Hypertelorism: nosologic analysis of 90 patients

Ocular Hypertelorism: Principles and Management

Background

Ocular hypertelorism (OH) was initially considered as un-differentiated congenital cranio-facial deformity, however, I.T Jackson mentioned it as teleorbitism, considering it as increase in the inter-canthal width, inter-pupillary as well as inter-orbital distance as a result of lateralization of the orbital complex in total. Furthermore, Sailer further refined it and included the distance from the lateral orbital wall, i.e. he denoted increased inter-orbital distance along with the distance between lateral orbital walls as true hypertelorism. This condition is rare and is seen in association with midline congenital defects affecting the cranio-facial region.

Classification and review of cases

The ideal time for the OH correction is usually between 5 and 8 years of age. However, the management of OH is complex, and several techniques have been described in literature for the same. Here, we describe our classification of OH, along with the evolution of the surgical aspects, the key treatment principles we follow, together with the types of the osteotomies and their indications. Furthermore, we delineate the four main principles that we have set for OH management.

Results

Though the improvement in appearance is seen immediately post-surgery, however, this challenging surgery faces a multitude and common postoperative complications which have been represented in this article. The surgeon needs both the technical expertise and an inclination towards aesthetics for the execution of such procedures.

Conclusion

It is preferred that the management of OH should be individualized as per the stage of the craniofacial growth and the psychosocial needs of the patient and the parents.

A critical appraisal of surgical outcomes following orbital hypertelorism correction: what is the incidence of true bony relapse versus soft tissue telecanthus?

BACKGROUND

Orbital hypertelorism (OHT) represents a congenital condition defined by lateralization of the bony orbit, unlike soft tissue telecanthus in which there is an increase in intercanthal distance without true bony lateralization. Existing literature remains very limited in its postoperative assessment of bony versus soft tissue relapse, which may both clinically present as telecanthus. We performed a critical appraisal of the literature to determine the postoperative incidence of bony versus soft tissue relapse following OHT repair.

METHODS

The PubMed, MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, and clinicaltrials.org were searched systematically for all English studies published in any time frame reporting relapse rates following primary OHT repair. The primary outcome was incidence of bony and soft tissue relapse defined as orbital lateralization and medial canthal drift, respectively. The secondary outcome measures include postoperative complications, predictors of postoperative complications, timing and type of surgery, and revision rates.

RESULTS

Eleven articles were included. A total of 84 (35.3%) patients experienced bony relapse while 43 (27.2%) patients experienced soft tissue relapse. Age at time of intervention (p < 0.92), severity at presentation (p < 0.90), and surgical technique (p < 0.09) were not found be significantly associated with relapse rate. Methods for long-term follow-up were not standardized, and there was no consistent measure to objectively assess telecanthus.

CONCLUSIONS

There is no general consensus on predictive factors of long-term relapse following OHT repair in the form of box osteotomy or facial bipartition. These findings call for cross-sectional outcome standardization to better understand long-term outcomes across institutional, provider, and patient differences.

Diagnostic analysis of vertical orbital dystopia and canthal tilt for surgical correction

Objectives

We sought to identify a clinically useful method of analyzing orbital dystopia to aid in diagnosis and treatment planning and to quantify vertical discrepancies in eye level and variations in canthal tilt in Koreans.

Patients and Methods

In 76 Korean patients with a mean age of 23.12 years, mean differences in the level of the pupils, lateral canthi, medial canthi, and canthal tilt were measured. The difference in pupil level was calculated from the perpendicular lines drawn from the midpupil area of each eye to the midline of the face to determine the amount of skeletal discrepancy of the eye. Soft tissue discrepancies were determined according to the vertical difference between the lines drawn from the lateral or medial canthus of each eye perpendicular to the midline of the face. The canthal tilt was determined from the inclination of a line connecting the lateral and medial canthi, then classified as class I, II, or III.

Results

Mean differences in pupil level, medial canthi, and lateral canthi were 1.57±1.10 mm, 1.14±1.07 mm, and 2.03±1.64 mm, respectively. The mean degree of canthal tilt were 8.45°±3.53° for the right side and 8.42°±3.81° for the left side. No study participants presented with class III canthal tilt. The mean canthal tilt values for those with class I tilt were 3.21°±1.68° for the right side and 3.18°±1.63° for the left side, while, for those who had class II tilt, the values were 9.60°±3.66° for the right side and 9.54°±2.99° for the left side.

