Operative Technique in Plastic Surgery – Kevin C.Chung

Endonasal-
endotracheal
tube intubation
■ Secure tube in multiple places with relief of any pressure on
ala to avoid alar rim necrosis, and routinely reassess tube
position.
Intraoperative
hypotensive
anesthesia
■ Maintain SBPs in 90s and MAP of 50s for best visualization
and to help minimize blood loss from osteotomies.
Gingivobuccal
sulcus incision
■ Maintain a generous cuff of tissue for closure because it
shrinks and may leave insufficient tissue coverage over
hardware.
Remain
subperiosteal in
maxillary
dissection
■ Avoid slipping out of the subperiosteal plane laterally over the
maxilla as it can violate the buccal fat pad, which can be pesky
and obscure view of the operative field.
Maxillary
osteotomy of
posterior wall
and
pterygomaxillary
junction
■ Maintain patience and control with these osteotomies; avoid
plunging or big movements with osteotome; avoid injury to
internal maxillary artery; and avoid severe hemorrhage.
Down-fracturing
the maxilla
■ Gentle digital pressure. If it does not go, do not force it, retrace
your osteotomies, and make sure they are complete. Do not
rush into an unfavorable fracture.
Pulsatile
intraoperative
bleeding
■ If can be identified, stop with bipolar cautery; if unable to
identify, apply pressure and reduce maxillary down-fracture to
tamponade.
■ If unable to control bleeding after down-fracture, cautery, and
tamponade, reposition the bony Le Fort segment. If bleeding
continues, resuscitate and consider interventional radiologist
consult for possible endovascular embolization procedure.
Consider aborting the procedure.
Preoperative
planning and
splint
■ Key to successful outcome. Virtual surgical planning is helpful,
predicable, and time saving over traditional model surgery.
■ This will provide a reliable outcome. Maintain patients in
postoperative occlusal splint for greater stability.
If advancement
greater than 9
mm
■ Consider distraction of the maxilla.

Verify bite is
stable and easily
reproducible
■ Bite should be reproducible and passively fit into prefabricated
occlusal splint.
■ In noncleft patients without segmentation, remove the splint
and place guiding elastics and allow to function with a soft diet.
■ In cleft patients with multisegmentation, keep the split in place
for additional stability. Consider guiding elastics if there is
excellent rigid fixation. Consider heavy elastic MMF if the
stability is suboptimal or if degree of advancement/expansion is
extensive or if there is significant palatal scar tissue.
Closure of
incision
■ If maxilla is advanced, consider V-to-Y closure of central
upper gingival incision to minimize excess central incisal show.
Cleft patients
■ These patients tolerate smaller advancements and expansions
of the maxilla; consider bone grafting; use delicate care of
premaxillary soft tissue when bilateral cleft patients undergo
three-piece Le Fort I.
POSTOPERATIVE CARE
■ Postoperatively, noncleft patients who have undergone segmental Le Fort I
osteotomy are not routinely held in MMF; cleft patients, however, due to an
altered bone stock along alveolar cleft sites, and the propensity of palatal scar
tissue from precious interventions, are maintained in MMF with elastics or
wires postoperatively for 4 to 6 weeks to minimize the propensity of relapse.
■ Cleft and noncleft patient cohorts are both maintained in postoperative
maxillary splints and remain on liquid/puree “no-chew” diets for 8 weeks.
■ Patients can drink with a straw but no negative pressure or “sucking” on
straw as this can place undue stress on intraoral incisions.
■ However, they may use a squeeze bottle to passively instill liquids or purees
intraorally to maintain their no-chew diet.
■ Postoperatively, the head of the bed should be elevated 35 degrees.
■ Patients who remain in MMF postoperatively will have bedside scissors (for
elastics) or wire cutter (for wires) at all times in case of airway emergency if
MMF needs to be removed.
■ Patients and families are taught before discharge home how and when to use
the scissors or wire cutter in case of emergency.
■ The patients receive humidified blow-by supplemental oxygen to moisten
mucous membranes overnight while in the hospital.

■ Patients also receive two more tapering IV doses of dexamethasone to reduce
facial edema, as well as topical triamcinolone cream over lips/oral
commissures.
■ Patients are given standing antiemetics if in MMF (ondansetron, scopolamine
patch, and/or Compazine) to reduce nausea.
■ All patients are watched overnight postoperatively for airway management
(continuous pulse oximetry), and routine vitals are taken.
■ Patients may start liquid diet immediately, transition to purees; if tolerating
oral diet, ambulating, pain is tolerable and airway without issues, they may be
discharged home as early as postoperative day 1.
■ Patients are discharged home on liquid medication for analgesia, oral swish
and gargle chlorhexidine solution, and oral antibiotics for 5 days with follow-
up in 2 weeks.
OUTCOMES
■ Routinely, patients who undergo Le Fort I osteotomy advancements,
segmented or otherwise, show a profoundly positive impact on their facial
balance, occlusal relationships, and overall quality of life.
■ Some element of relapse can be seen in roughly 20% of all patients
undergoing Le Fort I maxillary advancement and segmentation.
■ This is particularly the case for patients that have a history of previous cleft
palate repair.
■ The risk of relapse in the transverse and anteroposterior dimensions is
believed to be due to multiple sites for bony healing (or nonunion), previous
velopharyngeal scarring, the palatal tissue constraints/scarring, and lower-
quality bone stock in cleft patients.3
■ Most cases of relapse are minor in nature and can be corrected with
postsurgical orthodontics and thus will have negligible effect on form and
function.
■ If the relapse is significant, has detrimental effect on function or stability, and
cannot be corrected orthodontically, then secondary surgical intervention
should be considered. Relapse appears most closely correlated with distance of
maxillary advancement and history of previous palatal surgical intervention
due to facial clefting.4
COMPLICATIONS
■ Stability of the maxillary movement in cleft patients is less than that of

noncleft patients.
■ The risk of other complications is greater in patients with unilateral and
bilateral cleft palate and alveolus.
■ Patients who undergo movements greater than 9 mm have a higher risk of
complications.
■ Complications include bleeding, infection, relapse, nonunion or malunion, loss
of teeth, fistula, soft tissue recession, nerve injury, and necrosis of maxilla.5
■ Early postoperative relapse is usually secondary to suboptimal fixation or
position or the segmented maxilla. Late relapse, particularly in cleft patients, is
more likely due to the palatal scarring.
■ Loss of premaxillary segment has been reported in those patients with bilateral
clefts undergoing multisegmented Le Fort I osteotomy.
■ We advocate for a large gingival cuff to be left over the premaxilla,
atraumatic dissection along the alveolar ridge maintaining periosteal blood
supply, and extensive preoperative discussion with the patient and family.
REFERENCES
1. Bell WH, Fonseca RJ, Kenneky JW, Levy BM. Bone healing and
revascularization after total maxillary osteotomy. J Oral Surg. 1975;33(4):253-
260.
2. Scolozzi P. Distraction osteogenesis in the management of severe maxillary
hypoplasia in cleft lip and palate patients. J Craniofac Surg. 2008;19(5):1199-
1214.
3. Proffit WR, Phillips C, Turvey TA. Stability after surgical-orthodontic
corrective of skeletal class III malocclusion. 3. Combined maxillary and
mandibular procedures. Int J Adult Orthodon Orthognath Surg. 1991;6(4):211-
225.
4. Dowling PA, Espeland L, Sandvik L, et al. Le Fort I maxillary advancement:
3-year stability and risk factors for relapse. Am J Orthod Dentofacial Orthop.
2005;128(5):560-567.
5. Kramer FJ, Baethge C, Swennen G, et al. Intra- and perioperative
complications of Le Fort I osteotomy: a prospective evaluation of 1000
patients. J Craniofac Surg. 2004;15(6):971-977.

