Operative Technique in Plastic Surgery – Kevin C.Chung

■ An evaluation of the extremities is essential in patients with syndromic
craniosynostosis. Syndactyly is a major component of Apert syndrome.
Abnormalities of the thumbs and toes are elements of Pfeiffer and Carpenter
syndromes.
IMAGING
■ Computed tomography (CT) is useful to determine evidence of sutural fusion,
signs of increased intracranial pressure, and indications of pathologic
neuroanatomy.
■ Three-dimensional (3D) CT scan provides a clear image of the bony anatomy
and deformities of the craniofacial skeleton (FIG 4A) and can be combined
with plain films for surgical planning (FIG 4B).
■ MRI is necessary only if further detail of the brain is required or if a Chiari
malformation exists.
■ Structural anomalies of the central nervous system should be evaluated by a
pediatric neurosurgeon.

FIG 2 • Separation of the facial skeleton from the skull
and skull base at the Le Fort III level.

FIG 3 • A,B. Malar flatness and exophthalmos in a
patient with Pfeiffer syndrome. C. The cranium has a
trigonocephalic shape, and thumb printing can be seen
on the lateral x-ray. The close positioning of the
posterior pharyngeal wall to soft palate can lead to

airway compromise.
SURGICAL MANAGEMENT
Preoperative Planning
■ Patients undergoing Le Fort III distraction require a multidisciplinary team,
including a plastic and craniofacial surgeon, ophthalmologist, otolaryngologist,
and orthodontist.
■ The craniofacial surgeon and the orthodontist play important roles in the
surgical planning and in managing the pre- and postintervention occlusion and
appearance.6
■ The treatment strategy of a child with syndromic craniosynostosis includes a
series of operations separated over time responding to the growth and
development of the craniofacial skeleton.
■ This phased treatment plan is based on the differential growth patterns of the
cranial vault, the midface, and the mandible. Institutional preferences and
functional requirements may change the timing of these staged operations.
■ Midface advancement using Le Fort III distraction is generally performed
between 7 and 10 years of age.
■ The degree of airway obstruction and exposure of the globes may accelerate
timing of surgery to the midface.
Approach
■ Advancement of the midface can be performed with a conventional Le Fort III
osteotomy and rigid fixation or by using Le Fort III osteotomy with distraction.
■ Le Fort III distraction has several advantages over the traditional technique.
• The soft tissue envelope limits mechanical advancement of the midface with
the traditional procedure.
• Resistance of soft tissue is generally manageable for advancements of less
than 10 mm.5
• Elimination of soft tissue resistance using distraction leads to lower relapse
rates than conventional midface advancement techniques.7
• Conventional Le Fort III osteotomy often requires repeat surgery at
completion of facial skeletal growth. Le Fort III overdistraction can
compensate for future growth, avoiding the need for repeat surgery.8
• Le Fort III distraction eliminates the need for bone graft, thereby decreasing

length of the procedure and eliminates donor-site morbidity. There is also
significant decrease in blood loss and postoperative pain after the operation
and hospital stay is shorter.7
■ Le Fort III distraction can be performed with either internal or external
devices.
■ Internal systems are semiburied, laterally placed devices, and may be
tolerated better than external devices.
■ Internal systems limit control over the midfacial skeletal segments,
especially in vertical and transverse vectors. Lack of control over the central
midfacial structures tends to push the zygomas forward and create midline
collapse and increased facial concavity.9
■ The author’s preferred technique is external distraction.
■ Skull-anchored external halo distractors allow multidirectional, unlimited
distraction, and multiplanar adjustability of distraction forces at any time
during the distraction procedure.
■ The surgeon has the ability to focus treatment on only the affected skeletal
region, and there is no bone grafting or internal fixation device required.
FIG 4 • A. 3D CT view of a patient with Apert syndrome.
Bilateral coronal suture synostosis (note the ridging of
the coronal sutures) and a large anterior fontanelle are

common. B. Severe midface retrusion and class III
malocclusion of a patient with Crouzon syndrome.
T E C H N I Q U E S
■ Le Fort III Advancement With External
Distraction
Exposure
■ Incisions
■ The bitemporal (or bicoronal) zigzag incision provides exposure to the
frontonasal junction, medial orbital wall, lateral orbital rim, and lateral
orbital wall to the retromolar groove including the zygomatic arch (TECH
FIG 1A).
■ Infraorbital subciliary incisions provide exposure to the inferior orbital rim
and the floor of the orbit (TECH FIG 1B).
■ The superior vestibular sulcus incision provides exposure to the
pterygomaxillary junction (TECH FIG 1C).
■ After injecting local anesthetic with adrenaline at all sites, the bitemporal
incision is performed first.
■ Subperiosteal dissection is used and the coronal flap is turned down.

TECH FIG 1 • Combined incisions for the Le Fort III
osteotomy include bicoronal (A), subciliary (B), and
upper buccal sulcus (C).
■ The osteotomy sites are exposed with subperiosteal dissection around the
superior half of the orbit from the nasofrontal suture to the zygomatic arch.
■ The temporalis muscle is left in situ except in the areas posterior to the
lateral orbital wall and the zygomatic arch.
■ The subciliary and superior vestibular sulcus incisions are made in
standard fashion.
Osteotomies and Mobilization

■ Nasofrontal osteotomy is made with a reciprocating saw a few millimeters
below the nasofrontal junction extending into the medial nasal wall, behind
the posterior lacrimal crest (see FIG 1A,B).
■ The oblique section of the nasal septum is osteotomized with a curved
osteotome.
■ The lateral orbital wall osteotomy is made with a reciprocating saw, from the
zygomaticofrontal suture to the lateral orbital wall toward the inferior orbital
fissure.
■ A 4-mm osteotome is used for the orbital floor between 1 and 2 cm
posterior to the orbital rim and behind the lacrimal crest.
■ The same osteotome is used for the medial wall osteotomy behind the medial
canthus to complete the osteotomy around the orbital contents.
■ The zygomatic arch is reached from the bitemporal incision superiorly a
few centimeters below the lateral orbital rim and also sectioned with the
reciprocating saw (see FIG 1B).
■ A long, curved tip osteotome is used for pterygopalatine disjunction using
the upper buccal sulcus incision (TECH FIG 2A).
■ Once complete osteotomies are confirmed, the Rowe disimpaction forceps
are used to complete the down-fracture (TECH FIG 2B,C).
■ Complete mobilization should be performed to stretch all soft tissues and
separate remaining bony connections.

