery (FIG 4).
DIFFERENTIAL DIAGNOSIS
■ The following conditions should be considered when assessing a patient with
hypertelorism for a facial bipartition procedure.
■ Sincipital encephaloceles (nasofrontal, nasoethmoidal, naso-orbital, and
combined)
■ Craniofrontonasal dysplasia
■ Facial clefting and frontonasal dysplasia
■ Craniofacial dysostoses (eg, Apert, Crouzon, Pfeiffer)
■ Tumors
■ Vascular malformations
NONOPERATIVE MANAGEMENT
■ Hypertelorism does not always necessitate operative intervention.
■ A mild degree of hypertelorism is considered attractive and may not warrant
extensive surgical procedures for correction.

FIG 4 • Example of a 3-D skull model before and after
mock surgery.
■ Surgical management of hypertelorism may be directed toward the nose as a
camouflage procedure such as nasal dorsal augmentation and correction of
epicanthal folds.
SURGICAL MANAGEMENT
■ Indications
■ Facial bipartition is indicated to simultaneously correct mild to moderate
hypertelorism and maxillary arch constriction with anterior open bite
deformity.
■ Hypertelorism with concomitant intracranial hypertension and/or airway
compromise due to midface retrusion are indications to combine the facial
bipartion with a frontofacial monobloc advancement procedure.
■ Facial bipartition when performed as a distraction advancement is effective in
“unbending” the facial concavity associated with Crouzon, Pfeiffer, and Apert
syndromes.
■ Facial bipartition works best with symmetric conditions.
■ Facial bipartition may be performed safely in young (less than 5 years)
children but can be associated with high rates of relapse when performed at

this age.
■ Surgical timing of facial bipartition requires consideration of several factors.
■ The older the patient, the less likely there will be postoperative relapse of
hypertelorism.
■ Some studies indicate performing facial bipartition in children less than 6 to 8
years old has a high degree of relapse on long-term follow-up.6,7
■ Early intervention may also lead to decreased future midface growth.5–7
■ Timing of surgery must account for the child’s psychosocial development and
interaction with peers.
■ A midline cleft or encephalocele may leave the brain vulnerable to injury.
■ Surgical management of sincipital encephaloceles is out of the scope of this
chapter but is best performed in infancy.
■ Severe hypertelorism may affect development of stereotactic vision if
treatment is delayed; however, this is not well substantiated.8
■ Hypertelorism may be addressed through facial bipartition or box osteotomies,
depending on the goals of the intervention.
■ Facial bipartition can be performed in younger children, whereas orbital box
osteotomies should be done when the orbits have completed as much growth
as possible, the maxillary sinus has developed, and canine tooth buds have
descended away from the surgical field.
■ Correction of hypertelorism with facial bipartition may be limited by the
degree of maxillary expansion.
■ Facial bipartition medializes the orbits through rotational movement of both
the orbits and maxilla, which alters the canthal axis and maxillary occlusal
relationship (FIG 5).
■ Box osteotomies medialize the orbits through a translational movement of the
orbits alone, which should not change canthal axis or maxillary occlusion.
■ Overlying soft tissue diminishes the clinically observed difference of bone
medialization.

FIG 5 • Facial bipartition osteotomy. A. Markings. B.
When fully mobilized, narrowing of the orbits results in
midface lengthening and widening of the palate. C.
After fixation has been applied.
■ If midface advancement or increased facial convexity is desired, distraction
osteogenesis may be performed postoperatively with use of a rigid external
distraction device.9,10
■ A staged facial bipartition procedure may be indicated in patients with
significantly increased intraoptic nerve distance to prevent blindness.
Preoperative Planning
■ Risks of facial bipartition should be discussed with the patient and family,
including but not limited to
■ Risks associated with an intracranial procedure, including brain and dural
injury, damage to the venous sinuses, infection, CSF leak, bleeding, and the
need for transfusion
■ Risks to the orbital contents such as blindness, extraocular muscle injury, and
diplopia
■ General concerns, such as scarring, hardware failure, need for revision
surgery, and asymmetrical outcome
■ A CT scan assists in planning the amount and angle of midline resection to
achieve the desired medial rotation of the lateral segments (FIG 6A).
■ If available, a life-sized 3-D printed model allows the surgeon to plan the
surgical procedure, perform the osteotomies, and anticipate bony interferences
and consequences of segmental facial bone movements (FIG 6B).
■ The amount of bone resection necessary to obtain the desired interorbital

