Can Periorbtial Implants Achieve The Same Increase in Interpupillary Distance as Orbital Box Osteotomies?

Q: Dr. Eppley, I ask about options in orbital box osteotomies that don’t expose the brain? I dug up two examples I found online:

1.  Here’s a variation of the box osteotomy that tries to avoid the brain by cutting into the sinus instead:

2) Here’s an implants-focused approach with minimal/no osteotomies? 

It seems like this approach accomplishes many things at once that I’d like: increase in distance between the pupils and between the canthals, as well as widening the temples to fit the change.

Of course, I’d like to take a feminizing approach to the implants, which merits more nuance than adding more bony volume.

Would you be open to discussing either option? If so, I’d love to hear your thoughts!

A: When it comes to the Trsnscranial and Transinus Orbital Box Osteotomies the operative phrase is  ‘trying to avoid’ entering the cranial cavity’ does not eliminate the risk that it may happen and all the sequalae from it…still an ll-advised procedure in my opinion that does not justify the effort and risks for the aesthetic gain desired.

This is what happens when the patient aesthetic goals are a ‘tweener’, meaning the goal is too small for the big operation but just beyond what the smaller operation can do.

The implant approach to hypoteloric issues takes a 180 degree change in treatment direction. Here the question is not one of safety or magnitude of the surgery but one of will it be effective to achieve the goal. There is no doubt that periorbital implants can be designed and placed to change the shape/position of the orbital box…that is done not infrequently for horizontal rim augmentations. The critical question is whether doing so for a change in orbital box width (with a different implant design) will make the eyes appear to have an increased interpupillary distance. In theory it has the same effect as the orbital box osteotomy without cutting the bone as osteotomies do not really move the eyeball laterally unless they are a true 360 degree transcranial box osteotomy.

I would be cautious about interpreting the computer simulations you have attached as those are theoretical implant designs and the before and after result shown is simulated (with the eyes closed)….so we don’t really know what would happen on an actual patient. I think it would clearly make the orbital width wider, I just don’t know how that would affect the appearance of the interpupillary distance.

I can, however, borrow from my own clinical experience with perirorbital implants done for a slightly different purpose…to make the orbital width wider for a narrow forehead/temple/lateral orbital width. In looking at a few patients with matched before and afters there may be an increased interpupillary distance.(see attached)

It is an interesting concept because of its lower risk and for less severe hypotelorism cases. (wouldn’t work for more significance case) I can envision a periorbital implant design that has some potential for that effect. This largely adds width and little increased horizontal projection. Its design is very similar to the transcoronal 270 degree orbital box osteotomy.

Dr. Barry Eppley

World-Renowned Plastic Surgeon