24
CHAPTER
Le Fort II Osteotomy and
Advancement
Adi Rachmiel, Dekel Shilo, and Omri Emodi
DEFINITION
■ Patients with midface hypoplasia involving the maxilla and nasal complex,
with an acceptable position of the zygomatic complex and orbits, benefit from
Le Fort II advancement.1-3
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Midface deficiency can be secondary to
■ Traumatic deficiencies
• Need to assess mechanism of injury
• Assess for the presence of functional problems including
• Breathing difficulty
• Eating problems
• Speech problems
■ Nasomaxillary dysplasia
• Assess breathing, eating, and speech problems.
■ Cleft deformities
• Assess breathing, eating, and speech problems.
• Assess for potential palatal fistulas and need for bone grafting.
IMAGING AND OTHER DIAGNOSTIC STUDIES
■ Lateral cephalogram
■ Posteroanterior cephalogram
■ Cone-beam computed tomography (CBCT) or spiral CT scan
■ Cast models of the upper and lower jaws, setting the models in the articulator

DIFFERENTIAL DIAGNOSIS
■ Nasomaxillary hypoplasia; may involve the dentoalveolar segment.
■ Binder syndrome
■ Nasomaxillary hypoplasia with normal dental occlusion
SURGICAL MANAGEMENT
Preoperative Planning
■ Preoperative CBCT or spiral CT with lateral and posteroanterior cephalogram
■ Model casts are placed for assessment of occlusion. Preoperative orthodontics
require leveling, alignment, and decompensation-retrusion of the upper dental
arch and protrusion of the lower incisors to increase the amount of skeletal
advancement.
■ Prefabricate an occlusal wafer according to the predetermined planned
position of the midface.
FIG 1 • Bi-coronal approach. A. Marking of the coronal
incision, notice the hairline. B. Following flap elevation
notice the exposure of the nasofrontal suture and the
medial orbital wall.
Positioning
■ The patient is placed supine.
■ Nasal intubation is used to allow both intra- and extra-oral access
■ IV muscle relaxant for improved mouth opening.
■ Bite block maintains mouth open during surgery
■ Local anesthetic with adrenaline for vasoconstriction
■ Access must be possible to both sides of the patient’s face.
Approach1-11
■ Intraoral buccal sulcus incision is used to approach the midface. This includes
a circumvestibular incision from the right first molar to the left first molar.
■ Different options for extraoral incisions include
■ A coronal incision (FIG 1A,B)

■ Double Lynch, which includes a combination of a paranasal incision with an
inner canthus incision to expose the nasal bone (FIG 2A).
■ In older patients, it may be possible to use a single dorsal nasal incision via a
skin-crease seagull incision (FIG 2B).
FIG 2 • Alternative skin incisions for older patients. A.
Seagull – an incision on the frontonasal area. B. Lynch
incision – Fronto-ethmoidal medial orbitotomy
approach.
T E C H N I Q U E S
■ Le Fort II Osteotomy
Extraoral Approach
■ A skin incision is made according to the Lynch approach/dorsal nose
crease/coronal approach (FIG 1A).
■ The dissection is subperiosteal.
■ The floor and rim of orbit are exposed medially and inferiorly. Both the
infraorbital nerve and the nasolacrimal duct must be identified and preserved.
■ The osteotomy is made vertically between the nasolacrimal duct and the
infraorbital nerve (TECH FIG 1A).
■ The cut is then continued via the intraoral incision toward the posterior
maxilla as in a Le Fort I osteotomy.

■ The nasal mucosa is protected with a periosteal elevator during the vertical
cut; the orbital contents should be protected with a malleable retractor.
■ The nasal bridge is exposed.
■ The vertical cuts are connected via a horizontal osteotomy immediately
below the nasofrontal suture and above the lacrimal crests. The osteotomy
should be directed slightly downward to avoid penetrating the cribriform
plate (TECH FIG 1B).
■ This osteotomy should be the last procedure before mobilization, after
completing the intraoral osteotomies. This is due to a high risk of bleeding
from blood vessels in that area of the nasal osteotomy.
■ The nasal septum is divided through the frontonasal osteotomy using a chisel
(TECH FIG 1B).
■ A finger should be placed intraorally in the area of the posterior nasal spine
to mark the direction of the osteotomy and also to protect against
penetration of the osteotome through the palate mucosa.
Intraoral Approach
■ A bilateral horizontal incision is made in the maxillary vestibule 2 to 3 mm
above the attached mucosa, from the central incisor anteriorly toward the first
molar posteriorly.
■ Complete exposure is required of the lateral maxilla from the central incisors
toward the pterygomaxillary junction posteriorly.
■ Separating the nasal mucosa from the lateral nasal wall is preformed using a
periosteal or Freer elevator.
■ A lateral horizontal maxillary osteotomy is made on the lateral maxilla with
a reciprocating saw; the osteotomy is made at least 5 mm above the apex of
the teeth at the level of the nasal floor.
■ This cut extends from the pterygoid plate posteriorly to join the vertical cut
from the inferior orbital rim anteriorly.
■ These cuts must avoid damage to the apex of tooth roots.
■ The pterygomaxillary fissure is osteotomized using a curved osteotome. It is
critical to position the osteotome correctly, in an inferior and medial
direction.
■ The midface osteotomy is mobilized with Rowe disimpaction forceps and
advanced to the preplanned position. This procedure should be done firmly,
but gently.

Fixation
■ The desired osteotomy is shown in TECH FIG 2A.
■ Intermaxillary fixation is applied according to the preplanned final occlusion
using occlusal wafers and dental wires.
■ Extraoral fixation is applied at the nasal bridge using an inverted Y miniplate
or two L miniplates (TECH FIG 2B).
■ L miniplates are used at the zygomaticomaxillary buttress bilaterally.
■ Stabilization with bone grafts should be considered.
■ Bone grafts can be harvested from the calvarium if a coronal incision is
used or from the iliac crest if facial-only incisions are used.
■ Allograft blocks are also an option.
TECH FIG 1 • Le Fort II Osteotomy. A. The osteotomy
is made vertically between the nasolacrimal duct and
the infraorbital nerve. B. A chisel is used to separate
the segment in the nasofrontal area.

TECH FIG 2 • Le Fort II advancement and fixation. A.
The completed osteotomy. B. Extraoral fixation is
applied at the nasal bridge using an inverted L
miniplate. Intraoral fixation is applied at the
zygomatico-maxillary buttress. Bone grafts can be
harvested from the calvarium if a coronal incision is
used or an iliac crest bone graft when facial-only
incisions are used. Allograft blocks are also an option.
The purpose of the bone grafts is stability and
avoiding relapse (arrows).
■ High Le Fort I With Nasal Augmentation
■ This option is applied mostly in patients with Binder syndrome.
■ A bilateral horizontal incision is made in the maxillary vestibule 2 to 3 mm
above the attached mucosa, between the central incisor anteriorly and the first
molars posteriorly.
■ Expose the lateral maxilla from the central incisors toward the
pterygomaxillary junction posteriorly.
■ Separate the nasal mucosa from the lateral nasal wall using a periosteal or
Freer elevator.
■ A lateral horizontal maxillary osteotomy on the lateral maxilla is made using

a reciprocating saw; the osteotomy is made at least 5 mm above the apex of
the teeth at the level of the nasal floor from the pterygoid plate posteriorly,
making a high-step osteotomy in the area of the nasomaxillary buttress
(TECH FIG 3).
■ The pterygomaxillary fissure is osteotomized using a curved osteotome.
Position the osteotome in an inferior and medial direction.
■ The maxillary complex is mobilized with Rowe disimpaction forceps and
advanced to the preplanned position.
■ Intermaxillary fixation is applied according to the preplanned final occlusion
using occlusal wafers if needed and dental wires.
■ L mini plates are used at the zygomaticomaxillary buttresses and
nasomaxillary buttress bilaterally.
■ Incisions for access may be through a coronal incision, a bilateral Lynch
approach, or—in older patients—through a seagull approach (see FIG 2).
■ The nasal bone is exposed and a pocket is created at the nasal tip.
■ A costochondral bone graft or alloplast graft is fixated at the nasal bridge
using an inverted T miniplates or double L miniplates.
TECH FIG 3 • High-step osteotomy in the
nasomaxillary area.

