Evolution Of Box Osteotomy And Facial Bipartition For Orbital Malposition: A Two-decade Three-dimensional Comparative Analysis

PURPOSE: Orbital malposition presents a reconstructive challenge due to phenotypic variability and frequent coexistence of craniofacial anomalies. Over two decades, the senior author's approach evolved from monobloc facial bipartition (MBFB) to box osteotomy (BO), driven by BO's potential for multivector correction. This study integrates a longitudinal series with three-dimensional (3D) quantitative analyses to (1) compare BO and MBFB in improving midface projection, (2) evaluate a rotationally modified BO ("pinwheel BO"), and (3) outline an algorithmic framework for procedure selection. METHODS: A retrospective review was conducted of patients who underwent MBFB or BO by a single craniofacial surgeon at a tertiary pediatric center (2006-2025). Demographics, perioperative data, and complications were collected. Pre- and postoperative CT scans were processed using Mimics software for 3D reconstruction and craniometric analysis. For the comparative 3D study, anterior-posterior positions of the lateral and infraorbital rims were measured as orthogonal distances from the coronal reference plane at the level of the sella. Growth adjustment was applied using nasion-to-sella percentage change. Net and percentage changes were calculated, and multivariate regression assessed the independent effect of procedure type (BO vs MBFB). For standard versus pinwheel BO, vertical movement was measured relative to the Frankfort Horizontal plane. Rotational movement was defined as the angular change between the dacryon-zygomaticofrontal line and a perpendicular line through the dacryon. Postoperative rotational asymmetry, interdacryon distance, and lateral orbital distance were also compared. Significance was set at p0.05. RESULTS: Forty-five patients (mean age 10.3±3.7 years) underwent orbital repositioning: 17 BO and 28 MBFB. Of the BO group, six were unilateral and 11 bilateral; since 2016, BO has accounted for 65% of orbital malposition corrections. BO achieved significantly greater AP advancement than MBFB at all landmarks (median right/left lateral orbital rim=11.5/12.5 voxels vs 1.0/1.8 voxels; p=0.001, 0.007). The right/left infraorbital rim advanced 6.5/7.7 voxels for BO vs 2.1/2.4 voxels for MBFB (p=0.017, 0.19). After adjusting for age, sex, and prior fronto-orbital advancement, BO remained independently associated with greater AP advancement except at the left infraorbital rim. In the subset comparing standard and pinwheel BO, vertical movement was similar, while the pinwheel modification showed greater rotational movement (Right 2.3° vs 9.4°; Left 4.5° vs 6.9°) and improved symmetry (RA 2.9° vs 0.9°), though not statistically significant. CONCLUSIONS: MBFB remains a valuable tool for patients with proportional frontofacial hypoplasia with minimal multivector correction. However, BO achieves superior midface projection and multidirectional correction, while the pinwheel modification improves rotational symmetry. Procedure selection should reflect deformity pattern, dental and orthodontic factors, and the goal of minimizing lifetime interventions through comprehensive vector correction in a single stage.