distance should be calculated (FIG 6C,D).
■ The angle of resection (with convergence between the maxillary central
incisors) should be determined based on the desired resection width at the
radix, internal rotation of the orbits, and leveling of the maxillary dentition
(see FIG 6B).
■ In the presence of an encephalocele, an MRI delineates whether resection or
volumetric reduction of its contents is possible.
■ Hydrocephalus, craniosynostosis, or other pathologic findings may require
intervention prior to hypertelorism correction.
■ The surgeon should be familiar with techniques for addressing soft tissue
excess and canthal position that may be combined with facial bipartition.
■ In cases of severe nasal dysgenesis or excessive soft tissue in the midline, a
plan for resection and nasal obstruction should be considered.
■ Delayed or staged resection and nasal reconstruction may be an option.
■ The surgeon should decide if facial bipartition will be combined with
monobloc frontofacial advancement.
Positioning
■ The patient is positioned supine on the operating table using a slightly elevated
Mayfield head rest. A shoulder roll is placed to decrease neck flexion and
anteriorly position the head.
■ Oral intubation is performed with an endotracheal tube that is secured with an
interdental or circum-mandibular wire.
■ Note any preprocedural cuff leak as a comparison to determine timing for
postoperative extubation.
■ Corneas should be protected through temporary tarsorrhaphy sutures or similar
means.
■ A Foley catheter, adequate intravenous access, and arterial lines are placed.
■ Antibiotics are administered.
■ Injection of local anesthetic or tumescent solution is performed.
Approach
■ A bicoronal incision is used for access from the cranium; limited bilateral
upper buccal sulcus incisions may be used for access to the central maxilla.
■ If direct excision of excess soft tissue is desired, this is normally performed at
the end of the procedure after the bone segments are stabilized and the coronal

incision has been closed. Excess soft tissue may be left to contract, with the
option of later revision, if needed.
FIG 6 • A. Planning the surgical movements on a CT
printout can help understand the anticipated
movements of the facial skeleton. Yellow lines indicate
facial midline and canthal axes demonstrating mild
asymmetry between the two orbits. Red dashed lines
indicate the surgical cuts. Green reference lines
centered on the axis of rotation (red circle) will help
demonstrate the change in occlusal and orbital planes
after the rotation. The blue dashed line indicates the
position the supraorbital osteotomy should be placed in
order to attain a level supraorbital bar after
repositioning. B. A life-sized 3-D printed model allows

the surgeon to plan the surgical procedure, perform the
osteotomies, and anticipate bony interferences and
consequences of segmental facial bone movements.
C,D. Calculation of the amount of resected bone with
maintenance of sufficient bone around the orbital
perimeter to maintain skeletal integrity.
T E C H N I Q U E S
■ Exposure
■ Through a bicoronal incision, the frontal region is dissected in a subgaleal
plane inferiorly to the level of the superior orbital rim and laterally along the
deep temporal fascia to the level of the zygomatic arch.
■ The periosteum is incised, elevating an anteriorly based pericranial flap
extending down along the lateral orbital rim.
■ Dissection proceeds anteriorly to the end of the nasal bone complex,
facilitated by a midline incision through the periosteum.
■ Incisions through the periosteum are made along the lateral orbital rim and
down to the junction of the zygomatic arch and body.
■ The temporalis muscles are elevated and detached from the lateral orbital
wall and temporal fossa. A posterior back-cut may be made to advance them
to the lateral orbital wall at the end of the procedure to prevent temporal
hollowing.
■ Circumferential orbital subperiosteal dissection mobilizes all orbital contents
except for the medial canthus. It is critical not to detach the canthus from its
bony insertion (TECH FIG 1).

TECH FIG 1 • A. Craniofacial exposure through a
bicoronal incision elevating an anteriorly based
pericranial flap and taking down the temporalis
muscles to expose the lateral orbital regions.
Dissection proceeds circumferentially into the orbits,
with preservation of the medial canthal attachments
and simultaneous exposure of the entire nasal bone
complex. B. The amount of bone to be resected is
measured.
■ Anatomic landmarks during the orbital dissection include the anterior and
posterior ethmoidal arteries, the lacrimal fossa on the medial orbital wall, and
the anterior extent of the infraorbital fissure along the lateral wall.
■ A midline maxillary upper buccal sulcus incision is used to access the nasal
surface of the palate.
■ The mucosa is elevated from the piriform region along the maxillary crest
and, if necessary, the septum is detached.
■ If distraction is to be performed, the piriform margins are exposed as
percutaneous traction (24-gauge) wires can be placed through the thick robust
medial maxillary buttress.
■ The bifrontal craniotomy is marked leaving the bandeau intact.
■ A supraorbital bar is not left intact in this procedure.
■ Neurosurgery performs a bifrontal craniotomy in the standard fashion. It is
important to be able to access the middle cranial fossa for protection of the
temporal lobes during the orbital osteotomies.