PEARLS AND PITFALLS
Telecanthus
■ In large skeletal movements, place the medial nasal osteotomies
anterior to the medial canthus to avoid telecanthus.
Nasal
apparatus
■ When dividing the nasal septum, direct the osteotome slightly
downward and backward toward the posterior nasal spine.
Nasolacrimal
system
■ Avoid injury to the nasolacrimal system, especially to the lacrimal
sac during the osteotomy; at the infraorbital rim, make the
osteotomy as lateral as possible to avoid lacrimal system injury. Be
aware of the infraorbital nerve position.
Nerve
■ The osteotome should be introduced medial to the infraorbital
foramen in order to avoid nerve damage.
Bleeding
■ During osteotomy of the pterygoids, there is risk of iatrogenic
rupture of the internal maxillary artery or pterygoid venous plexus.
Position the osteotome correctly, in an inferior and medial direction
to avoid injuring these vessels.
Deficient
infraorbital
region
■ Extend the osteotomy of the orbital floor more laterally as close as
possible to the infraorbital foramen.
Scar
■ Paranasal incisions can be esthetically problematic.
■ Bicoronal incision may be considered as a better alternative in
some cases.
POSTOPERATIVE CARE
■ Intraoperative and postoperative intravenous steroids and antibiotics are given.
■ Prophylactic antibiotic treatment is continued for 1 week. A short course of
nasal decongestants is prescribed.
■ Patient will be on a liquid diet for 4 weeks due to MMF.
■ Once the patient has recovered, a CBCT, panorex and lateral cephalogram can
be obtained.
■ Skin suture removal should be performed at 2 weeks postoperatively.
■ Dental wires should be removed at 4 weeks.
OUTCOMES
■ Increased midface projection9,11

■ Class one dental occlusion—to avoid future relapse, the teeth of the upper jaw
are placed in an overcorrected position creating a positive overjet; this is
established by using prefabricated occlusal splints. Positioning of
allograft/autogenous bone in the area of the nasofrontal gap may also minimize
future relapse.
COMPLICATIONS
■ Infection
■ Postoperative bleeding can occur up to 3 weeks after surgery, due to injury of
the greater palatine vessels or the pterygoid venous plexus.
■ Loss of teeth near the osteotomy sites
■ Telecanthus
■ Loss of sensation in the infraorbital, supraorbital, and paranasal regions
■ Damage to the lacrimal apparatus
REFERENCES
1. McCollum AG, Wolford LM. Binder syndrome: literature review and long-
term follow-up on two cases. Int J Adult Orthodon Orthognath Surg.
1998;13(1):45-58. Review.
2. Steinhauser EW. Variations of Le Fort II osteotomies for correction of
midfacial deformities. J Maxillofac Surg. 1980;8(4):258-265.
3. Holmes AD, Lee SJ, Greensmith A, et al. Nasal reconstruction for
maxillonasal dysplasia. J Craniofac Surg. 2010;21(2):543-551.
4. Henderson D, Jackson IT. Nasomaxillary hypoplasia—the Le Fort II
osteotomy. Br J Oral Surg. 1973;11:77.
5. Van Sickels JE, Tiner BD. A combined Le Fort I and bilateral zygomatic
osteotomy for management of midface and maxillary deficiency. J Oral
Maxillofac Surg. 1994;52:327-331.
6. Epker BN, Wolford LM. Middle third facial osteotomies: their use in
correction of acquired and developmental dentofacial and craniofacial
deformities. J Oral Surg. 1975;33:491.
7. Tahiri Y, Taylor J. An update on midface advancement using Le Fort II and III
distraction osteogenesis. Semin Plast Surg. 2014; 28(4):184-192.
8. Yu H, Dai J, Wang X, et al. Le Fort II midfacial distraction combined with
orthognathic surgery in the treatment of nasomaxillary hypoplasia. J Craniofac
Surg. 2014;25(3):e241-e244.
9. Wang H, Yuan J, Zhang Y, et al. Modified nasomaxillary and hard palatine

osteotomy combined nasal implantation to correct Binder syndrome. J
Craniofac Surg. 2013;24(1):200-203.
10. Reyneke JP, Widegrow AD. Nasomaxillary osteotomy for the correction of
Binder’s syndrome (nasomaxillary dysplasia). Int J Adult Orthodon
Orthognath Surg. 1996;11(2):117-126.
11. Jackson IT, Moos KF, Sharpe DT. Total surgical management of Binder’s
syndrome. Ann Plast Surg. 1981;7(1):25-34.

25
CHAPTER
Le Fort II Advancement With
Distraction Osteogenesis
Eugenia K. Page, Colin M. Brady, and Joseph K. Williams
DEFINITION
■ A Le Fort type II is a pyramidal fracture pattern that peaks at the nasofrontal
suture and extends across the orbital floor and rim, underneath the zygoma, and
then wraps around the pterygomaxillary fissure through the pterygoid plates.
This was first described in 1901 by the French military surgeon Rene Le Fort.1
■ Variations of the Le Fort II osteotomy, including the anterior, pyramidal, and
quadrangular types, have been utilized to advance the hypoplastic midface
(FIG 1).
■ The various osteotomy patterns can be utilized with distraction osteogenesis
(DO) to achieve changes in the midface skeleton including nasal projection
and maxillary advancement.
ANATOMY
■ Identify the lacrimal system (ie, inferior lacrimal duct and sac) and the medial
canthal attachment in the superior/posterior aspect of the medial orbit, located
on the maxillary process of the frontal bone (FIG 2).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Nasomaxillary deficiency is commonly found in craniofacial syndromes such
as Crouzon, Apert, and Pfeiffer syndromes but can also be due to
craniosynostosis, hemifacial microsomia, Romberg disease, Binder syndrome,
traumatic defects, and cleft and non–cleft-related nasomaxillary hypoplasia.2–5

FIG 1 • Comparison of Le Fort II osteotomy patterns.
Blue, anterior; green, pyramidal; red, quadrangular.
■ Presurgical assessment should include airway, speech, occlusion, mastication,
and social/psychological consequences of the craniofacial deformity.
■ Physical findings include maxillary hypoplasia with an associated class III
molar relationship and varying degrees of recession of the nasal base as well as
malar deficiency.6
■ Exophthalmos is traditionally corrected with a Le Fort III advancement;
however, successful repair has been reported using a Le Fort II osteotomy that
includes the majority of the inferior orbital rim.7
■ Nasomaxillary retrusion is the most common finding in patients who need a
Le Fort II procedure in which a pyramidal Le Fort II pattern is used (TABLE
1).
IMAGING
■ Cephalometric analysis of the facial skeleton may be used to characterize and
quantitate the areas of deficiency.
■ Overlay grids taken from age-matched norms of facial skeletons may highlight
deficiencies and can be used to determine the amount of skeletal movement.
■ Dental radiographs and orthodontic records are obtained for orthodontic
preparation and timing of the procedure (mixed vs adult dentition).
■ Computed tomography with three-dimensional (3D) reconstructions should be
obtained.
■ Virtual surgical planning (VSP) uses CT images to improve accuracy of the
osteotomies and decrease operative time. VSP is advantageous for planning
vectors, advancement distances, manufacturing skull models and occlusal
splints, molding distraction devices preoperatively, and avoiding potential
periorbital asymmetries.8,9
■ Skull models are constructed from the scans via either stereolithographs or
3D modeling for presurgical planning and device fitting in the operating
room.
■ A polysomnogram may be needed to evaluate airway obstruction secondary
to the midface retrusion.
SURGICAL MANAGEMENT