TECH FIG 2 • A. Pterygomaxillary disjunction is
performed to complete anterior mobilization of the
midface. Rowe disimpaction forceps are used to move
the facial skeleton anteriorly (B) to complete the
down-fracture of Le Fort III osteotomies (C).
■ Incomplete osteotomies may lead to unfavorable fractures and require
higher forces for separation during the activation phase.
External Distraction Device Placement
■ After adequate mobilization of the Le Fort III segment, for inferior
anchorage, a custom-made rigid intraoral splint is attached to the maxillary
teeth (TECH FIG 3A).

■ For superior anchorage, special screw-plate devices may be an option
(TECH FIG 3B).
■ Alternately, the distractor system can be fixed directly to the infraorbital
rims using a surgical wire (TECH FIG 3C).14
■ In younger patients, disjunction of zygomaticomaxillary junction may occur
when distraction is initiated.
■ To avoid this, the junction can be reinforced with a titanium plate, with the
surgical wire placed around the plate.
■ After placement of the traction wires, all incisions are closed in layers and
drains are placed under the frontal flap.
■ The halo of the rigid external device is assembled and adjusted for the width
of the neurocranium. It is rigidly fixed around the head with three scalp
screws on each side.
■ Continuous traction force of 4 kg is sufficient to distract the midface after a
complete Le Fort III osteotomy (TECH FIG 3D,E).10
■ The halo is placed before extubation, but vertical rod and horizontal bars are
placed on the 5th postoperative day before distraction is initiated. This
maneuver allows the anesthesia team to extubate the patient safely (TECH
FIG 3F).

(Trang không có chữ)

TECH FIG 3 • A. A custom-made rigid intraoral splint
is attached to the maxillary teeth for the inferior level
of anchorage. B. Screw and plate combinations
designed by the manufacturer are placed through the
subciliary incisions. C. A surgical wire connected
directly to the infraorbital rim, immediately lateral to
the infraorbital nerve. D,E. Custom-made spring
scales attached to the distraction units. A continuous
tension force of 4 kg is found to be sufficient to
generate an advancement of 1.5 mm to the Le Fort III
segment. F. Lateral view of a patient with Crouzon
syndrome. The external halo distractor is anchored to
the skull, and distraction units are attached to the
midface during the activation period.

■ Modification of Technique for the Lateral Orbital
Wall
■ Le Fort III osteotomy with distraction results in further anterior positioning
of the Le Fort III segment.
■ Thus, a step may occur between the superior-most margin of the
advancement segment and the upper part of the lateral orbital rim above the
osteotomy line (TECH FIG 4A). This step can be felt easily with palpation
and may influence the appearance of the patient negatively.
■ To modify the described technique, another osteotomy line is added 1.5 cm
inferior to the original lateral wall osteotomy,12 creating a bone fragment at
the lateral wall.
■ This segment acts like a bridge between the frontal bone and the Le Fort III
segment.
■ The bone fragment is loosely attached to the frontal bone superiorly and Le
Fort III segment inferiorly with a 4-0 nonabsorbable suture (TECH FIG 4B–
D).
■ This loose attachment allows anterior movement of the Le Fort III segment
with the inferior pole of the bone fragment and avoids unexpected
movement of the bone fragment into another location.

TECH FIG 4 • A. 3D CT of the potential step that may
occur between the superior-most margin of the
advancement segment and the upper part of the
lateral orbital rim above the osteotomy line. This step
can be felt easily with palpation and may influence
patient appearance. B,C. The bone segment, created
at the lateral wall, will act like a bridge between the
frontal bone and Le Fort III segment. D. Postoperative
3D CT of the patient showing the smooth connection
of the osteotomy segments.

PEARLS AND PITFALLS
Physical
findings
■ Perform an ophthalmologic examination for functional and visual
status of the eyes preoperatively, and document findings.
■ Obtain appropriate imaging.
■ Discuss each patient preoperatively with anesthesia,
ophthalmology, and neurosurgery colleagues.
Technique
■ It may be difficult to decide whether to perform Le Fort III
advancement with or without distraction. Even for advancement
distances less than 10 mm, distraction osteogenesis has
demonstrated improved results.
■ Suture the endotracheal tube to the columella and place surgical
gauze intraorally to secure the airway while performing
osteotomies.
■ Meticulous bony technique is mandatory to avoid damage to the
orbital contents.
■ It is necessary to have complete osteotomy lines and full
mobilization of the Le Fort III segment at the end of the operation.
Check the osteotomy lines twice, especially the posterolateral
walls of the maxilla, pterygopalatine junction, and nasal septum.
■ While positioning the halo of the external distractor, place the
fixation screws carefully. It is easy to apply too much torque using
a wrench; therefore, if possible, place the screws manually.
■ If there is any doubt regarding intracranial pin migration
(persistent nausea and vomiting during the early postoperative
period) after radiologic examination, check pin depth and change
the position of the pins and/or halo, as necessary.
Postoperative
care
■ The early postoperative period may be troublesome because of
soft tissue edema.
■ External halo distractors are reliable and robust devices; therefore,
device failure is rare.
■ Wires connecting the Le Fort III segment to distraction units may
break during activation and should be repaired immediately.
■ Although overall characteristics of patients with syndromic
craniosynostosis are similar, long-term results after Le Fort III
distraction of Crouzon patients are better than others (including
patients with Apert and Pfeiffer syndrome).
Therapy
■ Postoperative orthodontic therapy is needed to correct occlusal
problems and for fine adjustments.