■ Circumferential Orbital Osteotomies
■ With the brain dissected from the anterior and middle cranial fossae and
safely retracted, the orbital roof osteotomy is performed medial to lateral
using a reciprocating saw about 1 cm behind the superior rim, exiting the
temporal bone.
■ The lateral orbital wall is osteotomized using a reciprocating saw as well,
taken down to the junction of the orbital floor and lateral wall, using the
anterior extent of the inferior orbital fissure as a landmark (TECH FIG 2).
TECH FIG 2 • A–H. Details of the positions of the
osteotomies in a 3-D model.
■ The orbital floor osteotomy is made gently with a narrow osteotome,
approximately 9 to 10 mm behind the inferior orbital rim.
■ The medial orbital wall osteotomy is also completed with a narrow
osteotome located anterior to the anterior ethmoidal vessel but behind the

lacrimal fossa.
■ Parts of the medial and floor osteotomies are performed blindly;
visualization would place too much traction on the orbital contents.
■ This should complete the circumferential orbital osteotomies.
■ Zygomatic and Maxillary Osteotomies
■ The zygomatic arch osteotomy is made using a reciprocating saw at the
junction of the arch and zygomatic body.
■ Pterygomaxillary osteotomies may be performed from superior to inferior
with a straight 1-cm osteotome. The osteotome is placed behind the
zygomatic body aiming downward and behind the maxillary tuberosity.
■ Palpating the maxillary tuberosity with one hand while the other hand
directs the osteotome is a helpful tactic.
■ An elevator placed through the anterior extent of the inferior orbital fissure
provides a useful landmark to guide the pterygomaxillary osteotomy.
■ Frontonasal Osteotomies
■ The final osteotomy is made using a reciprocating saw across the anterior
cranial fossa immediately in front of the cribriform plate. This osteotomy is
best done just prior to downfracture because bleeding may occur.
■ Orbital contents should be retracted during the osteotomies.
■ Once the osteotomy has been made across the anterior cranial base, a 1-cm
straight osteotome is driven downward and posteriorly, aiming for the
posterior nasal spine going through the septum.
■ A finger in the mouth behind the soft palate may be a useful tactile guide.
■ Downfracture
■ Rowe-Kelly forceps are applied and the entire fronto-orbito-maxillary
complex is levered anteriorly testing for areas where the osteotomies are not
complete.
■ Ideally, the surgeon should see the anterior cranial fossa osteotomy expand
during the anterior movement of the frontofacial complex.
■ A downfracture of the frontofacial complex is performed. This may involve

completing the midline septal osteotomy when visualization is improved with
the downfracture.
■ A straight osteotome is advanced through the nasofrontal osteotomy site,
aiming down to the posterior nasal spine to complete the nasal osteotomy.
■ Pterygomaxillary spreaders are very useful at this point and are placed
behind the maxillary tuberosity to further loosen and advance the midface
segment.
■ It is critical to fully mobilize the entire frontofacial complex.
■ Central Wedge Excision
■ The frontonasal wedge of bone is marked out maintaining at least 5 to 6 mm
of medial orbital margin on each side.
■ This is necessary to maintain the integrity of the orbital bony margin and
the position of the medial canthal complex.
■ From the mobilized segment, a central wedge of interorbital and nasal bone
is removed using a reciprocating saw. This should be carefully measured
according to the preoperatively determined specifications.
■ Nasal mucosa may be resected and repaired as needed to prevent soft tissue
interference with medialization of the two facial halves.
■ The ethmoid air cells are removed with a rongeur to allow medialization.
■ The maxilla is split along the edge of the maxillary crest between the central
incisors. This can be started with a reciprocating saw, but a dental osteotome
is useful when performing osteotomies between the two central maxillary
incisors.
■ Stabilizing the Two Halves
■ The upper portion of two facial halves are rotated to close the space at the
nasofrontal region and restore the midline and checked for symmetry (TECH
FIG 3). Any bony interferences are removed.
■ The point of rotation should be at the level of the maxillary incisors to
prevent a diastasis between the dentition (see FIG 6A).
■ Fixation is placed at the nasofrontal area. Our preference is to use two 26-
gauge wires followed by a titanium plate.
■ Stabilization of the frontofacial complex may be assisted with application of