■ In patients in whom the advancement required at the midface level is no more
than 6 to 8 mm, mobilization of the mild hypoplastic midface can be performed
with definitive advancement, bone grafting, and plate fixation.
■ In syndromic patients, those with moderate to severe midface hypoplasia with
significant negative overjet/class III malocclusal patterns, and adolescents still
in active facial development, use of techniques for midface level DO is
recommended.10

FIG 2 • Relevant skeletal anatomy. A. Sagittal view. B.
Coronal view. C. Skull base view.
Table 1 Indications for Using Le Fort Osteotomies
Fort
Class 3
Malocclusion
Maxillary
Hypoplasia
Nasal
Projection
(Short)
Inferior
Orbital
Rim
(Retrusion) Exorbitism
Malar
Eminence
(Retrusion
I
*
Limited




IIP
*
*
*



IIQ
*
*

*
Limited

IIC
*
*
*
*
*
*
III
*
*
*
*
*
*
IIP, Le Fort II pyramidal pattern; IIQ, Le Fort II quadrangular pattern; IIC, Le
Fort II conversion from Le Fort III.
*Indications for level of Le Fort osteotomies and their capacity to address
skeletal deficiencies.
Preoperative Planning
■ Two commercially available external halo devices are available (External
Midface Distractor, manufactured by Synthes, Oberdorf, Switzerland, and the
Rigid External Distractor, manufactured by KLS Martin, Tuttlingen, Germany).
■ The primary advantage of the external device is the ability to perform real-
time modification of the vectors of force during distraction and its versatility
for distraction at all Le Fort osteotomy patterns.
■ Secondary benefits of the external device include the technical ease of device
application and removal, as well as a decreased risk of unfavorable fracture
patterns in areas of thin cortical bony stock during pin application.
■ Disadvantages of the halo are patient noncompliance related to the
psychosocial stigma of wearing the device, as well as frame- and hardware-
related complications such as pin loosening and pin-site scarring.11
■ An internal maxillary device can also be used for both quadrangular and
pyramidal patterns.
■ Despite improved compliance, these designs are criticized because they
distract at a single pivot point, with an inability to adjust the vector of force
during distraction.
■ The consequent vector may result in a clockwise rotation of the entire
midface during distraction, leading to long midface and an uncorrected or
undercorrected class III malocclusion with a posterior open bite.
■ The potential for clockwise rotation of the midface during distraction at the Le
Fort II level may be addressed by using temporary anchorage devices (TADs)
or microimplants to hold interarch class III relationship elastics.
■ Bollard plates or C-plates can be attached to the lateral buttresses bilaterally
along with a single plate at the glenoid tubercle. Class III elastics can be
applied to the associated hooks to aid control of the transport segment during
distraction.

Approach
■ Various access incisions can be used.
■ Upper buccal vestibular incision for degloving of the maxilla (FIG 3A)
• Identify the inferior orbital nerve.
■ Coronal incisions are used for a superior approach to complete the nasal and
medial orbital osteotomies (pyramidal technique and Le Fort II with zygoma
fixation; FIG 3B).
• The plane of dissection to the zygomatic arch is below the superficial layer
of the deep temporal fascia at the level of the superior orbital rim.
• The frontal branch of the facial nerve is located above the superficial layer
of the deep temporal fascia.
■ Transconjunctival approach (quadrangular technique) is used to access the
infraorbital rim and floor.
• The incision is made several millimeters below the inferior border of the
tarsal plate (FIG 3C).
• Dissection is performed in the preseptal plane to the inferior orbital rim
(FIG 3D).

FIG 3 • Access incisions for Le Fort II level osteotomies.
A. Maxillary vestibular incision. B. Bicoronal incision
with deep temporal fat pad dissection. C.
Transconjunctival approach with lateral canthal
extension. D. Sagittal view demonstrating preseptal
plane.
T E C H N I Q U E S
■ Pyramidal Le Fort II Osteotomy
■ Access is obtained through a coronal incision to access the nasofrontal
junction and an intraoral vestibular incision to visualize the maxilla.
■ Bony osteotomy proceeds transversely across the nasofrontal junction
inferior to the anterior ethmoidal foramina with the use of a reciprocating

saw, an ultrasonic scalpel, or osteotomes (TECH FIG 1A).
■ The osteotomy at the medial orbit is made posterior to the insertion of the
medial canthus and the posterior lacrimal crest.
■ The osteotomy is propagated posterior to the inferior orbital rim and across
the orbital floor with the use of an osteotome or ultrasonic scalpel.
■ The osteotomy is continued across the inferior orbital rim immediately
lateral to the inferior orbital foramen.
■ From the vestibule, the osteotomy is continued lateral to the inferior orbital
foramen and then transversely at the Le Fort I level to the pterygomaxillary
fissure staying cranial to the apical roots of the teeth (TECH FIG 1B).
■ The pterygomaxillary disjunction is performed with a curved osteotome via
the vestibular incision at the pterygomaxillary groove.
■ Having dissected the nasal floor, Rowe disimpaction forceps are applied and
the pyramidal Le Fort II complex is mobilized.
■ An external halo device is applied with pin sites cranial and caudal along the
medial buttress, with the addition (if needed) of another caudal pin along the
lateral buttress above the apical roots.
■ If an internal maxillary device is used, it is applied with footplates above and
below the transverse osteotomy along the lateral buttress (TECH FIG 1C).
■ Bollard plates, C-plates, or TADs can be applied intraorally, to allow
placement of intermaxillary class III elastics to help prevent clockwise
rotation of the midface during transport of the osteotomized segment.

TECH FIG 1 • Le Fort II osteotomy: pyramidal pattern.
A. Nasofrontal disjunction using an osteotome. B.
Illustration of osteotomy pattern. C. Outline of
osteotomy pattern with application of maxillary
distraction device.
■ Le Fort II Distraction and Zygomatic
Repositioning (Le Fort III Conversion to Le Fort
II)
■ In 2013, Hopper et al.12 published an innovative approach to the unique
central facial deformity encountered in Apert syndrome in which a Le Fort III
osteotomy was performed and then modified by rigidly fixing the zygoma
and placing the distraction device on the central midface.
■ The Le Fort II osteotomy pattern used most closely resembles the

pyramidal approach.
■ Access incisions include a combined coronal, transconjunctival, and
vestibular approach.
■ A Le Fort III level osteotomy is performed, disimpacted, and advanced until
the lateral orbital rims are level with the coronal corneal plane.
■ Fixation of the posterior zygoma to the anterior aspect of the lateral orbital
rim proceeds with 1.5-mm profile plates (TECH FIG 2).
■ With the nasofrontal disjunction already performed as part of the Le Fort III
osteotomies, the pyramidal Le Fort II pattern osteotomy proceeds through the
inferior orbital rims and then caudally, lateral to the infraorbital foramen.
■ An external halo device is applied with suspension wires attached to the
piriform rim and inferior lateral maxillary buttresses.
■ Distraction proceeds after a 3-day latency phase and is followed by 6 to 8
weeks of consolidation.
TECH FIG 2 • Le Fort II with zygomatic repositioning.
■ Quadrangular Osteotomy Le Fort II Level
Design and Exposure
■ This pattern of osteotomy was first described by Kufner et al. in 197113
(TECH FIG 3A,B).