Conclusion

The presented diagnostic method of orbital dystopia can be used to effectively establish a treatment plan that takes into consideration the patient's skeletal and soft-tissue discrepancies.

State-of-the-Art Hypertelorism Management

Orbital hypertelorism represents lateralization of the orbits, meaning increased interorbital and outer orbital distances. Interorbital hypertelorism represents a failure of medial orbital wall medialization in the setting of normally positioned lateral orbital walls. The etiology and type of hypertelorism influence selection of an operative procedure, whereas the severity of deformity dictates surgical need. Choice of surgical procedure is dictated by anatomic considerations, such as degree of orbital hypertelorism, midfacial proportions, and occlusal status.

Surgical approach of hypertelorbitism in craniofrontonasal dysplasia

OBJECTIVE

to present our experience in the hypertelorbitism surgical treatment in craniofrontonasal dysplasia.

METHODS

retrospective analysis of craniofrontonasal dysplasia patients operated through orbital box osteotomy or facial bipartition between 1997 and 2015. Surgical data was obtained from medical records, complementary tests, photographs, and clinical interviews. Surgical results were classified based on the need for additional surgery and orbital relapse was calculated.

RESULTS

seven female patients were included, of whom three (42.86%) underwent orbital box osteotomy and four (57.14%) underwent facial bipartition. There was orbital relapse in average of 3.71±3,73mm. Surgical result according to the need for further surgery was 2.43±0.53.

CONCLUSION

surgical approach to hypertelorbitism in craniofrontonasal dysplasia should be individualized, respecting the age at surgery and preferences of patients, parents, and surgeons.

Surgical correction of grade III hypertelorism

Orbital hypertelorism is an increased distance between the bony orbits and can be caused by frontonasal malformations, craniofacial clefts, frontoethmoidal encephaloceles, glial tumors or dermoid cysts of the root of the nose, and various syndromic or chromosomal disorders. We report a series of 7 cases of hypertelorism that were treated in our hospital. The underlying causes in our series were craniofacial clefts 0 to 14 (4 cases), craniofacial clefts 1 to 12 (1 case), and frontonasal encephalocele (2 cases), all congenital. Surgical techniques used to correct the deformity were box osteotomy and medial wall osteotomy with or without calvarial and rib grafts. A few of our cases were reoperations with specific challenges.

Primary aesthetic correction of nasal anomaly with costal graft in treating orbital hypertelorism

Orbital hypertelorism is a common congenital craniofacial anomaly in Asians. As Tessier pointed out, the correction of hypertelorism is effectively the correction of the nasal deformity, which is characterized by a broad, flat nose accompanying an increased interorbital distance and a lack of nasal projection.

OBJECTIVES

To measure the changes in the orbital and nasal parameters after Tessier box osteotomy and primary aesthetic rhinoplasty, performed concurrently with otogenous costochondral graft.

METHODS

From 2009 to 2013, 49 hypertelorism patients were treated in our craniofacial unit. Correction involved a classic Tessier box osteotomy combined with aesthetic augmentation and reconstruction of the nasal dorsum using a costochondral graft. All patients underwent photographic and tomographic documentation both before and 12 months after surgery. Patients underwent morphometric analysis to document the change in interorbital distance, IOD, hypertelorism index, and aesthetic nasal parameters, including the nasal dorsum and alar width, the nasal dorsal height, and the index of nasal apex protrusion versus nasal length.

RESULTS

All patients were satisfied with the outcome of the combined orbital and nasal repair. Morphometric analysis indicated that the IOD, hypertelorism index, and aesthetic nasal parameters all improved following surgery. The resorption rate of the costochondral graft was 16-19%, and graft warpage was nearly absent. Although complications included infection, cerebrospinal fluid leak, and hyposomia, no severe or life-threatening complications occurred.

CONCLUSION

Tessier box osteotomy with primary aesthetic rhinoplasty using costochondral grafts has shown to be efficacious in the treatment of patients with hypertelorism.

Ocular Morbidity in the Correction of Orbital Hypertelorism and Dystopia: A 15-Year Experience

BACKGROUND

Complex surgery for appearance change is controversial. Correction of orbital hypertelorism risks diplopia and loss of stereopsis for aesthetic gain. The risk-to-benefit ratio remains ill-defined. The aim of this study was to define specific ocular morbidity following orbital translocation.

METHODS

The authors compared stable preoperative and postoperative orthoptic indices (i.e., angle of strabismus, ocular motility, and acuity) for 23 consecutive patients who underwent orbital translocation between 2000 and 2015 and noted the requirement for corrective surgery.

