Correction of Hypertelorbitism: Evaluation of Relapse on Long-Term Follow-Up Derrick C. Wan, MD,* Ben Levi, MD,Þ Henry Kawamoto, MD, DDS,* Neil Tanna, MD,* Christina Tabit, BA,* Cassio Raposo do Amaral, MD,þ and James P. Bradley, MD* Background: Hypertelorbitism has been associated with a variety of congenital deformities. Appropriate timing for surgical correc- tion remains controversial. We present our long-term experience of 33 patients with hypertelorbitism undergoing facial bipartition or orbital box osteotomy. Methods: Patients with hypertelorbitism treated with either facial bipartition or orbital box osteotomy and repositioning who had long-term follow-up were studied (n = 33). Age at the time of first surgery, preoperative interdacryon distance, and immediate post- operative interdacryon distance were recorded. Relapse was deter- mined on postoperative follow-up, and the need for secondary correction was noted. Physician satisfaction score (range, 0Y4) was also assessed. Results: Patients had a mean total follow-up of 14.0 years. With regard to age at the time of initial procedure, patients younger than 6 years were all noted to have relapse, and 83% underwent revision surgery. In patients 6 years or older, only 11% had relapse and required a second operation. Yet, satisfaction scores were similar (3.2 versus 3.5). With regard to the severity of hypertelorbitism, there was no relapse noted among patients with mild hypertelorbitism (interorbital distance [IOD], 30Y34 mm). Among those with mod- erate hypertelorbitism (IOD, 35Y40 mm), 29.4% developed relapse. By contrast, all patients with severe hypertelorbitism (IOD, 940 mm) were noted to have relapse requiring repeat correction. Satisfaction scores were similar (3.4 versus 3.3 versus 3.1). Conclusions: Relapse after surgery for hypertelorbitism is related to the age of the patient at correction and the preoperative severity. When possible, surgical repositioning of the orbits should be de- layed until later childhood. Key Words: Hypertelorbitism, surgical timing, facial bipartition, orbital box osteotomy (J Craniofac Surg 2012;23: 113Y117) H ypertelorbitism was first described by Greig in 1924 with his presentation of 2 craniofacial malformations resulting in ‘‘great breadth between the eyes.’’ 1,2 In subsequent years, arbitrary use of the term hypertelorbitism resulted in significant confusion. By def- inition, hypertelorbitism refers to an abnormal increase in the bony interorbital distance and must be distinguished from other defor- mities associated with telecanthus, the latter of which may also give the illusion of hypertelorbitism but warrants an entirely distinct sur- gical approach. 1 The dacryon, defined as the most medial osseous part of the orbit, has been most frequently used as a landmark to objectively determine orbital distance. Although studies have shown interdacryon distance to vary with age, measurements in excess of approximately 25 mm in the growing child have been described as abnormal. 3Y6 Hypertelorbitism has been observed to be associated with a variety of deformities. Both syndromic and nonsyndromic cranio- synostoses may present with increased interorbital distance. Further- more, some of the most severe cases of hypertelorbitism may be seen in patients who fall within the spectrum of median craniofacial dysplasia. Also referred to as a Tessier no. 0 to no. 14 cleft, inter- nasal dysplasia, median cleft face syndrome, or frontonasal dys- plasia, patients with this deformity may demonstrate a duplicated anterior nasal spine and spectrum, broad and flattened nasal bones, enlarged ethmoid and sphenoid sinuses, and a frontal encephalocele all associated with dramatic hypertelorbitism. 6,7 Although the underlying etiology may vary, from a surgical perspective, hypertelorbitism can be distilled down to an anatomic deviation with excess tissue resulting in abnormal spacing between the orbits. Frequently, the actual size of the orbits fall within the norm, and it is the surfeit of intervening bone and soft tissue that must be removed to restore a proper interdacryon distance. 1 Sur- gical procedures aimed at correction of hypertelorbitism have un- dergone significant evolution during the last century, with Tessier laying the foundation for contemporary combined intracranial- extracranial approaches. 8Y10 His original description in 1967 led to subsequent reports on rates of early postoperative complications and long-term persistence of stigmata. 11 McCarthy, 12 however, provided one of the earliest studies on the durability of correction for hypertelorbitism, showing that surgery could be performed safely at 7 years or younger and that the orbits could be reposi- tioned with stability. This was subsequently confirmed in another study consisting of patients averaging 3.9 years at the time of surgery. 13 In addition, there may be psychosocial benefits for op- erating at a young age. Despite such reports, appropriate patient age for correction of hypertelorbitism remains controversial. Mulliken et al 2 found that in younger patients, recurrence of increased interorbital distance was noted. Furthermore, midface surgical procedures at an early age in- terfere with normal anterior facial growth. To address some of the debate over timing of surgery and postoperative relapse, we there- fore evaluated our own experience with correction of hypertelor- bitism. We present 33 patients undergoing facial bipartition or orbital ORIGINAL ARTICLE The Journal of Craniofacial Surgery & Volume 23, Number 1, January 2012 113 From the *Division of Plastic and Reconstructive Surgery, Department of Surgery, University of California, Los Angeles School of Medicine, Los Angeles; †Hagey Laboratory for Pediatric Regenerative Medicine, Plastic and Reconstructive Surgery, Stanford University School of Medi- cine, Stanford, California; and ‡Institute of Craniofacial Plastic Surgery, Sobrapar, Campinas, Brazil. Received November 9, 2011. Accepted for publication May 29, 2011. Address correspondence and reprint requests to James P. Bradley, MD, Division of Plastic and Reconstructive Surgery, 200 Medical Plaza, Suite 465, Los Angeles, CA 90095; E-mail: jpbradley4@mac.com The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e318240fa84 Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.