■ Use of this technique in the correction of midface hypoplasia can obviate the
unfavorable “long-nose” deformity that inherently results from the Le Fort III
advancement.
■ As the nasofrontal junction does not need to be accessed for this osteotomy
pattern, a coronal dissection can be avoided (TECH FIG 3C,D).
■ Access to the relevant facial skeleton is obtained via a maxillary vestibular
incision in addition to a transconjunctival approach with lateral canthal
extension (TECH FIG 3E).

TECH FIG 3 • Le Fort II osteotomy: quadrangular

pattern. A. Illustration of osteotomy pattern. B. Outline
of osteotomy pattern with application of maxillary
distraction device. C,D. Intraoperative skull model
representing a patient with a significant class III
malocclusion and malar hypoplasia extending to the
infraorbital rim. E. Intraoral buccal incision to expose
the maxilla. The nasal floor is elevated and the
septum has been separated from the vomer.
Maxillary Device Placement
■ The maxillary device is prefitted onto the sterile skull model (TECH FIG
4A,B).
■ The devices are placed onto the maxilla in situ. Two screws are used to
secure the device, one screw on the malar area and the second on the lateral
buttress (TECH FIG 4C-E).
Osteotomy and Completion
■ Lines for the osteotomy are placed on the maxillae (TECH FIG 5A–C).
■ The osteotomy begins medially via the transconjunctival incision from the
medial aspect of the infraorbital rim through the frontal process of the
maxilla into the cranial aspect of the piriform aperture bilaterally, allowing
avoidance of the medial canthal tendon and lacrimal apparatus (TECH FIG
5D).
TECH FIG 4 • A,B. Prefitting the maxillary devices
onto the skull model prior to placement in the patient.
C. Placement of the marker screws in relation to the
osteotomy sites. D. Initial in situ fitting of the
distraction device prior to the osteotomies. E. The
device has been removed and the marker screws
have been placed. The screws allow the appropriate
placement of the proposed osteotomy location in

relation to the devices. Screw placement also allows
easy and accurate placement of the devices after
completion of the osteotomies.
■ The osteotomy continues via the lid incision with an osteotome or ultrasonic
scalpel posterior to the infraorbital rim, extending medial to lateral, to the
level of the lateral aspect of the infraorbital foramen (TECH FIG 5E).
■ A lateral canthal extension of the transconjunctival incision allows the
osteotomy to proceed through the lateral buttress in a number of vectors:
■ A high Le Fort I pattern down to the pterygomaxillary fissure
■ Through the zygomatic arch–zygoma junction
■ Through the caudal 5 mm of the lateral orbital wall in patients with more
significant lateral malar hypoplasia
■ The pterygomaxillary disjunction proceeds via the vestibular incision.
■ Elevation of the nasal floor along the piriform aperture facilitates placement
of the Rowe disimpaction forceps to allow a controlled mobilization of the
midface segment.
■ Two options exist for distraction:
■ An external halo device can be applied with pin sites along the medial and
lateral buttresses above the apical roots.
■ An internal maxillary distractor can be applied with footplates above and
below the transverse or oblique osteotomy along the lateral buttress.
■ Control of the midface pitch during distraction is achieved with Bollard
plates, C-plates, or TADs attached to intermaxillary class III elastics to help
prevent clockwise rotation during transport.

TECH FIG 5 • A. Outline of the quadrangular
osteotomy on the maxilla on the intraoperative skull
model. B. After the marker screws have been placed,
the lines for the osteotomy are placed on the right
maxilla. C. Lines for the osteotomy are then placed on
the left maxilla. The osteotomy is outlined medial to
the marker screw on the malar eminence and must
capture some of the malar eminence before extending

onto the lateral buttress. D. Illustration of the medial
and lateral osteotomies of the maxilla extending to the
infraorbital rim. E. Osteotomy across the orbital floor
with an osteotome using the transconjunctival incision.
PEARLS AND PITFALLS
General
■ Distraction procedures do not require intraoperative occlusal
fixation or postoperative maxillary mandibular wire closure.
Therefore, oral intubation is appropriate for these procedures.
■ An oral RAE tube can be placed and is easily positioned away from
the operative field. If prolonged intubation is anticipated, a regular
endotracheal tube provides better access for suction in the ICU and
is preferred.
■ If Le Fort II distraction with an internal maxillary device is planned
for a patient with a cleft and midface deficiency, a quad-helix
orthodontic expansion device is placed prior to the procedure. The
device is not used for expansion but provides a more rigid appliance
during late distraction, when vector forces tend to be directed to the
midline.
■ A 2.0-mm bridging plate is placed across the alveolar cleft, even
with adequate bone stock in the cleft, to stabilize the site and
prevent uncoordinated movements of the maxillary segments.
Osteotomies
■ Marking the medial canthal periosteal insertions with gentian violet
or methylene blue prevents overdissection of soft tissues at the
nasofrontal bridge and midline structures that can result in difficult-
to-correct deformities.
■ Mobilization of the Le Fort II transport segment, irrespective of
osteotomy pattern chosen, should proceed via a two-operator
approach.
■ Capture an adequate amount of the malar eminence with the lateral
osteotomy to provide stability of the infraorbital component of the
quadrangular Le Fort II segment and avoid unfavorable fractures
through the antrum.
■ One operator should perform controlled movements with Rowe
disimpaction forceps, while gradual mobilization of the segment is

performed by the second surgeon to mitigate unfavorable fracture
patterns.
Distractors
for Le Fort II
osteotomy
■ The use of the skull model with Le Fort II osteotomies is
imperative; an ill-placed osteotomy may compromise the placement
of the internal maxillary distraction device.
■ Outlining the location of the osteotomies and temporarily placing
the internal devices on the skull model avoids an inadequate bone
platform for the zygomatic footplate.
■ Placement of internal maxillary devices following completion of the
osteotomies and disimpaction of the central midface is facilitated by
placing a landmark screw on both the zygomatic footplate and the
inferior maxillary plate of the device at the initial fitting in situ and
prior to completion of osteotomies.
■ The screws are removed and returned to the original holes after
removal of the device.
■ These screws are maintained during the bone cuts and then removed
and reinserted into the original screw hole after the device is
replaced appropriately (see TECH FIG 3C,D).
■ If internal distraction techniques are used, Bollard plates, C-plates,
or TADs attached to class III intermaxillary elastics prevent rotation
of the midface during transport.
POSTOPERATIVE CARE
■ Airway ICU management
■ Patients are transferred from the OR to the ICU. Extubation is possible in
most patients. Excessive bleeding, concerns about airway, or prolonged
operative time may warrant continued intubation.
■ IV steroids are given postoperatively for 48 hours to mitigate peak soft tissue
and airway edema.
■ Perioperative antibiotics are given to cover oral and sinus flora for 7 days
postoperatively.
■ Head of bed is elevated to more than 30 degrees.
■ Pain and anxiolytic management should be employed via continuous drips or
administered as needed, and tailored to the patient’s convalescence.
■ In patients with significant syndromic midface dysmorphism, severe
preoperative obstructive sleep apnea, or submental intubations, extubation in
the OR with easy access to anesthesia staff and advanced airway adjuncts
should be considered.