intermaxillary fixation. This may require an endotracheal tube exchange
during surgery (see Pearls and Pitfalls below).
■ If no distraction osteogenesis is planned, the facial bipartition segments are
oriented anteriorly with proper relation to the globes and fixed laterally with
titanium plates to the temporal bone and the zygomatic arches.
■ If distraction osteogenesis is planned, the facial bipartition segments are
secured laterally with nonpermanent suture (4-0 PDS) for stabilization during
the latency period.
■ Plates and drill holes needed for attachment of the rigid external distraction
device are placed.
■ Orbital aperture shape may be contoured with a rongeur or bur for symmetry.
TECH FIG 3 • Following mobilization of the frontofacial
complex and excision of the bone wedge in the
nasofrontal region (A), the two halves of the face are
brought together in the midline (B).
■ Anterior Vault Reconstruction
■ The anterior cranial fossa is sealed from the nasopharynx with split skull
bone graft, pericranial flaps, tissue glue, or other suitable materials, as
available.
■ The pericranial flap may be folded down into the anterior cranial fossa and
held in place with sutures before sealing with tissue glue (TECH FIG 4).
■ Forehead reconstruction is performed using the frontal bone, which may

need to be narrowed and adjusted.
■ Titanium or resorbable fixation may be used to secure the frontal bone
reconstruction to the bandeau.
■ With distraction osteogenesis, titanium hardware may offer more stability
of the construct against anterior distraction forces.
■ Frontal bone reconstruction may be secured posteriorly to the intact cranial
bone with titanium mesh or resorbable plates.
■ If distraction is planned, securing with nonpermanent suture provides
stability during the latency period.
■ If nasal support or augmentation is required, nasal bone grafting is
performed using calvarial bone graft.
■ Remaining bone fragments are packed into calvarial defects.
■ Larger defects may be reconstructed with titanium mesh.
■ Temporal muscles are advanced and sutured to the lateral orbital wall via
drill holes.
■ Any remaining pericranial flap may be used to contour a concavity or secure
over the cranial reconstruction.

TECH FIG 4 • After stabilization of the frontofacial
complex, the anterior vault is reconstructed and soft
tissue is resuspended. A,B. The temporalis muscles
are advanced and attached to the lateral orbital walls.
C. Note the pericranial flap that has been folded into
the anterior cranial fossa before the frontal bone was
replaced.
■ Soft Tissue Reconstruction
■ It is critical to resuspend the soft tissues of the face prior to closure (TECH
FIG 5).
■ However, lateral canthoplasties may or may not be formally done
depending on surgeon preference.
■ If performing distraction, place any remaining hardware or wires needed to
secure the rigid external distraction device. Distraction may be done using

internal devices or external headframes depending on surgeon preference.
■ Two suction drains are placed over the temporalis muscles, exiting posterior
to the coronal incision.
■ Close the coronal incision.
■ Close the upper buccal sulcus incision.
■ Excise excess midline soft tissue, if desired.
■ If performing distraction, attach rigid external distraction device.
TECH FIG 5 • A. Once the soft tissue has been
redraped, excess tissue can be marked and removed.
B. It is useful to employ external soft tissue bolsters to
allow the tissue to redrape along the naso-orbital
valley.
PEARLS AND PITFALLS
Planning
■ 3-D models are extremely useful to plan for a facial bipartition.
■ Positioning the bifrontal craniotomy and measuring anticipated
bone resection in the nasofrontal region ensures better accuracy
and saves valuable time during the procedure.
■ Performing the osteotomies on a 3-D model allows the surgeon to
understand the movements of the facial skeleton and anticipate the
areas of bony interference.
■ The model surgery allows the surgeon to understand the
relationship between narrowing the interorbital distance and its

