Would Subcranial Orbital Box Osteotomies Be Effective For Mild Hypotelorism?

Q: Dr. Eppley, I am writing regarding aesthetic hypotelorism and orbital/midface asymmetry. My measurements are approximately: * IPD: 57.5 mm * ICD: 27.5 mm * Eye width: 28 mm * Bizygomatic width: around 133 mm My main concerns are: * slightly close-set eyes relative to my facial proportions and midface length * left-sided orbital/zygomatic recession and asymmetry * downward curvature/scleral show of the left lower eyelid * deviated nose, likely related to the asymmetry I previously consulted another surgeon who proposed a traditional 360-degree transcranial orbital box osteotomy, but after researching the coronal/craniotomy approach and its morbidity, I no longer feel comfortable pursuing that route. I found your discussions regarding the modified subcranial/inferior 180-degree orbital box osteotomy and wanted to ask whether my case sounds potentially suitable for that approach instead, since my desired increase is relatively modest (approximately 4–5 mm total IPD increase). I would also like to ask: * how much true IPD and ICD increase can realistically be expected from this procedure * whether the procedure produces actual globe movement or mainly orbital framing/perceptual widening * whether you have before/after cases of patients with similar measurements/goals * what the lower eyelid and infraorbital nerve risks are in your experience * whether custom orbital rim/malar implants, canthoplasty, and septorhinoplasty could potentially achieve most of the desired improvement without orbital osteotomy. Thank you for your time.

A: The only truly effective procedure for increasing the IPD 2 – 3mms per side is 360° orbital box osteotomies. But as you have appropriately determined the potential trade-offs of the procedures are not worth its benefits. This then raises the question as to whether a lesser degree of orbital box osteotomy could be effective. It possibly could but requires a 3-D CT scan to look at the orbital anatomy, evaluate bone cut location etc to provide a more qualified answer.

Certainly building up the rims and cheek area with implants is not going to be helpful and will likely worsen the appearance of the current eye spacing.

A rhinoplasty is only helpful to create the illusion of an increased IPD if significant nasal bone narrowing is needed. This is clearly not needed in your case.

Dr. Barry Eppley

Plastic Surgeon