■ Distraction
■ We recommend a latency period of 5 days.
■ Distraction is instituted on the morning of POD 5 at 0.5 mm twice daily (1
mm/d).
■ Family members are instructed on how to perform rotation of the activating
arms.
■ The active phase of distraction averages 10 to 20 days (10 to 20 mm).
■ If preoperative asymmetries exist, differential advancements of the activating
arms may be required to achieve optimal facial harmony.
■ Regular follow-up with clear communication from family via pictures can
guide the distraction interval.
■ Unlike advancement, the goal of distraction is not ideal occlusion, but
midface harmony in profile. Occlusion is formalized via either postoperative
orthodontic treatment or formal orthognathic surgery.
■ Following completion of distraction, the activating arms can generally be
removed in clinic.
■ We recommend a consolidation phase of 3 months prior to device removal.
■ If an internal Le Fort I level device is utilized for the Le Fort II distraction,
the device can be removed with a vestibular incision.
■ If Bollard plates, C-plates, or TADs have been used, they are removed
simultaneously.
■ Lateral canthopexies or lid-tightening procedures can be employed at this
stage to complete reconstruction.
■ If vertical orbital dystopia has resulted from the advancement, bone grafting
(eg, split calvarium) of the orbital floor can be performed to achieve
symmetry.
■ Patients with severe obstructive sleep apnea should have a postoperative
sleep study to assess breathing improvement; continuous positive airway
pressure, or supplemental oxygen may no longer be required.
OUTCOMES
■ Midface distraction distances ranged from 8 to 21 mm.
■ Skeletal relapse is a significant concern, but long-term data are scant. Swennen
et al.14 reviewed 285 articles on DO between 1966 and 1999, which included
mandibular, maxillary, midface, and craniofacial distraction.
■ Of the 96 patients identified who underwent midface or cranial distraction,
only 19 patients had data on relapse.

■ Of these 19 patients, only 2 (10.5%) demonstrated mild relapse.
■ Much of the historical data suggest that unacceptably high rates of relapse
after midface advancement were secondary to:
■ Underappreciation of the contradictory force vectors of the midface soft
tissue envelope
■ Formal advancements of more than 10 mm prior to the advent of DO
■ Underuse or nonutility of at least 8 weeks of postoperative intermaxillary
fixation with occlusal splints
■ Poor cortical bony stock for plate fixation in certain osteotomy patterns
■ Relapse rates have been mitigated due to adherence of several principles:
■ Current use of internal and external DO techniques that allow for interval
histogenesis of the midface soft tissue envelope
■ Guidance of the midface transport segment via halo device, intraoral Bollard
plates, C-plates, or TADs
■ Adherence to 8 or more weeks of IMF in cases of formal advancement
COMPLICATIONS
■ Infection
■ Bleeding
■ Bony malunion
■ Nonunion
■ Premature consolidation
■ Skeletal instability
■ Relapse
■ Device failure
■ Development of velopharyngeal incompetence
■ Injury to the infraorbital nerve
■ Partial or complete avulsion of the medial canthal tendon
■ Injury to the nasolacrimal system
REFERENCES
1. Tessier P. The classic reprint: experimental study of fractures of the upper jaw.
3. Rene Le Fort, M.D., Lille, France. Plast Reconstr Surg. 1972;50:600-607.
2. Hara S, Mitsugi M, Kanno T, et al. Endoscopically assisted intraoral modified
Le Fort II type midfacial advancement using piezoelectric surgery and an
intraoperative RED system. J Oral Maxillofac Surg 2013;71:e93-e103.

3. Lakin GE, Kawamoto HK Jr. Le Fort II osteotomy. J Craniofac Surg.
2012;23(suppl 1):1964-1967.
4. Stirrups DR, Patton DW, Moos KF. A cephalometric analysis of the Le Fort II
osteotomy in the non-cleft patient. J Maxillofac Surg. 1986;14:260-266.
5. Ward-Booth RP, Bhatia SN, Moos KF. A cephalometric analysis of the Le Fort
II osteotomy in the adult cleft patient. J Maxillofac Surg. 1984;12:208-212.
6. Henderson D, Jackson IT. Naso-maxillary hypoplasis—the Le Fort II
osteotomy. Br J Oral Surg. 1973;11:77-93.
7. Burstein F, Soldanska M, Granger M, et al. Initial experience with a new
intraoral midface distraction device. J Craniofac Surg. 2015;26:1224-1228.
8. Gray R, Gougoutas A, Nguyen V, et al. Use of three-dimensional,
CAD/CAM-assisted, virtual surgical simulation and planning in the pediatric
craniofacial population. Int J Pediatr Otorhinolaryngol. 2017;97:163-169.
9. Klug C, Cede J. Technical modifications for intraoral quadrangular Le Fort II
osteotomy. J Oral Maxillofac Surg. 2017;75:402 e1-402 e16.
10. McCarthy JG, Stelnicki EJ, Mehrara BJ, Longaker MT. Distraction
osteogenesis of the craniofacial skeleton. Plast Reconstr Surg. 2001;107:1812-
1827.
11. Fearon JA, Whitaker LA. Complications with facial advancement: a
comparison between the Le Fort III and monobloc advancements. Plast
Reconstr Surg. 1993;91:990-995.
12. Hopper RA, Kapadia H, Mortonm T. Normalizing facial ratios in Apert
syndrome patients with Le Fort II midface distraction and simultaneous
zygomatic repositioning. Plast Reconstr Surg. 2013;132:129-140.
13. Kufner J. Four-year experience with major maxillary osteotomy for retrusion.
J Oral Surg. 1971;29:549-553.
14. Swennen G, Schliephake H, Dempf R, et al. Craniofacial distraction
osteogenesis: a review of the literature. Part 1: Clinical studies. Int J Oral
Maxillofac Surg. 2001;30:89-103.

26
CHAPTERLe Fort III Advancement
Ghassan S. Abu-Sittah and Rawad S. Chalhoub
DEFINITION
■ Le Fort III, first described by Rene Le Fort in 1901, is a pattern of craniofacial
fractures that involves the nasofrontal suture, traverses the orbital floor, and
crosses the zygomaticofrontal suture and zygomatic arch (FIG 1).1
■ In the 1960s and 1970s, Gillies and Tessier applied Le Fort’s classification to
facial osteotomies for the treatment of patients with midface hypoplasia.
■ Le Fort III osteotomy with advancement, also known as craniofacial
disjunction, is currently used for the correction of functional and aesthetic
problems in patients with craniofacial dysostosis syndromes such as Crouzon,
Apert, or Pfeiffer syndromes.
■ These conditions usually present with midfacial retrusion, shallow orbits,
exorbitism, malocclusion, obstructive sleep apnea, and facial imbalance (FIG
2).
■ Le Fort III advancement restores normal midface projection, re-establishes
normal dental occlusion, increases the vertical dimensions of the face, and
corrects exorbitism.
ANATOMY
■ Normal facial growth depends on the coordinated expansion of the brain and
overlying skeletal elements.
■ The skull is relatively well developed at birth to protect the brain, whereas the
facial skeleton continues to grow during childhood to accommodate dental
development, orbital modeling, and airway formation.