impact on occlusion.
Airway
■ If the facial bipartition is being performed in combination with a
frontofacial monobloc advancement, the entire procedure can be
performed with an endotracheal tube.
■ In the event of a facial bipartition without distraction
advancement, the endotracheal tube may require a change to a
nasotracheal tube to facilitate application of intermaxillary
fixation. This should be done after mobilization of the frontofacial
complex with experienced anesthesia support. Only rarely is a
tracheostomy required.
Osteotomies
■ The upper facial osteotomies are basic and easy to perform unless
there has been previous cranio-orbital reshaping. It is crucial to
protect the anterior projection of the temporal lobe of the brain,
which is susceptible to injury when the reciprocating saw extends
through the lateral extension of the sphenoid wing.
■ The pterygomaxillary osteotomies are performed blindly and can
be a challenge. It is useful to place a finger intraorally behind the
maxillary tuberosity and aim the osteotome toward your finger.
■ Performing standard pterygomaxillary osteotomies through an
intraoral approach may also be a useful maneuver, especially in
older patients.
Mobilization
■ The key to mobilization is completing the osteotomies.
■ Fully mobilize the frontofacial complex before splitting it into two
segments.
■ Invariably, the soft tissues in the pterygomaxillary region are the
reason for restricted movement and can be stretched by judicious
placement of pterygomaxillary spreaders behind the maxillary
tuberosity, which allows manipulation of the maxillary segment.
Bony
interferences
■ Removal of bony interferences allows apposition of the bone
edges.
■ Marginal excision of the region of the anterior nasal spine allows
better apposition of bone in this region.
Soft tissue
■ Soft tissue excess will be generated by orbital medialization.
■ This tissue may be left to contract with possible revision at a later
date.
■ External bolsters may be applied to guide redraping of tissue in the
medial canthal region.
■ If direct excision is desired, perform this after closure of the
coronal incision.
■ Orient soft tissue excision vertically at the midline or paramidline

if felt to be aesthetically more appropriate in terms of closure.
Advancement
■ When combining facial bipartition with monobloc advancement,
distraction osteogenesis exhibits decreased complications
compared to a single intraoperative advancement.
POSTOPERATIVE CARE
■ Postoperatively the patient remains intubated in the intensive care unit for
observation and airway protection. Neurological vitals (best verbal, best motor
response, and assessment of neurological status after craniotomy) and visual
and pupillary checks are carried out regularly.
■ Extubation is preferred on the first postoperative day. While only a theoretical
concern, positive pressure ventilation may force air into the anterior cranial
fossa and increase the risk of infection.
■ There is no consensus about the use of perioperative antibiotics for prolonged
periods.
■ If performing distraction, the latency period is typically 7 days, followed by
activation of approximately 1 mm/d until advancement is achieved.
■ After advancement, the consolidation period is 8 to 12 weeks, prior to
removal of the distraction device.
■ The patient is started on a clear liquid diet and advanced to a soft no-chew diet
for the duration of bone healing.
■ A postoperative low-dose bone-only CT scan is routinely done to assess the
extents of the osteotomies and facial configuration.
■ Discharge home occurs when the patient has eyes open and adequate pain
control.

FIG 7 • A 4-year-old boy with severe frontonasal
dysplasia and bilateral cleft lip and palate before (A)
and 3 months after (B) a facial bipartition with nasal
dorsal augmentation using calvarial bone graft.
Titanium mesh was used to reconstruct full-thickness
calvarial defects. CT images before (C) and
immediately after (D,E) reconstruction.
OUTCOMES
■ Achieving a normal postoperative appearance with facial bipartition is not
common (FIGS 7 and 8) and should be stated clearly in preoperative
discussions. The intent is primarily to improve hypertelorism and occlusal
discrepancies.
■ When performed as a monobloc frontofacial advancement, additional benefits
include increased intracranial volume, improvement in exorbitism, increased
size of nasopharyngeal airway, and resolution of obstructive sleep apnea;
unbending of the concave facial profile in specific craniofacial dysostoses
syndromes; and improved dental and skeletal balance.

■ Breakey et al.5 determined movement of the medial canthi is proportionate to
the change in interorbital distance, although the absolute distance between the
medial canthi remains larger than the interorbital distance.
■ Intercanthal width was increased by 10.2 to 13.8 mm compared to bony
interorbital distance, due to the thickness of the overlying soft tissue.
■ Wan et al.7 performed a retrospective review of patients treated with facial
bipartition and box osteotomies for hypertelorism, focusing on patients with
greater than 5 years of follow-up. Patients undergoing simultaneous monobloc
advancement were not excluded.
FIG 8 • A 6-year-old girl with bilateral Tessier 1/13 clefts
before (A) and 1 year after (B) a facial bipartition
procedure followed by composite ear grafts to
reconstruct the bilateral nasal clefts. CT images are
shown preoperatively (C) and immediately after (D)
reconstruction.

