Top Articles

Background:  Vertical orbital dystopia (VOD) is usually a developmental asymmetry of the periorbital region. While it can occur in isolation it is usually part of an overall facial asymmetry where the affected face is vertically shorter or more compressed than the opposite side. It presents in two forms differing in the degree of inferior eye asymmetry. I refer to them as major (craniofacial) and minor (aesthetic) VOD which is differentiated by how much discrepancy exists at the horizontal pupillary level. (how different are the eye levels) Aesthetic VOD is when the horizontal pupillary diffferences are less than 5mms. This also makes it treatable without doing an orbital box osteotomy. 

In aesthetic VOD the level of the orbital differences is the most measured component of the deformity by using a 3D CT scan to preoperatively design an implant to raise the orbital floor. Mirroring the opposite side allows an exact as possible lifted orbital floor and rim (and sometimes the cheek) to create bony symmetry. Usually this is 2 to 3mms 

But raising the eye up alone is never enough. Everything around the eyeball has developed with the eye in the lower position. If the eye was just raised there would be increased scleral show from the lower eyelid, a created upper eyelid ptosis as well as persistent lower eyebrow position. VOD management must factor in soft tissue adjustments and the often lower brow bone can not be forgotten either.  

Case Study: This male had a persistent VOD deformity despite prior custom jawline and infraorbital-malar implants. The difference was 3mms in the central anterior floor with the existing custom implant having largely corrected the lower infraorbital rim and cheek.

Under general anesthesia and through a combined lower and upper eyelid incisions, a double hole lateral canthoplasty was performed after the inferior lateral brow bone was reduced. (raised) 

The floor of the orbit was raised beyond where the existing implant stopped just inside the infraorbital rim. The existing silicone infraorbital-cheek implant, with lack of tissue ingrowth, made a minimally traumatic dissection further back onto the floor.

The implant was slipped over the rim into position and secured with a single 7mm long screw through both implants.

The foundational procedure in aesthetic VOD is to correct the inferior bony displacement of the orbit. Using a 3D CT scan to design an implant to do so provides the most exacting method of bony symmetry improvement. But the implant is just one component of VOD surgery who result will be disappointing if the surrounding soft tissues are not addressed as well.

Case Highlights:

1) A part of vertical dystopia (VOD) surgery is a method to elevate the globe best achieved by a custom orbital floor-ri  implant.

2) The limits of safely raising the anterior floor of the eye in VOD is 3 to 4mms.

3) A custom VOD implant can be designed to be placed over an existing implant on the infraorbital rim if the amount asymmetry so warrants.

Dr. Barry Eppley

Indianapolis, Indiana

Top Articles