FIG 1 • Pattern of Le Fort III fracture pattern.
■ Cranial dysostosis describes syndromic craniosynostoses in which suture
involvement includes the cranial vault, cranial base, and midface skeletal
structures.
■ Midface skeletal hypoplasia leads to both functional and cosmetic problems.
■ Le Fort III advancement is generally required in these patients.
PATHOGENESIS
■ Mutations of FGFR genes 1 to 3 lead to syndromic craniosynostoses,
including Apert, Pfeiffer, Crouzon, Beare-Stevenson, Jackson-Weiss, Crouzon
with acanthosis nigricans, and Muenke syndromes.2
■ Environmental causes include paternal occupation, maternal age, exposure to
tobacco smoke, and medications during pregnancy, including nitrofurantoin
and warfarin.3
NATURAL HISTORY
■ Craniosynostosis occurs in an estimated 1 out of every 2000 live births; it can
occur as an isolated condition or part of a syndrome.
■ Syndromic craniosynostosis affects 1:30 000 to 1:100 000 live births.4
■ The midface hypoplasia in these conditions is progressive, becoming more

noticeable as the patient grows.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Craniofacial dysostosis patients suffer from a series of sequelae from growth
abnormalities.
■ Increased intracranial pressure (ICP) can occur as a result of the rapidly
growing brain during infancy with limited space for expansion.
■ Untreated ICP can cause papilledema and optic nerve atrophy, which can
eventually lead to blindness.
■ Vision problems may also occur secondary to exorbitism (exophthalmos)
leading to corneal exposure with ulceration.3
■ Dental, occlusal, and hearing deficits are higher in patients with craniofacial
dysostosis than in the general population.2
■ The most severe consequence of midface deficiency is obstruction of the
developing airway, with narrowing of nasal and nasopharyngeal spaces,
leading to increased airway resistance.5
■ Newborns are obligate nasal breathers; airway obstruction forces them to
breathe through the mouth, resulting in an inability to feed and breathe
simultaneously. These newborns are at high risk for malnutrition and failure to
thrive.
FIG 2 • A. Exorbitism secondary to shallow orbits. B,C.
Lateral views of a patient with Apert syndrome.
Midfacial retrusion and shallow posterior fossa are
evident.

■ Patients with severe symptoms, generally obstructive sleep apnea or
exorbitism, may require a combination Le Fort III advancement with cranial
advancement. Monobloc advancement is preferentially performed as a
distraction procedure.6
■ Patients who are mildly affected undergo Le Fort III advancement at skeletal
maturity.
IMAGING
■ Preoperative imaging required for patients undergoing Le Fort III
advancement includes
■ Anteroposterior and lateral x-rays
■ Panoramic x-rays
■ Two-dimensional (2D) and three-dimensional (3D) CT scans (FIG 3)
■ These images will demonstrate midface hypoplasia, as well as the various
anomalies associated with the cranial sutures.
■ CT scans are the preferred imaging modality and can be used with computer-
aided design and modeling for preoperative planning to optimized the surgical
approach.7
SURGICAL MANAGEMENT
■ In planning and timing of the Le Fort III advancement in patients with
craniofacial dysostosis, the experienced surgeon should take several factors
into account.

FIG 3 • 3D CT reconstruction of a patient with midfacial
hypoplasia and malocclusion.
■ Age at presentation, the presence of functional problems such as upper airway
obstruction, the presence of elevated ICP, and the tendency of growth
restriction in facial bones undergoing surgical manipulation
■ The main steps of the Le Fort III procedure include
■ Osteotomies using a Le Fort III design through the frontozygomatic suture,
floor of the orbit, and the nasion
■ Mobilizing the Le Fort III segment
■ Internal fixation to zygomatic arch
■ The objective of the procedure is to address functional problems (breathing,
feeding, ocular), advance and normalize the occlusion, and improve facial
aesthetics.5
Preoperative Planning
■ Preoperative imaging helps planning for the surgery, such as using CT scans
with computer-aided design and modeling to create stereolithographic models
for optimization of osteotomies and designing patient-specific implants for
perfect bony match.
■ Communicate openly and effectively with parents regarding expectations
before, during, and after the surgery.

■ A multidisciplinary team approach, with pediatric intensivists, pediatric
anesthesia, and orthodontics should be assembled to perform the surgery.
■ Cross-matched blood should be available in the operating room.
■ Appropriate plating systems must be available.
■ Appropriate surgical instruments must be available.
Positioning
■ Patients are positioned supine with hands by their sides.
■ A single IV is started.
■ Orotracheal intubation is utilized, but nasal intubation may be necessary in
certain conditions.
■ A Foley catheter is placed to assess fluid status.
■ A warming blanket is used for temperature regulation.
■ Eyes are protected with moisturizing ointment and sterile plastic adhesives
placed over the cornea after the skin has been prepped.3
■ Preoperative antibiotics and steroids are administered.
■ Tranexamic acid should be administered, because of evidence that it
effectively reduces perioperative blood loss.8
Approach
■ Approach is through a coronal incision.
T E C H N I Q U E S
■ Exposure
■ A coronal incision is marked on the scalp behind the hairline and injected
with 0.5% lidocaine with epinephrine 1:200 000 based on pediatric weight
guidelines (TECH FIG 1A).
■ Exposure is obtained of the frontotemporal skull, lateral and medial orbits,
nasion, zygomatic arch, and zygomatic body (TECH FIG 1B).5
■ Dissection in the subgaleal plane is deepened subperiosteally about 1 cm
above the orbits to preserve the supraorbital and supratrochlear nerves.
■ To provide adequate visualization of the inferior orbital margin along with
the lateral orbital wall and orbital floor, a subciliary incision is preferred.

Special care should be taken to protect the cornea from abrasions.
■ An upper buccal sulcus incision provides access to the infraorbital region,
maxilla, malar body, and anterior aspect of the malar arch. It is important to
leave a cuff of mucosa on the alveolar aspect for easy closure of the incision.
Osteotomies and Advancement
■ Osteotomies are performed using the reciprocating saw through the
zygomatic arch, followed by the lateral, inferior, and medial orbital walls.
■ These cuts are then extended to the anterior region of the inferior orbital
fissure and across the orbital floor.
■ We complete the osteotomy by separating the medial orbital wall posterior to
the nasolacrimal duct. The medial canthal tendon is left intact during this
maneuver.
■ Pterygomaxillary disjunction via sectioning the maxillary tuberosity from
the pterygoid plates from above. Special care should be taken because in
several craniosynostotic syndromes a dense bony block exists (TECH FIG
2A).
■ A broad osteotome is used to cut the nasal septum.
■ After performing the osteotomies, the facial skeleton is freely mobile and
can be placed to its desired position using the Rowe forceps (TECH FIG
2B).
■ The surgeon must be cautious during the mobilization of the Le Fort III as
this step carries high morbidity in blood loss.
Fixation and Completion
■ Intermaxillary fixation is applied with an acrylic wafer to hold this segment
in place until bone grafts are set in place.
■ Bone grafts are harvested from either the calvarium or the ileum and
designed to fit in the space created by the advancement at the zygomatic
arches, lateral orbital wall, orbital floor, and nose.
■ Bone grafts are secured in the desired position with titanium plates and
screws.
■ IMF is released and the soft tissue is released and resuspended with lateral
canthopexies (TECH FIG 3A).
■ A Jackson-Pratt drain is placed.

TECH FIG 1 • A. Coronal incision marked on the
scalp. B. Exposure of the calvarium and facial
skeleton.
TECH FIG 2 • A. Pterygomaxillary disjunction. B.
Mobilization of the midfacial skeleton using the Rowe
forceps.

TECH FIG 3 • A. Lateral canthopexy. The subciliary
(B) and superior buccal sulcus (C) incisions. D. Frost
suture.
■ The coronal flap is closed in layers.
■ Buccal sulcus and subciliary incisions are closed in layers, with meticulous
care in closing the periosteum when using the subciliary incision (TECH FIG
3B,C).
■ A nasopharyngeal airway is placed as well as a nasogastric tube for
postoperative feeding.
■ With the expected periorbital edema following such a procedure, Frost
sutures are placed to prevent ectropion and corneal damage that would result
from the edema (TECH FIG 3D).