RESULTS

Eighteen patients underwent 33 box osteotomies (15 bilateral and three unilateral). Five patients underwent facial bipartition. Diagnosis was craniofrontonasal dysplasia in 11, frontonasal dysplasia in six, facial cleft in four, and Saethre-Chotzen syndrome in two cases. Median grade of orbital hypertelorism was III. Median age at surgery was 13 years (range, 5 to 17 years). Nontransient change (favorable or unfavorable) in angle of strabismus was noted in 14 patients. Ocular motility was altered in 12. Six patients had stereopsis preoperatively that was disrupted in two cases because of changes in ocular alignment and/or motility. There was one perioperative ophthalmic emergency (superior orbital fissure syndrome) and three acute reexplorations for external ocular muscle entrapment. Corrective surgery for strabismus was performed for four patients. Three required secondary canthopexy and three required surgery for blepharoptosis.

CONCLUSIONS

Orbital translocation is associated with ocular risks including changes to angle of strabismus, ocular motility, and (when present) loss of stereopsis. Secondary surgery to correct strabismus or eyelid malposition is common. Orbital translocation is an operative process, not a single procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Hypertelorism and Orofacial Clefting Revisited: An Anthropometric Investigation

OBJECTIVE

Since the 1960s, multiple studies have reported a tendency toward hypertelorism in individuals with nonsyndromic orofacial clefts (OFCs). However, the association between specific cleft types and increased interorbital distance has been inconsistent. Using three-dimensional (3D) surface imaging, we tested whether different forms of clefting showed evidence of increased interorbital distance.

METHODS

Intercanthal and outercanthal distances and intercanthal indices were calculated from 3D facial surface images of 287 individuals with repaired OFCs. Raw measurements were converted to sex and age-normalized Z-scores. Mean Z-scores for individuals with cleft lip (CL), cleft lip and palate (CLP), and cleft palate (CP) were compared with reference normative values (controls) and one another directly using t tests and analysis of variance.

RESULTS

The CLP group showed a significant increase in intercanthal width (P = .001) and intercanthal index (P < .001) compared with reference norms. The CP group showed a significant decrease (P < .001) in outercanthal width. The CL group showed no difference from reference norms. The proportion of clinically hyperteloric individuals was generally low but highest in the CLP group (7.4%). Cleft severity had little effect on interorbital spacing.

CONCLUSIONS

Individuals with CLP exhibited on average a tendency toward mild hypertelorism, driven primarily by an increase in intercanthal distance. This tendency was not seen in CL or CP.

Hypertelorism and micro-orbit simultaneous correction in a patient with paramedian bilateral facial clefts

The aim of this paper is to report a case of a patient with paramedian bilateral facial clefts and hypertelorism associated with a severe encephalocele and micro-orbit. The patient required a facial bipartition to correct a transsphenoidal encephalocele, and a modified medialization surgery of the orbits to simultaneously expand the micro-orbit and correct the hypertelorism. These procedures achieved hypertelorbitism correction, orbital expansion which allowed symmetrical facial growth, and a functional orbit that permitted the use of an ocular prosthesis. We present this unique case to highlight the predictable results of a procedure that combines 2 surgical reproducible techniques of craniofacial surgery.

Nasal chondroma presenting as hypertelorism

PURPOSE

To report a rare case of nasal chondroma presenting as hypertelorism.

CASE REPORT

We report a case of a 16-year-old boy with a large calcified mass arising from the posterior nasal cavity presenting as hypertelorism. Surgical excision was done, and the histopathological examination revealed a chondroma. The hypertelorism resolved postoperatively.

CONCLUSIONS

Nasal chondroma may also present innocuously as hypertelorism as in this case.

The value of three-dimensional printing modelling for surgical correction of orbital hypertelorism

Orbital hypertelorism is defined as an increased distance between both medial and lateral sides of the orbits. Most common causes are frontonasal malformations, craniofacial fissures, encephalocele and a miscellaneous group of various syndromic or chromosomal disorders. Surgical correction of orbital hypertelorism is still challenging. The present report describes a case of severe orbital hypertelorism of an 11-year-old boy, where surgical correction was planned using three-dimensional printing modelling. This approach allowed reducing time of surgery, accurately planning the location of the osteotomies and precontouring the osteosynthesis material. Three-dimensional models are very helpful tools in planning complex craniofacial operative procedures.