POSTOPERATIVE CARE
■ Distraction protocol
■ A 5-day latency period is followed by an activation rate of 1 mm/d.
■ Activation is completed when the desired amount of transport has been
achieved.
■ Plain radiographs are performed preoperatively and weekly during the
postoperative period to follow the status of the bony segments and the
distraction process
■ The consolidation period may vary among patients and can be up to 12 weeks.
■ Midface advancement can be associated with considerable blood loss and may
be further complicated by challenging airways.
■ Postoperative care of these patients requires comprehensive intensive care
management.
OUTCOMES
■ Distraction is a safe and effective way of reconstructing the craniofacial
skeleton using inductive bone generation rather than traditional grafting and
repair and can be viewed as an endogenous form of tissue engineering.7
■ Le Fort III distraction effectively treats respiratory and ocular problems.
■ Normalization of appearance is also a major goal of the procedure. Midface
hypoplasia is successfully corrected.
■ Patients should have an Angle class I occlusion after distraction (FIGS 5 and
6).
■ Postoperative relapse may occur in up to one-third of patients and generally
develops within the first 6 months after distraction.11

D

FIG 5 • Preoperative (A,B) and postoperative (C,D)
views of a patient with Crouzon syndrome after Le Fort
III osteotomy with external distraction. The
advancement was less than 10 mm, and the results are
stable after 2 years. Preoperative (E) and postoperative
(F) intraoral photos.
FIG 6 • Preoperative (A,B) and postoperative (C,D)
views of a patient with Crouzon syndrome. The patient
underwent rhinoplasty several years after the Le Fort III
osteotomy with external distraction. Lateral
cephalograms taken preoperatively (E), during

activation (F), and postoperatively (G) show that
upward rotation of the maxilla created an open-bite
deformity, which may be seen frequently, when the
inferior anchorage is through the rigid intraoral splint.
Postoperative orthodontic therapy resulted in angle
class I occlusion.
■ Long-term stability may be affected by the phenomenon known as
pseudorelapse, which is defined as ongoing normal growth of the mandible
combined with diminished growth of the maxilla, giving the perception of
maxillary relapse.12
■ Such relapse is typically seen in patients undergoing Le Fort III distraction
during childhood and is managed at skeletal maturity with Le Fort I
orthognathic surgery.
■ Although major improvements can be achieved with Le Fort III distraction in
patients with syndromic craniosynostosis, normalization of facial aesthetics
may be difficult to obtain in patients with severe bony and soft tissue
deformities (FIG 7).
COMPLICATIONS
■ Superficial infections, mostly around the pin sites at the cranium
■ External halo complications, including mechanical failure, pin loosening,
frame migration, and intracranial migration of the fixation pins with dural
violation (FIG 8A,B)
■ This last complication can be avoided by placing temporary titanium mesh or
resorbable plates in the temporal areas at the sites of pin fixation (FIG 8C–
E).13
■ Ectropion after subciliary incision
■ Excessive bleeding requiring transfusion
■ Maxillozygomatic disjunction may occur in young patients and can be avoided
by strengthening the suture with microplates and screws.
■ Globe injury
■ Infraorbital nerve injury
■ Dural injury with subsequent cerebrospinal fluid leak
■ Incomplete or atypical fractures

FIG 7 • Preoperative (A,B) and postoperative (C,D)
views of a patient with Pfeiffer syndrome. Preoperative
(E) photo. Angle class I occlusion is obtained after
surgical and orthodontic therapy.

FIG 8 • Photograph (A) and plain x-ray (B) of a patient
with intracranial migration of fixation pins after trauma.
The distraction and recovery periods were completed
without complication. C–E. Resorbable plates were
placed in both temporal areas for pin fixation.
REFERENCES
1. Gillies H, Harrison SH. Operative correction by osteotomy of recessed malar
maxillary compound in a case of oxycephaly. Br J Plast Surg. 1951;3:123-129.
2. Tessier P. Osteotomies totales de la face: syndrome de Crouzon, syndrome
D’Apert: oxycephalies, scaphocephalies, turricephalies. Ann Chir Plast.
1967;12:273.
3. Cohen SR, Rutrick RE, Burstein FD. Distraction osteogenesis of the human
craniofacial skeleton: initial experience with new distraction system. J
Craniofac Surg. 1995;6(5):368-374.
4. Akizuki T, Komuro Y, Ohmori K. Distraction osteogenesis for
craniosynostosis. Neurosurg Focus. 2000;9(3):e1.
5. Chin M, Toth BA. Le Fort III advancement with gradual distraction using
internal devices. Plast Reconstr Surg. 1997;100:819-830.

6. Saltaji H, Altalibi M, Major MP, 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.
7. McCarthy JG, Stelnicki EJ, Mehrara BJ, Longaker MT. Distraction
osteogenesis of the craniofacial skeleton. Plast Reconstr Surg. 2001;107:1812-
1827.
8. Fearon J. The Le Fort III osteotomy: to distract or not to distract. Plast
Reconstr Surg. 2001;107:1091-1103.
9. Fearon J. The Le Fort III osteotomy: to distract or not to distract. Plast
Reconstr Surg. 2001;107:1104-1106.
10. Tunçbilek G, Mavili ME, Vargel I, et al. Midface distraction using spring
scale attached to rigid external device. Plast Reconstr Surg. 2004;113(5):1410-
1416.
11. Mofid MM, Manson PN, Robertson BC, et al. Craniofacial distraction
osteogenesis: a review of 3278 cases. Plast Reconstr Surg. 2001;108(5):1103-
1114.
12. Mavili ME, Tunçbilek G. Seesaw modification of the lateral orbital wall in Le
Fort III osteotomy. Cleft Palate Craniofac J. 2004;41(6):
579-583.
13. Mavili ME, Vargel I, Tunçbilek G. Stoppers in RED II distraction device: is it
possible to prevent pin migration? J Craniofac Surg. 2004;15(3):377-383.
14. Mavili ME, Tunçbilek G, Vargel I. Rigid external distraction of the midface
with direct wiring of the distraction unit in patients with craniofacial dysplasia.
J Craniofac Surg. 2003;14(5):783-785.

