To the Editor.
—The "Photo Essay" in the November 1991 issue of the Archives on the cause and treatment of conjunctival prolapse following craniofacial surgery by Levine and Buckman1 was understandably concise and well illustrated. They listed cerebrospinal fluid leakage and dependent edema as the main causes of conjunctival prolapse in this setting. There is, however, another cause of conjunctival prolapse following craniofacial surgery that has important therapeutic implications. During combined intracranial-extracranial craniofacial surgery, such as bifrontal forehead rim advancement, the brain may be decompressed by intravenous osmotic agents, cerebrospinal fluid drainage, and hyperventilation. After the supraorbital rim is advanced, the effective cranial cavity is enlarged, thereby increasing the relative dead space formed by the shrunken brain. After surgery, the brain size reequilibrates and expands to fill the enlarged anterior fossa space, thereby pushing air out of the cranial cavity and into either the subgaleal space or the orbit
Patrinely JR, George RE, Stal S. Conjunctival Prolapse Following Craniofacial Surgery. Arch Ophthalmol. 1992;110(10):1359. doi:10.1001/archopht.1992.01080220021006