Stereolithography: a method for planning the surgical correction of the hypertelorism

Hypertelorism is a deformity characterized by an increase in interorbital distance. The treatment can be orbital mobilization, or if the malformation goes along with occlusal alterations, the indicated treatment is a facial bipartition with hemifacial rotation.The intention of the present study was to describe a surgical planning technique in locating the anatomic points and planes on a stereolithographic model of a patient with 0-14 fissure and its surgical application.

3D visualization and simulation in surgical planning system of orbital hypertelorism

Simulation and three-dimensional visualization of object motion is a prerequisite for any surgical planning system. Orbital hypertelorism is a disease, which is most commonly associated with craniofacial malformations. We have developed a surgical planning system for planning and evaluation of orbital hypertelorism surgery. In our system CT-based virtual surface models fitted by oriented bounding boxes (OBB) are manipulated. Three-dimensional motion as well as a correction surgery can be simulated. Both are controlled by collision detection. The computer-based interactive surgery simulation systems (CISSS) presented here can take virtual surgical operation and forecast facial features after the correction of orbital hypertelorism, our surgical planning is cheaper and faster than the current methods, surgical outcome was also better than the current methods.

Oriental surgical protocol in orbital hypertelorism

OBJECTIVE

To summarize and analyze the diagnosis, treatment protocol, and therapeutic effect of orbital hypertelorism in the past 30 years in our center.

METHODS

This retrospective study reviews the records of 128 patients from 1978 to 2008. Both radiologic measurements, such as the interorbital distance and the outer orbital distance, and anthropometric measurements, such as the width of the inner canthi (W-IC), the width of the palpebral fissure, the width of the face, and the nasofrontal angle, were conducted before and after the operation to evaluate both osseous and soft tissue alteration. An analysis of the etiology, surgical method, and complication has been undertaken.

RESULTS

The main cause of orbital hypertelorism in our center was craniofacial cleft. Significant improvement in cranio-orbital appearance was noted, and 91.4% of the patients were satisfied with the surgical correction. Follow-up examinations showed a statistically significant difference between preoperative and postoperative measurements: interorbital distance; outer orbital distance; facial ratios W-IC/width of the palpebral fissure and W-IC/width of the face (P < 0.01); and nasofrontal angle (P < 0.05). Temporary complications and side effects remained low, with cerebrospinal fluid leakage occurred as the major complication (6.3%).

CONCLUSION

There are several important protocols regarding the management of orbital hypertelorism that will provide patients with great benefit in achieving more aesthetic facial appearance.

Frontorhiny, a distinctive presentation of frontonasal dysplasia caused by recessive mutations in the ALX3 homeobox gene

We describe a recessively inherited frontonasal malformation characterized by a distinctive facial appearance, with hypertelorism, wide nasal bridge, short nasal ridge, bifid nasal tip, broad columella, widely separated slit-like nares, long philtrum with prominent bilateral swellings, and midline notch in the upper lip and alveolus. Additional recurrent features present in a minority of individuals have been upper eyelid ptosis and midline dermoid cysts of craniofacial structures. Assuming recessive inheritance, we mapped the locus in three families to chromosome 1 and identified mutations in ALX3, which is located at band 1p13.3 and encodes the aristaless-related ALX homeobox 3 transcription factor. In total, we identified seven different homozygous pathogenic mutations in seven families. These mutations comprise missense substitutions at critical positions within the conserved homeodomain as well as nonsense, frameshift, and splice-site mutations, all predicting severe or complete loss of function. Our findings contrast with previous studies of the orthologous murine gene, which showed no phenotype in Alx3(-/-) homozygotes, apparently as a result of functional redundancy with the paralogous Alx4 gene. We conclude that ALX3 is essential for normal facial development in humans and that deficiency causes a clinically recognizable phenotype, which we term frontorhiny.

Telecanthus and hypertelorism in frontoethmoidal meningoencephaloceles and the surgical correction of these conditions: Part I. An orbital anthropomorphometric evaluation of the Khmer subpopulation of Cambodia

This is the first of the two parts of a paper concerning a novel method on the surgical treatment of orbital dysmorphisms, especially telecanthus (TC) and hypertelorism (HT). The normal orbital values of a given ethnic group is an essential factor in determining the degree of correction intended in that patient population. We did not find any data related to the normal orbital values in Khmer-Cambodians in whom we performed the corrective surgeries. Thus, the aims of this article are to evaluate the orbital morphometric data procured in Khmer-Cambodians and to analyze the contradictory definitions of TC and HT found in the literature. We measured the inner canthal distance, outer canthal distance, and interpupillary distance in 688 Khmer-Cambodians. The measured normal values are presented and compared with other Asian populations. We discovered that the Khmer-Cambodian orbital morphometry did not resemble the general conception of an Asian appearance, but rather showed a similarity to values found in Indians. Telecanthus and hypertelorism are frequent orbital dysmorphisms that, however, find conflicting definitions in the literature. By means of a short literature review, we have attempted to reorganize the multiplicity of definitions in orbital measurements, as well as clarify the confusing terminology used in TC and HT.