■ Patients (n = 33) were analyzed by age (less than 6 or greater than or equal to
6 years) and hypertelorism severity.
■ Mean surgical age was 9.2 years. Average follow-up length was 14 years.
■ All patients less than 6 years old at the time of surgery (n = 6) exhibited
relapse compared with normal interdacryon distances for their ages.
■ In patients older than 6 years at the time of correction (n = 27), only three
patients exhibited relapse.
■ All patients with severe hypertelorism (n = 4) exhibited relapse, with an
average surgical age of 6.3 ± 3.2 years.
■ Five patients had complications, including wound infection (n = 2),
meningitis (n = 1), seizures (n = 1), and postoperative bleeding requiring a
return to the operating room (n = 1). There were no mortalities.
■ Raposo-Amaral et al.6 in a similar retrospective review (n = 22 patients)
concluded that patients younger than 8 years old at the time of surgery have a
significantly increased risk of relapse. Patients were excluded if monobloc
advancement was simultaneously performed.
■ This finding was regardless of procedure (facial bipartition or box osteotomy)
and regardless of the severity of hypertelorism.
■ Average follow-up length was 15.2 years (5–30 years).
■ Complications included recurrent meningitis secondary to a dural leak (n = 1)
and seizures (n = 1). There were no mortalities.
■ Frontal lobe ischemic changes have been demonstrated on postoperative
imaging in 64% of patients (n = 50) undergoing monobloc with and without
bipartition, corresponding with points of intraoperative cerebral retraction.11
■ Five of these children (n = 38) suffered new-onset postoperative seizures,
whereas two children without ischemic changes (n = 12) also experienced
seizures.
■ Long-term significance of these findings is not known.
■ Combining distraction with facial bipartition has demonstrated consistent
improvement of midface retrusion and concave facial profiles, through
differential central face distraction.9,10
■ In cases with frontofacial advancement, the increased use of distraction
osteogenesis instead of a single intraoperative advancement has led to a
significant reduction in postoperative infections and complications.12
■ Occlusal abnormalities are treated after presurgical orthodontic treatment and
skeletal maturity, typically after the age of 16 in girls and 18 in boys.12

■ Additional nasal reconstruction with split calvarial grafts, costochondral grafts,
or forehead flaps may be performed 12 months postoperatively.
COMPLICATIONS
■ Failure to adequately treat hypertelorism is the most common complication.
■ Even when initial results have sufficient correction, relapse of hypertelorism is
possible.
■ Infection is a significant complication and may result in bone resorption or
nonunion.
■ Visual (diplopia, visual loss)
■ Asymmetries and orbital dystopia
■ Enophthalmos
■ Anosmia
■ CSF leakage postoperatively may require a temporary lumbar drain.
■ Meningitis
■ Seizures
■ Blood transfusion
REFERENCES
1. van der Meulen JC. Medial faciotomy. Br J Plast Surg. 1979;32:339-342.
2. van der Meulen JC, Vaandrager JM. Surgery related to the correction of
hypertelorism. Plast Reconstr Surg. 1983;71:6-19.
3. Colton C, Krkler S, Schatzker J, Trafton P. Hypertelorism [online].
www2.aofoundation.org, 2016.
4. Gunther H. Konstitutionelle Anomalien der augenabstandes und der
interorbitalbreite. Virchows Arch Pathol Anat. 1933;290:373.
5. Breakey W, Abela C, Evans R, et al. Hypertelorism correction with facial
bipartition and box osteotomy: does soft tissue translation correlate with bony
movement? J Craniofac Surg. 2015;26(1):196-200.
6. Raposo-Amaral CE, Raposo-Amaral CM, Raposo-Amaral CA, et al. Age at
surgery significantly impacts the amount of orbital relapse following
hypertelorbitism correction: a 30-year longitudinal study. Plast Reconstr Surg.
2011;127(4):1620-1630.
7. Wan DC, Levi B, Kawamoto H, et al. Correction of hypertelorbitism:
evaluation of relapse on long-term follow-up. J Craniofac Surg.
2012;23(1):113-117.
8. Okumoto T, Inoue Y, Yoshimura Y. A case of orbital hypertelorism with