28
CHAPTER
Minimal Access Le Fort III
Osteotomy for Midface
Hypolasia
Scott J. Rapp and Christopher B. Gordon
DEFINITION
■ Midface hypoplasia can lead to significant aesthetic and functional airway
compromise.
■ Le Fort III distraction osteogenesis is a useful surgical approach to address
hypoplasia and facial dysmorphism at skeletal maturity or when severity of
symptoms warrants earlier intervention.
■ A Le Fort III approach involves osteotomies to the floor/lateral/medial wall of
orbit, nasal bones, zygomaticofrontal suture, pterygoid plates of sphenoid,
ethmoid, zygomatic arch, and posterior wall of maxillary sinus.
ANATOMY
■ Midface hypoplasia (FIG 1) is characterized by:
■ Facial disharmony
■ Malar deficiency and concavity to profile
■ Exorbitism, lack of globe protection
■ Class III occlusion
■ Posterior airway space (PAS) narrowing
■ Dental crowding
PATHOGENESIS
■ Events leading to severe craniofacial skeletal dysplasia are likely
multifactorial but are believed to be associated with abnormalities in neural
crest cell development and migration.1
■ Most are associated with genetic syndromes, but occasionally they may be

sporadic.2
■ Midface sutures such as the spheno-occipital suture may prematurely fuse
leading to growth disturbances.3
■ Genes associated with midface hypoplasia are the fibroblast growth factor
receptor genes (FGFR2, FGFR3), twist-related protein gene (TWIST), and
treacle ribosome biogenesis factor 1 gene (TCOF1).1
■ Midface hypoplasia is often observed with concomitant craniosynostosis, most
often with bicoronal synostosis seen in syndromic patients:
■ Apert (FGFR2)
■ Crouzon (FGFR2)
■ Saethre-Chotzen (TWIST)
■ Meunke (FGFR3)
■ Other syndromes leading to maxillary hypoplasia include Treacher Collins
syndrome and craniofacial microsomia (hemifacial microsomia, Goldenhar
syndrome).
■ Neurologic dysfunction may be present including:
■ Hydrocephalus/ventriculomegaly
■ Gyral abnormalities
■ Hypoplastic/heterotopic white and gray matter
■ Corpus callosal agenesis
■ Kleeblattschadel/megalocephaly
NATURAL HISTORY
■ Surgical approaches to the midface in syndromic patients were first reported
by Gilles in the 1950s and then advanced through Paul Tessier’s work in the
1960s.4
■ Midface osteotomies have been historically performed at skeletal maturity to
prevent undergrowth or reduce relapse rates.
■ However, distraction techniques provide greater bony movements and more
structural stability at an earlier age to address life-threatening airway
compromise and ocular exposure.

FIG 1 • Midface hypoplasia can have profound effects
on projection (A), occlusion and airway (B), and eye
protection (C).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Clinical exam findings may include
■ Midface retrusion
■ Craniosynostosis
■ Exorbitism/shallow orbit
■ Keratitis/corneal ulcers
■ Lagophthalmos/scleral show
■ Orbital hypertelorism
■ Class III occlusion
■ Anterior open bite
■ Narrow arch/dental crowding
IMAGING
■ Cephalometric consideration for PAS (FIG 2A)
■ Nasopharynx
■ Pterygomaxillare (pm) to posterior pharyngeal wall (upaw)
■ Oropharynx
■ Tip of uvula (U) to posterior pharyngeal wall (mpaw)
■ Hypopharynx
■ Tongue base (V) to posterior pharyngeal wall (lpaw)
■ Plain film/CT exam findings (FIG 2B)
■ Shallow orbits

■ Hypertelorism
■ Exotropia
■ Bicoronal synostosis—brachycephaly
■ Choanal stenosis/atresia
DIFFERENTIAL DIAGNOSIS
■ Syndromes that may require Le Fort III advancement
■ Crouzon
■ Apert
■ Pfeiffer
■ Treacher Collins
■ Nager
FIG 2 • Imaging (A) demonstrates posterior airway
space narrowing that can be measured through
cephalometrics (B) to determine distance required
during distraction.
■ Meunke
■ Saethre-Chotzen
■ Carpenter

NONOPERATIVE MANAGEMENT
■ Severe midface hypoplasia observed in syndromic newborn may require early
nonsurgical management.
■ Airway compromise may be managed with:
■ Prone positioning
■ Positive pressure ventilation or assistance
■ Mandibular distraction for concomitant tongue-based obstruction
■ Globe protection
■ Taping
■ Eye lubrication
SURGICAL MANAGEMENT
■ A multidisciplinary team is required for optimal surgical intervention,
including:
■ Plastic surgery/oral surgery
■ Orthodontics
■ Genetics
■ Dentistry
■ Ophthalmology
■ Speech pathology
■ Otolaryngology and audiology
■ Social work and psychology
Preoperative Planning
■ Planning between surgeon and orthodontist is critical to optimize the desired
end point of centric occlusion.
■ Virtual surgical planning (VSP) or model surgery assists in anticipated
distance and vectors for distraction.
■ Stereolithic models can assist with identification of permanent teeth and root
location.

FIG 3 • Supine positioning with a shoulder roll and
horseshoe headrest provides adequate access.
Securing the endotracheal tube with circumdental,
circum-mandibular, or transalveolar suturing/wiring to
reduce intraoperative malposition of the endotracheal
tube is recommended.
■ Patient may require palatal expansion prior to Le Fort III osteotomy.
■ Maxillary third molars may be removed prior to intervention; secondary Le
Fort I osteotomy is anticipated to obtain class I occlusion.