PEARLS AND PITFALLS
Physical
findings
■ Midfacial hypoplasia can be accompanied by severe symptoms
such as obstructive sleep apnea, increased ICP, and exorbitism.
Technique
■ The craniofacial surgeon makes use of the naturally occurring
weaknesses along suture lines to separate the facial bones into
subunits.
■ Infiltrating the facial soft tissues with a tumescent solution
containing Harmtan, Xylocaine, Hyalase, adrenaline,
triamcinolone, and Marcaine can significantly reduce
postoperative swelling.
■ A posterior flap may also be raised when additional exposure of
the calvarium is needed.
■ Protection of the brain, meninges, and venous sinuses is crucial in
all craniofacial operations. Dural lacerations should be
meticulously repaired in order to prevent postoperative CSF leaks.
■ To prevent migration of the plates and screws as a result of bone
growth, dissolving plates and screws made of polylactic acid
polymers should be used.
Postoperative
■ Hypovolemia is the most common problem after Le Fort III
advancement. Signs include tachycardia, delayed capillary refill
(less than 2 s), cool peripheries, and hypotension. Treat
hypovolemia by giving an immediate fluid bolus of 10 mL/kg.
■ Patients with a history of feeding difficulties and borderline
swallowing status presurgery must be closely monitored
postsurgery for potential feeding difficulties.
■ All contact sports should be avoided for at least 3 months.

FIG 4 • Before (A) and after (B) photos of a patient with
midfacial hypoplasia who underwent a Le Fort III
advancement.
POSTOPERATIVE CARE
■ Postoperative oral feeding is limited to water for the first week with liquid
feeding via the nasogastric tube until the nasopharyngeal airway is removed.
■ A soft diet is introduced and continued for the next 3 months while
consolidation of the osteotomies is taking place. Follow-up CT scans are done
12 to 18 months postoperatively unless the patient has neurologic deterioration.
For postoperative hematomas or hydrocephalus, an MRI is preferred over the
risks of the ionizing radiation from CT scans.
OUTCOMES
■ Le Fort III advancement achieves midface advancement anywhere between 8
and 12 mm9 (FIG 4).
■ Adequate fixation of the osteotomies decreases the relapse rates of the
advancement.9,10
■ Pseudorelapse is observed when the rate of mandibular growth is greater than
that of the maxilla. This can be managed with a subsequent Le Fort I after
skeletal maturity.10
COMPLICATIONS

■ Nerve injuries, including transection of the infraorbital nerve
■ Ptosis secondary to facial nerve injury
■ Partial anosmia
■ Strabismus5
■ Respiratory distress necessitating tracheostomy
■ Infection of hardware
■ Cerebrospinal fluid leakage with fistula formation
■ Visual loss due to nerve compression from a retro-orbital hematoma
REFERENCES
1. Tessier P. The classic reprint. Experimental study of fractures of the upper jaw.
I and II. Rene Le Fort, M.D. Plast Reconstr Surg. 1972;50(5):497-506.
2. Posnick JC, Tiwana PS, Ruiz RL. Craniofacial dysostosis syndromes:
evaluation and staged reconstructive approach. Atlas Oral Maxillofac Surg
Clin North Am. 2010;18(2):109-128.
3. Nagy L, Demke JC. Craniofacial anomalies. Facial Plast Surg Clin North Am.
2014;22(4):523-548.
4. Wilkie AO. Craniosynostosis: genes and mechanisms. Hum Mol Genet.
1997;6(10):1647-1656.
5. Nout E, et al. Advancement of the midface, from conventional Le Fort III
osteotomy to Le Fort III distraction: review of the literature. Int J Oral
Maxillofac Surg. 2008;37(9):781-789.
6. Holmes AD, et al. LeFort III internal distraction in syndromic
craniosynostosis. J Craniofac Surg. 2002;13(2):262-272.
7. Mardini S, et al. Three-dimensional preoperative virtual planning and
template use for surgical correction of craniosynostosis. J Plast Reconstr
Aesthet Surg. 2014;67(3):336-343.
8. Goobie SM, et al. Efficacy of tranexamic acid in pediatric craniosynostosis
surgery: a double-blind, placebo-controlled trial. Anesthesiology.
2011;114(4):862-871.
9. Saltaji H, et al. Le Fort III distraction osteogenesis versus conventional Le
Fort III osteotomy in correction of syndromic midfacial hypoplasia: a
systematic review. J Oral Maxillofac Surg. 2014;72(5):959-972.
10. Kaban LB, et al. Midface position after LeFort III advancement. Plast
Reconstr Surg. 1984;73(5):758-767.

27
CHAPTER
Le Fort III Osteotomy With
External Distraction
Gökhan Tunçbilek
DEFINITION
■ The Le Fort III osteotomy corrects midface retrusion for patients with
syndromic craniosynostosis and after the sequelae of Le Fort III fractures.
■ Gillies performed the first Le Fort III advancement in a patient with Crouzon
syndrome.1
■ Tessier refined the technique using Le Fort III fracture lines as a guide for
osteotomies (FIG 1A–E).2
■ The first attempts of combining the Le Fort III procedure with distraction
osteogenesis were in the mid-1990s and have become an effective, reliable
technique for managing patients with midface hypoplasia.3,4
■ Midface retrusion may cause significant functional, morphological, and
psychological impairment in patients with syndromic craniosynostosis.
■ All the parts of the face and forehead are affected, leading to breathing
difficulties and ocular and occlusal problems, all of which impair the life of
the patient.
■ Anterior movement of the facial skeleton addresses all of these problems.
■ Combining Le Fort III osteotomies with gradual distraction overcomes soft
tissue resistance and produces skeletal corrections greater than 10 mm, which
is the upper limit for conventional osteotomies with rigid fixation alone.5
ANATOMY
■ The midface consists of a maxilla-ethmoidonasal complex located between the
two zygomas. This complex is suspended from the middle portion of the frontal
bone anteriorly and the anterior cranial fossa posteriorly. The midface region is
bounded above by a transverse line connecting the zygomaticofrontal sutures,

passes through the frontomaxillary and frontonasal sutures, and is defined
inferiorly by the occlusal plane of the maxillary teeth. Posteriorly the region is
limited by the sphenoethmoidal junction and includes the free margins of the
pterygoid plates inferiorly.
■ The skull and the facial skeleton have a fixed relationship. The facial skeleton
is connected to the pterygoid process through the intermediate palatine bones
and to the body of the sphenoid through the septonasal strut.
■ It is fixed laterally by the zygomatic arch and suspended from the frontal
bone by the processes of the zygomatic bones and of the maxilla (FIG 2).
■ The facial region is subject to the vertical strains of mastication and therefore
arranges its osseous trabeculae vertically and horizontally in areas of strength
(pillars), which are separated by zones of weakness.
■ The facial complex is weakened by the presence of two kinds of cavities—air
cavities (sinuses) and receptor cavities (orbits)—and sutures.
■ The sinuses are accessories to the nasal fossa, whose extent determines the
degree of facial skeletal pneumatization; the receptor orbits house the
peripheral receptors of vision.
PATHOGENESIS
■ Midface retrusion is a major finding of syndromic craniosynostosis, caused
primarily by autosomal-dominant FGFR mutations and MSX2 and TWIST 1
mutations.
■ Most infants born with syndromic craniosynostosis present with bilateral
coronal suture synostosis and a variable degree of midface retrusion.
FIG 1 • A–E. Osteotomy lines of traditional Le Fort III

osteotomy.