Operative Technique in Plastic Surgery – Kevin C.Chung

the ideal duration of use.
■ The use of ice packs may also be beneficial for pain and swelling in the
immediate postoperative period.
■ When conservatively treating zygomatic arch fractures by elevation alone
(without plating), it is important to instruct the patient not to lie on the side of
the fractured arch.
■ Some surgeons advocate the use of aluminum eye shields or protectors or
some other external splints to be sutured to the lateral aspect of the zygomatic
arch, with the suture being driven deep to the arch. This may serve as a
buttress to prevent a reduced arch fracture that has been displaced, from
collapsing medially. Others argue that it also reminds the patient not to sleep
on that side. Our study suggests that if the arch is properly reduced, it remains
stable.7 Generally, if the patient is having pain, he does not lie on the fractured
side of his face.
OUTCOMES
■ If proper reduction is achieved and care is taken with the surgical approaches,
excellent results are achieved with the anteroposterior projection and the
transverse dimension of the face.
COMPLICATIONS
■ Complications can include blindness, entrapment of the periorbital contents,
orbital dystopia, widening of the midface, or other sequelae from an improper
reduction.
■ Numbness of the infraorbital nerve distribution is common but often resolves
with time.
■ Many surgeons have suggested a resuspension of the soft tissues after
degloving the midface to prevent sagging of the tissues. Others feel an
adequate layered closure of the various periorbital approaches or a more
limited degloving of the soft tissue may avoid the problem of soft tissue sag.
REFERENCES
1. Lee EI, Mohan K, Koshy JC, Hollier LH Jr. Optimizing the surgical
management of zygomaticomaxillary complex fractures. Semin Plast Surg.
2010;24(4):389-397.
2. Turvey TA, Golden BA. Orbital anatomy for the surgeon. Oral Maxillofac
Surg Clin North Am. 2012;24(4):525-536.
3. Anastassov GE, van Damme PA. Evaluation of the anatomical position of the

lateral canthal ligament: clinical implications and guidelines. J Craniofac Surg.
1996;7(6):429-436.
4. Zingg M, Laedrach K, Chen J, et al. Classification and treatment of zygomatic
fractures: a review of 1,025 cases. J Oral Maxillofac Surg. 1992;50:778-790.
5. Barta RJ, Schubert W. Ratio of simple versus comminuted lateral wall
fractures of the orbit. Craniomaxillofac Trauma Reconstr. 2013; 6:241-246.
6. Jordan DR, Allen LH, White J, et al. Intervention within days for some orbital
floor fractures: the white-eyed blowout. Ophthal Plast Reconstr Surg.
1998;14:379-390.
7. Kobiena BJ, Sultz J, Migliori MR, Schubert W. Portable fluoroscopy in the
management of zygomatic arch fractures. Ann Plast Surg. 1998; 40:260-264.
8. Wilde F, Lorenz K, Ebner AK, et al. Intraoperative imaging with a 3D C-arm
system after zygomatico-orbital complex fracture reduction. J Oral Maxillofac
Surg. 2013;71:894-910.
9. Gellrich NC, Schramm A, Hammer B, et al. Computer-assisted secondary
reconstruction of unilateral posttraumatic orbital deformity, Plast Reconstr
Surg. 2002;110:1417-1429.

64
CHAPTER
Addressing Late
Malpositioning of the
Zygomaticomaxillary
Complex
Warren Schubert and Yeshaswini Thelekkat
DEFINITION
■ Late malpositions of the zygomaticomaxillary complex (ZMC) result when
fractures either were not addressed at the time of the original trauma or were
opened and internally fixated but not properly reduced.
■ The term late in this chapter refers to fractures that have healed in a
malposition and require an osteotomy to mobilize and reposition the zygoma.
■ The term OIF (opened and internally fixated, but not reduced) has been
popularized by Joseph Gruss to suggest that rather than have a proper ORIF
(open reduction and internal fixation) the patients have been opened and
internally fixated but not properly reduced, resulting in a malposition of the
ZMC.
■ The authors have been impressed that elderly and malnourished patients with
ZMC fractures—even 6 weeks after initial trauma—can occasionally be
replicated and mobilized using an osteotome without a saw and then fixated
using methods outlined in the chapter on primary fixation of acute ZMC
fractures.
■ Osteotomies in a potentially new plane should always be avoided if the exact
positions of the previous fractures can be replicated.
ANATOMY
■ The key is attaining proper repositioning and stabilization of the zygomatic
processes and buttresses.