■ An ophthalmologic evaluation is required to assess for corneal ulceration and
abrasion and to identify preoperative visual dysfunction (ie, strabismus,
exotropia, V-pattern esotropia/exotropia).
FIG 4 • Access for Le Fort III osteotomies can be
exposed through a traditional bicoronal incision (A) or
transconjunctival incision with extended lateral
canthotomies (B).
■ Identify symptoms of sleep apnea including frequent snoring, apneic episodes
during sleep, daytime somnolence, or growth abnormalities.
■ Perform a sleep study to determine preoperative apnea-hypopnea index (AHI)
or respiratory distress index (RDI).
■ Perform tracheostomy if central sleep apnea is observed.
■ Imaging should include CT exam with 3D reconstruction for bone/soft tissue
evaluation and MRI for intracranial evaluation.
■ Anesthesia consultation is important to assess perioperative airway risk.
■ Ear, nose, and throat (ENT) consultation for airway assessment.
Positioning
■ Access to the midface can be accomplished with supine positioning and the
use of a horseshoe headrest (FIG 3).
■ Rigid cranial fixation is not required.
■ A shoulder roll assists in creating a level facial plane.
■ Secure the airway with either circumdental, circummandibular, or

transalveolar suturing/wiring to reduce intraoperative malposition of the
endotracheal tube.
■ In mixed dentition, avoid placing suture or wire through the alveolus, which
would result in tooth bud injury.
■ Oral RAE endotracheal tube
■ Turn the table 90 degrees to allow access to both sides of the patient.
■ Proper pressure relief is necessary due to length of case. Use foam or gel under
the occiput, elbows, hips, knees, and heels.
■ Serial compression devices are used in older patients.
Approach
■ Access to the midface is accomplished through a traditional coronal incision
(FIG 4A) or extended transconjunctival incision (FIG 4B).
■ The extended transconjunctival incisions may avoid intraoral incisions.
T E C H N I Q U E S
■ Incision and Access to the Orbital Rim and Floor
■ Clear corneal eye protectors are placed.
■ The conjunctiva is infiltrated with 0.5% lidocaine with epinephrine 1:200
000 and 10 minutes are allowed to elapse.
■ Medial and lateral traction stitches in the gray line of the lower lid help with
identification of the lower lid tarsal border through retraction (TECH FIG
1A).
■ An inferior lateral canthotomy is created sharply, extending 5 mm beyond
the lateral canthus (TECH FIG 1B).
■ Needle tip cautery with blend-cutting mode is used to divide the conjunctiva
immediately inferior to tarsus.
■ Bipolar cautery is used to coagulate prominent vessels in the dissection
plane for controlled hemostasis.
■ Cotton-tip applicators are used bluntly and atraumatically to develop a
preseptal plane to the orbital rim (TECH FIG 1C).
■ The periosteum at the orbital rim is divided with electrocautery with minimal
anterior stripping of the maxillary periosteum.

■ The orbital floor periosteum is elevated medially up to the nasolacrimal duct
insertion, which is carefully identified and preserved. Dissection continues
beyond the duct to the nasal and ethmoid bones.
■ Laterally, subperiosteal dissection is extended up to the zygomaticofrontal
suture.
TECH FIG 1 • A. With extended transconjunctival
incisions, medial and lateral tarsal retraction stitches
assist in developing the appropriate preseptal plane to
the orbital rim. B. Inferior lateral canthotomy. C.
Orbital osteotomies are created under direct
visualization. A larger lateral window is created so that

the Sonopet can reach the pterygoids from the orbit.
■ Osteotomies, Pterygomaxillary Disjunction, and
Midface Mobilization
■ A Sonopet Ultrasonic Osteotome (Stryker, Kalamazoo, MI) allows for
minimal soft tissue disruption and carefully controlled osteotomies.
■ Selected tips are the Nakagawa knife, micro claw, or aggressive serrated tip;
the protective sheath is removed to reduce the diameter of the orbital floor
osteotomy required.
■ With the lid retracted and all soft tissue protected from the exposed Sonopet
shaft, the osteotomies are made medially from the most anteromedial aspect
of the inferior orbital fissure to the lacrimal fossa. The osteotomy extends
posterior to the insertion of the nasolacrimal duct (TECH FIG 2A).
■ A transcutaneous incision is made over the nasofrontal junction to expose
the position where the orbital floor osteotomy meets the nasal bone.
■ The nasal bones and underlying perpendicular plate of ethmoid bone are cut
with the Sonopet. This leads to minimal disruption to nasal mucosa.
■ Alternatively, an osteotome can be used to make these cuts (TECH FIG
2B).
■ The orbital floor osteotomy is then extended laterally and cranially to the
level of the zygomaticofrontal suture.

TECH FIG 2 • A. The lateral orbitotomy is extended
through the zygomaticofrontal junction. B. The
nasofrontal osteotomy is accessed through a small
stab incision. The osteotomy can be started with the
Sonopet and checked for completion with an
osteotome. C. The pterygomaxillary osteotomy is
reached from the lateral orbital floor window. D.
Correct placement and angle is confirmed by digitally
palpating the tip of the Sonopet. E. To ensure
adequate pterygomaxillary dysjunction, perform gentle
passes to remove small portions of bone.

■ Within the orbit, the lateral floor osteotomy is widened to facilitate pass of
the Sonopet through the antrum to approach the pterygomaxillary junction
(TECH FIG 2C).
■ The Sonopet is then obliquely angled from within the antrum of the maxilla
to divide the posterolateral maxilla at the junction with the pterygoids
(TECH FIG 2E).
■ The zygomatic arches are accessed from the lateral orbitotomy.
■ Alternatively, the arch can be cut transmucosally with an osteotome;
however, this is not recommended due to oral contamination.
■ A 3-mm osteotome is used to ensure that all cuts are complete.
■ Down-fracture is possible by digital manipulation alone if osteotomies are
performed correctly.
■ Rigid External Device Placement
■ A rigid external device (RED) is placed in the horizontal plane as just above
the superior helix of the ear.
■ The screws are advanced by hand and turning stopped when “finger tight.”
■ Two maxillary titanium L-plates are positioned over the
zygomaticomaxillary buttress with the arms bent, curving around the soft
tissue, and fixated to the RED by 24-gauge dental wire (TECH FIG 3A).
■ Locking screws are used to fixate the plate transmucosally avoiding
disruption of tooth roots (TECH FIG 3B).
■ Orbital plates may be positioned along the inferior orbital rim to more
evenly distribute the forces of distraction.

