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Archive for the ‘orbital reconstruction’ Category

Aesthetic Vertical Orbital Dystopia Correction Strategies

Saturday, January 21st, 2017


orbital dystopia_edited-2Vertical orbital dystopia is a frequent feature of many facial asymmetry patients. When facial asymmetry affects the midface region most of the time some form of globe dystopia will be present. It is perceived most easily by the difference in the horizontal level of the pupils.

Orbital dystopia is always most clearly seen in pictures as the eyes look ‘off’. This is where patients will notice it the most as well as when looking directly in the mirror. (or in selfies)  There will be one good eye and the affected eye will usually be sitting lower. It is rare that the affected eye is the higher one. For unknown reasons in my experience vertical orbital dystopia occurs much more frequently in the right eye.

The most important step when the eyes appear at different levels is to make the proper diagnosis. This will require a 3D CT scan of the entire face and not just the orbits. Aesthetic (non-craniofacial) orbital dystopia usually has other facial asymmetries as well particularly of the superior brow bone and the inferior cheeks. The entire orbital skeletal box is lower. As a result, the eyebrow and brow bone will also be lower, the upper eyelid may have some mild ptosis and the cheek will be flatter and asymmetric.

Hydroxyapatite Cement Orbital Floor Reconstruction Dr Barry Eppley IndianapolisMild cases (2 to 5mms) of vertical orbital dystopia can be treated by numerous extracranial techniques. Augmentation of the anterior orbital floor (and in some cases the inferior orbital rim), a brow lift and cheek augmentation are the three main skeletal techniques. While numerous implant materials can be used for the orbital bone, including autologous bone grafts, I find the use of hydroxyapatite cement (HA cement) to be very effective. It is easy to apply and shape to the orbital floor and up over the inferior orbital rim if needed.

Orbital Floor Lowering Dr Barry Eppley IndianapolisIn uncommon cases an adjunctive strategy can be to lower the opposite eye as well. If the affected eye can not be adequately raise due to the amount of horizontal pupillary disccrepancy (4mms or greater) the opposite eye can be slightly lowered. This is done by removing part of the bone on the anterior orbital floor. Short of a full orbital decompression, the goal is to achieve a 1 to 2mm lowering of the globe. This dual approach raises the lower eye and very slightly lowers the opposite eye.

In the correction of vertical orbital dystopia, it is also important to be aware of what may happen to the upper eyelid-globe relationship. In most cases of congenital orbital dystopia the upper eyelid follows the eye to maintain a normal appearing upper eyelid to globe relationship. But as the lower eye is surgically lifted, the eye can be come more buried under the upper eyelid. Ptosis repair may be needed to get the eyelid back up higher on the iris.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Correction of Eye/Orbital Asymmetry with Hydroxyapatite Cement

Saturday, May 4th, 2013


Background: The eyes are a central feature of the face and draw immediate attention whether one is looking at themselves or in where others look. Because the eyes are paired structures, their symmetry in appearance is important. Any differences in the appearance of the eyes is readily seen and could be the result of soft tissue differences (eyebrows or eyelids) or from underlying supportive bone deformities. (eye socket and cheek)

Orbital dystopia refers to differences in the shape of the bony box that makes up the encasement for the eyeball or globe. The bony orbital box is made up of a merging of bones from the forehead, nose, cheek and upper jaw. If this confluence of bones is not well matched in both horizontal or vertical position between the two sides, differences in the position of the eyeball can readily be seen.

Vertical orbital dystopia is when one of the orbital boxes is lower than the other, creating a lower eye that may also be set further in as well. This may be the result of a traumatic injury like a cheekbone fracture or from how the orbital bones are formed. As the bony box is situated lower so goes the eyeball. This can be easily measured by drawing a horizontal line connecting the two levels of the pupils of the eyes. The amount of orbital dystopia is determined by how many millimeters the horizontal pupillary lines differ. The projection (forward position) of the eyeball may also be affected with a more inward or retracted position as determined by looking at globe projection from above the forehead or with the head tilted back from below. A 3D CT scan is the best method to diagnose eye asymmetry due to orbital dystopia.

Case Studies: This 35 year-old male had long been bothered by the differences in the appearance of his eyes. His left eye was situated lower than his right. He had no history of a traumatic facial injury. He could see without problems and had no double vision. He felt he was look at as strange and unattractive. He had searched for methods to correct his eyeball appearance but could not find any short of major craniofacial surgery. An examination showed that the lower eye socket bone (infraorbital rim and cheek) were positioned lower than the normal right side.

Under general anesthesia, a transcutaneous approach was used to approach the lower orbitomaxillary skeleton. A lower blepharoplasty incision with a short lateral canthal extension wa made and a skin-muscle flap elevated done to the lower orbital rim. Most of the orbital floor, the entire orbital rim and the cheek bone were exposed. Using hydroxyapatite cement and the feel of the opposite normal bones as a guide, the orbital floor, rim and cheek areas were built up in the less then 10 minute windown that the set of the material allowed. The corner of the eye (lateral canthal tendon) was lifted and tightened to the bone as well. The incision was then closed with an orbicularis muscle suspension technique.

His postoperative course was typical for any such orbital reconstructive procedure. The position of the eye initially looked too high and bulgy due to the swelling. But within weeks had settled down as the swelling resolved and the result can the be appreciated. One year later, the new level of his eyeball had been maintained and the much improved orbital symmetry could be seen.

There are numerous surgical approaches to the treatment of orbital asymmetry. They essentially break down to either moving the orbital bones or building up the deficient areas. Most mild to moderate cases of orbital asymmetry cam be treated by an implant approach, of which there are a large number of material and technique options. The use of hydroxyapatite cement is one implant technique for orbital augmentation that has the advantage of being the most ‘natural’ to the bone to which it is applied and has no risk of migration or loosening afterwards as it bonds directly to the bone.

Case Highlights:

1) Orbital asymmetry is the result of the shape and position of the underlying orbital and cheek bones.

2) A lower set eye as a cause of orbital asymmetry is due to the entire zygomatico-orbital bone complex being set lower than the other normal side.

3) Building up the orbital floor, infraorbital rim and cheek bone with hydroxyapatite cement can be an effective treatment for mild to moderate cases of orbital asymmetry/dystopia.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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