Craniofrontonasal dysplasia: a surgical treatment algorithm

BACKGROUND

Craniofrontonasal dysplasia is a rare, familial X-linked syndrome with coronal synostosis (brachycephaly or plagiocephaly), hypertelorbitism (frequently asymmetric), and extracranial anomalies. Details of the timing and technique of the craniofacial correction have not been well described. The largest series of patients with craniofrontonasal dysplasia treated at a single institution was used for review.

METHODS

A review of patients at the University of California, Los Angeles Craniofacial Clinic with the diagnosis of craniofrontonasal dysplasia was performed (n = 21). Data included office, hospital, and operative records; photographs; lateral cephalograms; and three-dimensional computed tomographic scans. Based on surgical outcomes, a treatment algorithm was created.

RESULTS

Fourteen patients were female, seven were male, and five had a family history of craniofrontonasal dysplasia (24 percent). Eight patients had unilateral coronal synostosis (plagiocephaly) and 13 had bilateral coronal synostosis (brachycephaly). Eleven patients had asymmetric hypertelorbitism and 10 had symmetric hypertelorbitism. Patients also had cleft lip-cleft palate (10 percent), ear deformities (19 percent), strabismus or esotropia (81 percent), dry frizzy hair (100 percent), syndactyly (14 percent), and nail (100 percent) or other anomalies. After fronto-orbital advancement, no patients had increased intracranial pressure problems or difficulty related to resynostosis. After hypertelorbitism correction, three patients relapsed. Because of this, correction in later patients was delayed until after eruption of permanent maxillary incisors. The mean anterior interorbital distance was reduced in patients from 184 percent to 98 percent of sex-matched controls.

CONCLUSIONS

The phenotypic expression of craniofrontonasal dysplasia is described to recognize patients early. A treatment algorithm for craniofrontonasal dysplasia based on timing and technique is offered to decrease the need for revision and improve outcomes.

Contiguous gene deletions involving EFNB1, OPHN1, PJA1 and EDA in patients with craniofrontonasal syndrome

Craniofrontonasal syndrome (CFNS [MIM 304110]) is an X-linked malformation syndrome characterized by craniofrontonasal dysplasia and extracranial manifestations in heterozygous females. In the majority of patients CFNS is caused by mutations in the EFNB1 gene (MIM 300035). We identified three girls with classical CFNS and mild developmental delay harboring de novo deletions of the EFNB1 gene. Applying haplotype analysis, Southern blot hybridization and array-comparative genomic hybridization, deletion of EFNB1 was found to be part of contiguous gene deletions in the patients. In one patient the deletion interval includes the genes for oligophrenin-1 (OPHN1 [MIM 300127]) and praja 1 (PJA1 [MIM 300420]). In the second patient the deletion includes OPHN1, PJA1 and the gene for ectodysplasin A (EDA [MIM 300451]). In the third patient EFNB1 gene deletion may include deletion of regulatory regions 5' of OPHN1. Previously, the OPHN1 gene has been shown to be responsible for recessive X-linked mental retardation. Although it is too early to predict the future cognitive performance of the two infant patients with contiguous gene deletions of OPHN1-EFNB1-PJA1, mild learning disabilities have been recognized in the older, third patient. It is important for genetic counseling to be aware that their male offspring may not only be carriers of CFNS but may also be affected by mental retardation and anhidrotic ectodermal dysplasia.

Potential blindness: an unusual complication of lateral canthopexy

Lateral canthopexy is a commonly performed procedure in craniofacial and cosmetic surgery. In craniofacial surgery, lateral canthal fixation is performed in conjunction with a wide range of transcranial or subcranial procedures during the process of soft tissue re-suspension. A number of fixation materials have gained popular use. A case of craniofrontonasal dysplasia is reported in which a wire loop canthopexy fixation has become disengaged 3 months after a history of trauma and rotated to present a sharp surface against the sclera. Urgent surgical exploration prevented the apparently imminent complication of globe penetration with associated threat to vision.