TECH FIG 3 • A. Titanium plates are placed
transmucosally with locking screws (arrow). They are
bent to prevent ulceration to the upper lip when
distracting. B. Use of a rigid external device allows for
multiple vector movements and extended distraction
distance.
■ Distraction Protocol
■ Distraction is started on postoperative day 1.
■ Movement is 0.5 mm twice daily for 1 mm/day.
■ Weekly lateral cephalograms performed at 72′′ follows progress of
distraction.
■ The consolidation period is 5 days before the RED, plates, and screws are
removed.
PEARLS AND PITFALLS
Bony
■ Osteotomy plane

regenerate
■ Avoid intranasal or intraoral mucosal disruption to minimize bacterial
contamination of the bone callus during distraction.
■ The Sonopet causes thermal injury to bone if stationary and is capable
of burning through soft tissue, vessels, and nerves.
Technique
■ Incomplete osteotomy
■ The midface should be freely mobile using digital pressure alone.
■ Confirm all osteotomies with a 3-mm osteotome.
■ Tooth root disruption
■ Utilize screw lengths of 6 mm or less and refer to medical model for
aberrant tooth locations.
Distraction
protocol
■ It is the senior author’s preference to forego a latency phase.
■ Movement can be up to 2 mm/d.
■ Confirm bony consolidation with CT.
RED on
infant
■ Thin calvarial bone
■ Overtightening of screws may lead to inner calvarial table
penetration.
■ Risks can include dural disruption, cerebrospinal fluid (CSF) leaks, or
brain injury.
■ Mesh underlay can add thickness to areas of thin bone to prevent
overpenetration.
POSTOPERATIVE CARE
■ The patient should remain intubated and admitted to the ICU following
surgery.
■ Extubation may be performed with ENT/anesthesia at bedside once airway
swelling has subsided or demonstration that PAS is improved in cases of severe
sleep apnea.
■ A nasogastric feeding tube may be used in severe cases but is often
unnecessary for oral intake.
■ Distraction can be continued as an outpatient, and consolidation can be
confirmed with CT imaging.
■ Weekly lateral cephalograms can be used to determine end point of distraction,
with slight overcorrection by a few millimeters.
■ The RED device and oral plates can be removed as an outpatient procedure
following cessation of distraction.
OUTCOMES
■ Average maxillary advancements of 16 mm have been reported (6–31 mm).5,6

■ FIG 5 demonstrates expected nasopharyngeal airway improvement.
FIG 5 • 3D reconstructions of the upper airway following
distraction show improved volume and space.

■ Soft tissue changes can drastically improve midface projection, occlusion, and
globe protection (FIG 6).
■ There is evidence that a reduction in the respiratory disturbance index or
apnea/hypopnea index can be achieved in over 50% of patients6,7 (FIG 7).
■ RED devices are tolerated well with proper education and counseling.
COMPLICATIONS
■ Incomplete osteotomy
■ Premature consolidation
■ Zygomatic fracture during distraction
■ Permanent tooth damage
■ Excessive pressure on globe during pterygomaxillary osteotomy
■ Nonunion following advancement
■ Relapse of advanced bony segment
■ Malocclusion
■ Fracture propagation
■ Blindness
FIG 6 • Soft tissue aesthetics are greatly enhanced with

successful Le Fort III distraction. (A) demonstrates pre-
operative midface hypoplasia; (B) demonstrates
improved facial form.
FIG 7 • Symptoms of obstructive sleep apnea can be
mitigated or entirely corrected within posterior
nasopharyngeal space after Le Fort III distraction.

REFERENCES
1. Suzuki A, Sangani DR, Ansari A, Iwata J. Molecular mechanisms of
midfacial developmental defects. Dev Dyn. 2016;245(3 suppl):276-293.
2. Paliga JT, Goldstein JA, Vossough A, et al. Premature closure of the spheno-
occipital synchondrosis in Pfeiffer syndrome: a link to midface hypoplasia. J
Craniofac Surg. 2014;25(1 suppl):202-205.
3. Tessier P. Total facial osteotomy. Crouzon’s syndrome, Apert’s syndrome:
oxycephaly, scaphocephaly, turricephaly (in French). Ann Chir Plast.
1967;12:273-286
4. Merrill AE, Bochukova EG, Brugger SM, et al. Cell mixing at a neural crest-
mesoderm boundary and deficient ephrin-Eph signaling in the pathogenesis of
craniosynostosis. Hum Mol Genet. 2006;15(8 suppl):1319-1328.
5. Flores RL, Shetye PR, Zeitler D, et al. Airway changes following Le Fort III
distraction osteogenesis for syndromic craniosynostosis. A clinical and
cephalometric study. Plast Reconstr Surg. 2009;124: 590-601.
6. Ettinger RE, Hopper RA, Sandercoe G, et al. Quantitative computed
tomographic scan and polysomnographic analysis of patients with syndromic
midface hypoplasia before and after Le Fort III distraction advancement. Plast
Reconstr Surg. 2011;127(4 suppl):1612-1619.
7. Fearon JA. Halo distraction of the Le Fort III in syndromic craniosynostosis: a
long-term assessment. Plast Reconstr Surg. 2005;115: 1524-1536.

29
CHAPTER
Secondary Alveolar Bone
Grafting of the Cleft Alveolar
Defect in Cleft Palate
Richard E. Kirschner, Michelle A. Scott, and Matthew A.
Hiersche
DEFINITION
■ Alveolar clefts are present in patients with orofacial clefts that involve the
maxillary alveolar ridge.
■ The defect can range from a simple alveolar notch to a complete cleft that
involves the alveolus, maxilla, and inferior piriform rim.
■ Secondary alveolar bone grafting, as originally described by Boyne and
Sands,1 is the final step in closure of the orofacial cleft. This procedure closes
the nasoalveolar fistula, unites the maxillary arch in preparation for definitive
orthodontic treatment, creates support for the affected nasal structures, and
provides alveolar bone for the support of the lateral incisor (if present), the
canine, and surrounding dental structures.
■ Alveolar bone grafting is most often performed by utilizing autogenous bone
from the iliac crest, which remains the standard.
■ Other donor sites include the cranium, tibia, and mandibular symphysis.2–4
■ The use of allogenic bone and bone morphogenetic protein (BMP) has also
been reported.5,6
ANATOMY
■ An alveolar cleft is a three-dimensional cleft in the maxilla most often
extending from the piriform rim to the alveolar margin.
■ The bony cleft is shaped as an inverted pyramid with its base at the piriform
rim and its pinnacle at the alveolar margin (FIG 1).
■ Distal to the cleft, the alveolus may be hypoplastic, and the lateral maxillary

segment may be displaced posteriorly and collapsed medially.
■ The alveolus/piriform rim acts as the “foundation” for the overlying soft tissue
of the lip and nasal tip.
■ Alveolar clefting and displacement of the lateral maxillary segment may thus
result in displacement and distortion of the lip, nasal sill, and alar base.
■ Dental anatomy adjacent to the cleft is often anomalous, demonstrating
abnormalities in the position, shape, and presence of the canine and lateral
incisor. Likewise, abnormalities in dental structure (eg, enamel hypoplasia,
root abnormalities) and in dental eruption patterns are often noted.7
PATHOGENESIS
■ The face is formed through the fusion of five facial prominences that develop
and fuse in weeks 6 to 8 of development. These facial prominences are the
midline frontonasal prominence, the paired lateral nasal prominences, and the
paired maxillary prominences.
■ The frontonasal prominence (median nasal prominence) forms the forehead,
nasal bridge, nasal tip, columella, philtrum and central upper lip, septum, and
premaxilla (primary palate).
■ The paired lateral nasal prominences form the alae of the nose.
■ The paired maxillary prominences form portions of the cheek, the lateral
components of the upper lip, the maxilla, and the lateral palatal shelves
(secondary palate).
■ In normal development, the primary palate, which receives its blood supply
via the sphenopalatine artery from the septum, fuses with the bilateral palatal
shelves to complete the development of the palate.
■ In clefts involving the alveolus, the primary palate and secondary palate fail to
fuse at the alveolus, maintaining a connection between the oral and nasal
cavities.

FIG 1 • A,B. Cone-beam CT demonstrating the
pyramidal defect of the alveolar cleft.
■ The etiology of cleft lip and palate is multifactorial with both genetic and
environmental factors contributing to the development of orofacial clefts.
■ To be etiologic, environmental factors must affect the fetus between weeks 6
and 8 of development, as this is the critical time for development of the
primary palate.
■ Medications that have been implicated in the development of a cleft lip and
palate include anticonvulsants, folate antagonists, benzodiazepines,
corticosteroids, and beta-blockers.
■ Certain maternal factors have been implicated in the development of cleft lip
and palate, including smoking, excessive alcohol consumption, and obesity.
■ Maternal health conditions may also contribute, including diabetes and
maternal fever.
■ Lastly, a family history of cleft lip and palate is one of the strongest risk
factors for the development of a cleft lip or palate, implicating a complex
genetic component.
NATURAL HISTORY
■ The need for repair of the alveolar cleft is generally accepted; however, timing
of alveolar bone grafting remains controversial.
■ Primary alveolar bone grafting is not practiced at most centers in light of
evidence that it has a negative influence on maxillary growth.8,9
■ The remainder of this chapter is pertinent to secondary alveolar bone
grafting.
■ In the absence of primary alveolar bone grafting or gingivoperiosteoplasty, the

alveolar cleft remains as a persistent nasoalveolar fistula following closure of
the lip and palate.
■ The persistent fistula allows regurgitation of oral contents into the nose and
passage of nasal secretions into the oral cavity. Additionally, the cleft traps
food products, reduces oral clearance, obstructs basic hygiene, and may
contribute to periodontal disease and dental decay.
■ Without alveolar bone grafting, patients may maintain a flat, depressed lip,
nasal sill, and alar base secondary to inadequate bony support of the soft
tissues overlying the deficient piriform rim. Likewise, inadequate bone stock
may lead to dental loss due to insufficient periodontal support.
■ The reconstructed alveolus and piriform rim support the overlying nasal
structures.
■ Following closure of the alveolar cleft, orthodontic canine substitution may be
employed to camouflage the defect resulting from an absent lateral incisor.
Alternatively, the graft may be used to support replacement of the absent lateral
incisor through implant placement.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Regurgitation of liquids or solids into the nose through a persistent
nasoalveolar fistula may be reported.
■ Oral hygiene practices, regular dental evaluations, and current or prior
orthodontic treatment must be documented and discussed in detail, as the
proper coordination of dental and orthodontic care is important in ensuring
optimal outcomes in secondary alveolar bone grafting.
■ It is important to solicit the patient’s surgical history as it pertains to any prior
cleft lip or palate procedures, as well as prior surgical treatment of the alveolus,
whether primary or secondary.
■ Additional treatment for or the presence of additional oronasal fistulae should
be assessed.
■ On physical examination, the presence, location, stability, and morphology of
the dentition adjacent to the cleft should be assessed, as well as noting overall
oral hygiene, dental decay, and periodontal disease.
■ Overall, arch form should be assessed, as orthodontic preparation of the arch
through expansion is often necessary to place the alveolar segments in an
optimal position for bone grafting.
■ Evaluation for the presence of an additional oronasal fistula should be