Multidisciplinary management of Opitz G BBB syndrome

Opitz G BBB syndrome is a rare condition characterized by the 3 major anomalies of hypertelorism, cleft lip and palate, and hypospadias, although there may be other associated anomalies. The underlying genetic causes are complex and consist of both X-linked recessive and autosomal dominant forms of the disorder. Previously, there have been publications on the underlying genetics and case reports, but there have been few reports regarding the long-term outcome. The aim in this study was to review the range of clinical presentation and evaluate outcomes of the multidisciplinary management of a cohort of patients with Opitz G BBB syndrome. In a 25-year period, 7 patients with Opitz G BBB syndrome were managed by the Australian Craniofacial Unit (ACFU), 5 male and 2 female. Most of the patients are now reaching skeletal maturity. Each one presented with a range of severity in the triad of hypertelorism, cleft lip and palate, and hypospadias anomalies. The males all exhibited the triad of anomalies, while the females both had hypertelorism, only 1 had isolated cleft palate, and neither had any genitourinary anomalies. Each patient underwent multidisciplinary assessment to make a treatment plan for staged management of different anomalies. Plan for surgical corrections of facial anomalies were performed according to the unit's protocol management of both hypertelorism and cleft lip and palate, but the presence of these coexisting anomalies required adjustment of the standard protocol of management of cleft lip and palate. In conclusion, we recommend that patients with Opitz G BBB syndrome require careful evaluation, and management of the anomalies should be in a coordinated manner by a multidisciplinary team.

MR imaging of fetal head and neck anomalies

This article describes an approach to imaging of fetal head and neck anomalies. Topics include cleft lip and palate, facial clefts, amniotic band sequence, micrognathia and retrognathia, ocular and orbital abnormalities, craniosynostosis, posterior nuchal translucency, cephaloceles, vascular anomalies, and tumors. Some of the more common syndromes are also described.

Three-dimensional prenatal diagnosis of frontonasal malformation and unilateral cleft lip/palate

Frontonasal malformation includes a spectrum of anomalies involving the eyes, nose, lips, forehead and brain. We present a case in which a fetal labial cleft was initially identified using traditional two-dimensional sonography. Three-dimensional sonography with multiplanar reconstruction and surface-rendering were essential to establish the diagnosis of frontonasal malformation with severe nasal hypoplasia and unilateral complete cleft lip/palate.

Bony orbital distances among the Filipino population

Six hundred and seventy seven radiographs were selected from the logs of films taken in a major hospital in Metro Manila, Philippines over the course of the previous year. Two hundred and eighty-eight female and 389 male, healthy Filipinos between the ages of birth and twenty years were selected based on the availability of a modified Waters' projection and lateral skull film taken at the same time. Measurements for the lateral orbital wall were made at the site of the suture on the medial surface of the zygomatic bone. The medial orbital wall measurement was the distance between the dacrya using a correction factor formula of CF = D-d/D where D is the target film distance and d is the object film distance (1). The actual bony measurements were calculated. The data was gathered and plotted according to sex and in age in years. Graphs were generated using SAS over a graph software. Lines were smooth using cubic spline technique developed by Reinsch with the smoothest value of 75 (2). The mean plus two, four, and six standard deviations were included in each of the curves.

The craniofacial surgeon as amateur geneticist

Craniofacial surgeons, by nature and training, focus on how to correct anomalies rather than on why they occur. Surgeons often leave diagnosis and etiopathogenic speculation to geneticists. Craniofacial surgeons should cross over the specialty line and learn to think like geneticists. This article reviews definitions of basic words in the genetic language and emphasizes the three diagnostic levels, phenotypic, pathogenic, and genetic, for the principal categories of craniofacial anomalies. Whenever possible, examples are given to illustrate how genetic knowledge can influence surgical strategy. As a member of the perinatal team, the craniofacial surgeon must be "cyber-savvy" to counsel parents and communicate with geneticists.

A new syndrome: heart defects, laryngeal anomalies, preaxial polydactyly, and colonic aganglionosis in sibs

We present two siblings, one male and one female, who have heart defects, duplication of toes, airway anomalies, and aganglionosis. The brother also has a bilateral complete cleft lip and palate. His airway anomalies include short epiglottis and aryepiglottic folds, which are different from his sister who has a bifid epiglottis with a central epiglottic mass. Both siblings have had some developmental delay. This constellation of anomalies appears to be unique and may represent a new autosomal recessive disorder.