performed, noting the prior method of palate repair.
IMAGING
■ Panoramic and occlusal x-rays have been traditionally used to image the
alveolar defect and to assess graft take postoperatively.
■ When available, a cone-beam CT scan offers improved three-dimensional
evaluation of the cleft area and the adjacent dentition.
■ It may be used to more accurately assess bone graft take by providing a high-
resolution, three-dimensional image of the alveolus.
NONOPERATIVE MANAGEMENT
■ Patients who are not candidates for or who decline alveolar bone grafting may
be offered prosthetic habilitation of the cleft site.
■ This can be achieved with a variety of fixed and removable devices for
aesthetic replacement of the missing dentition and acrylic coverage of
remaining fistulae.10,11
SURGICAL MANAGEMENT
■ Repair of the alveolar cleft is generally performed during the stage of mixed
dentition, which ranges from 6 to 10 years of age.
■ Graft placement should be performed before eruption of the permanent
canine (or lateral incisor, when present) adjacent to the cleft.
■ Imaging is performed to assess root formation of the canine or lateral incisor,
and grafting is performed once approximately half of the root has developed.
■ Performing the surgery at this stage provides bony support for the tooth as it
erupts, and eruption of the tooth through the bone graft supports retention of
graft volume.
■ Delayed tooth eruption into the graft area may result in loss of alveolar
height and bony support. Thus, the goal is to provide early bony support for
tooth eruption while minimizing the time between grafting and eruption of
the permanent canine or lateral incisor.
■ The main steps in the procedure are as follows:
■ Development of soft tissue flaps to close the nasal floor, surface the buccal
gingiva, and close any residual palatal fistulae
■ Approximation of the nasal and palatal flaps to line the periosteal pocket for
the bone graft
■ Harvest of cancellous iliac crest bone graft

■ Placement of the bone graft into the prepared pocket
■ Approximation of the buccogingival flaps
■ Placement of an intraoral splint, if necessary
■ Closure of the iliac donor site in layers, including closure of the cartilaginous
cap of the iliac crest
■ Indications for surgical management: patent alveolar fistula, dental arch
collapse, deficiency of the piriform rim, support of adjacent teeth, and
completion of dental habilitation (orthodontics and prosthodontics)
■ Contraindications to surgical management: noncompliance with preoperative
orthodontic preparation and poor oral hygiene resulting in gingivitis or caries
adjacent to the alveolar cleft
Preoperative Planning
■ Panoramic and occlusal radiographs or cone-beam CT scan should be obtained
to determine stage of root development and bony support of teeth immediately
adjacent to the cleft.
■ Physical examination is performed to assess the condition of soft tissues and
dentition, arch form, and presence of oronasal fistulae.
■ Dental/orthodontic consultation should be obtained to assess the patient’s
overall oral hygiene, readiness for bone grafting, and the need for dental
extractions, restorations, and alignment prior to bone grafting.
■ Orthodontic consultation should be obtained to determine the need for
maxillary expansion to restore arch form and transverse width (FIG 2).
■ Teeth that have erupted horizontally in such a way as to impede access to the
surgical site or that are in traumatic occlusion should be repositioned with
orthodontic devices using caution to avoid moving the roots of teeth into the
cleft defect.
■ Teeth that have erupted into the cleft site or primary teeth that will interfere
with the soft tissue closure of the graft site should be extracted prior to alveolar
bone grafting.
Positioning
■ The patient is placed in the supine position.
■ If an autologous bone graft from the iliac crest is to be harvested, the operative
hip should have a small bump placed beneath it to assist in exposure for the
graft harvest.

■ A small shoulder roll and slight extension of the head will assist with
exposure.
■ A Dingman retractor may be utilized for exposure, placing the hooks on the
upper lip for exposure of the alveolus and on the alveolar ridge for exposure of
the anterior palate.
Approach
■ Intraoral exposure of the cleft site is obtained through the elevation of
buccogingival and, if necessary, palatal flaps.
■ The donor site is approached through a 3-cm incision placed 2 cm posterior to
the anterior superior iliac spine to avoid the lateral femoral cutaneous nerve.
■ The incision should be placed slightly lateral to the most prominent portion of
the iliac crest in order to avoid irritation from clothing postoperatively.
FIG 2 • Maxillary dental arch before (A) and after (B)
orthodontic expansion.
T E C H N I Q U E S
■ Alveolar Cleft Dissection
Preparation
■ The oral splint should be fit prior to the procedure to ensure proper retention
postoperatively.
■ Slight extension of the neck is ideal for exposure, particularly if a palatal
fistula is present and will require closure.

■ Corneal protection is imperative for the duration of the procedure. The
senior author’s preference is to apply adhesive dressings over the eyes prior
to skin preparation, but protection methods vary and are at the discretion of
the surgeon.
■ After skin preparation and draping, the oral cavity is rinsed with Peridex
solution.
■ A Dingman mouth gag is then used to provide exposure to the alveolus
(TECH FIG 1).
■ The hooks are placed on the upper lip to provide retraction of the lip and
exposure of the labial alveolus and dentition.
■ The cheek retractors should be used to retract the cheeks and stabilize the
mouth gag.
■ The alveolar and, if present, palatal fistulae should be examined closely at
this time. Lacrimal probes may be used to interrogate the fistulae and define
their extent.
TECH FIG 1 • Placement of the Dingman retractor for
proper exposure.
Dissection of the Fistula

Video p2-c029
■ The incisions are marked along both the lateral and medial aspects of the
alveolar fistula. The incision is marked along the gingival margin extending
from the cleft mesially no further than the midline.
■ Laterally, the incision begins at the lateral cleft margin and extends along
the gingival margin.
■ Distal to the tooth adjacent to the cleft, the incision may be extended
obliquely from the gingival margin, extended just above the attached
gingiva, and then posteriorly to the position of the first molar.
■ At the first molar, a back cut can be made to facilitate advancement of the
gingival flap (TECH FIG 2A).
■ The fistula and surrounding labial/palatal mucosa are injected with a 1:200
000 epinephrine solution for hemostasis.
■ As the mucosa is highly vascular, it is traditionally recommended that the
surgeon wait 7 to 10 minutes between injection and incision to allow for
vasoconstriction. However, recent studies indicate that waiting 26 minutes,
when clinically feasible, may provide optimal vasoconstriction.12
■ The incisions are then made at the gingival margin, avoiding injury to the
papillae while dividing the periodontal ligament.
■ This dissection is extended onto the alveolus in a subperiosteal plane.
■ The incision proceeds around the cleft margin, a maneuver that may be
facilitated by use of an angled crescent knife (TECH FIG 2B).
■ The lateral and medial buccogingival flaps are then elevated to expose the
bony cleft margin to the piriform rim (TECH FIG 2C).
■ The periosteum at the base of the lateral flap is then scored in order to
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