■ Though not absolutely required, the surgeon may consider a coronal approach
when addressing a late malposition. As a result, a plate on the zygomatic arch
to restore the AP position of the zygoma is more likely to be considered when
addressing a late malposition than in routine acute ZMC fractures.
■ The goal is to re-establish the alignment and proper position of the
zygomaticofrontal (ZF) fracture, the lateral wall of the orbit (junction between
the greater wing of the sphenoid and the zygoma), the orbital floor, the inferior
orbital rim, the lateral maxillary column of the midface, and the zygomatic
arch (FIG 1).
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The patient may present with a variety of deformities including blunting of the
malar eminence, enophthalmos, diplopia, dystopia of the eye, lateral canthal
malposition, widening of the midface or depression of the zygomatic arch, and
numbness in the infraorbital nerve distribution.
IMAGING
■ As with an acute ZMC fracture, the appropriate radiologic workup requires
fine-cut computed tomography (CT) slices.
■ The ideal workup includes axial cuts, reformatted coronal cuts, and oblique
parasagittal cuts through the orbit. 3D reformatting of the midface may also
be useful (FIG 2).
■ Because the surgeon is faced with issues of remodeling of the bony fragments,
exact repositioning of the osteotomized segments may present a challenge.
■ The surgeon may choose to use intraoperative CT to ensure the proper
reduction of the osteotomized segments in the same way that surgeons have
used this technique for acute fractures.1
■ Navigation may be used intraoperatively in a similar way that intraoperative
imaging is used if this technology is available to the surgeon.2
■ With navigation, obtaining a preoperative CT with a fiducial guide may be
necessary.
■ The surgeon is able to perform a virtual correction of the proper placement of
the ZMC on the injured side by mirroring the proper position of the ZMC
from the contralateral uninjured side.
■ At the time of surgery, the malpositioned ZMC is moved into its proper
position as visualized in the virtual image.

FIG 1 • Key anatomic points that need to be realigned
and fixated: (1) Fronto-zygomatic suture; (2) Zygomatic
arch; (3) Infraorbital rim; (4) Zygomatico-maxillary
buttress; (5) Orbital floor.
FIG 2 • A. AP CT of a late malposition of the ZMC in a
patient who has had multiple past procedures, including
a bone graft of the inferior orbital rim. It is clear that the
ZMC was fixated without reduction (OIF). B. Lateral CT
shows that a proper reduction of the ZF suture and the

zygomatic arch was never achieved.
NONOPERATIVE MANAGEMENT
■ Nonoperative management is always an option.
■ The authors’ only experience with blindness with a ZMC repositioning
occurred after an osteotomy was performed for correction of a late malposition.
Our impression is that addressing a chronic deformity with enophthalmos has a
significantly higher associated risk of blindness, possibly due to an orbital
compartment syndrome, than does repositioning of an acute ZMC fracture.
SURGICAL MANAGEMENT
Preoperative Planning
■ A complete ophthalmic examination should be performed by documenting the
canthal and lid positions, identifying if there is a superior sunken sulcus of the
upper eyelid, full movement of the extraocular muscles, diplopia, dystopia, and
field defects.
■ Exophthalmometric measurements of the degree of enophthalmos may be
useful.
■ As the lateral aperture of the orbit is often displaced, we prefer using a
Naugle exophthalmometer over a Hertel and resting the Naugle on the frontal
bar (FIG 3A). This assumes that the fractures being addressed do not include
a displaced frontal bar.
■ A McCoy facial trisquare is useful in measuring the relative location of the
medial and lateral canthi to the contralateral lateral canthi (FIG 3B). An
analysis of canthal positioning in photographs can be useful as well.
■ Using either a photo or a trisquare, a horizontal line is drawn through the
medial canthi to determine the relative positions of the lateral canthi.
■ Our recommendation is to compare with the position of the contralateral
(uninjured lateral canthi) with the eyes both open and closed.
■ A complete neurologic examination including assessment of sensation of the
infraorbital nerve distribution and the function of the motor branches of the
facial nerve should be included in the workup.
■ Preoperative photographs and high-quality CT imaging with the cuts
mentioned previously, possibly with fiducials (if navigation is available),
should be obtained for all patients.

FIG 3 • A. Demonstration of a Naugle
exophthalmometer for measuring globe protrusion. The
advantage of this exophthalmometer is that unlike the
Hertel, it does not rest on the lateral orbital aperture. If
the malar eminence is involved with the trauma, it is
possible to slightly tip the device up so that it is resting
on the frontal bar. Though the absolute measurements
may be slightly distorted, the surgeon is able to gain a
good idea of the relative degree of globe protrusion (or
enophthalmos) compared to the uninjured side. B.
Demonstration of the use of the McCoy facial trisquare
to examine the relative position of the medial and lateral
canthus.
Positioning
■ Positioning of the patient should allow the surgeon access for a coronal
incision.
■ Because we commonly use intraoperative imaging, we position the OR table
180 degrees from the anesthesiologist, with a straight oral tube for intubation.
■ If intraoperative imagining is not available, positioning the table at 90 degrees
from the anesthesiologist is adequate.
Approach

■ It may be a difficult decision, depending on the complexity of the case, to
determine the number of surgical approaches required to perform the
osteotomies and obtain an adequate reduction of the zygoma.
■ A further determinant may be the exact location of the previous fractures and
the required locations of the osteotomies. It may be possible to use the same
surgical approaches as with the acute ZMC.
■ This would include an upper blepharoplasty incision to approach the ZF
suture; a periorbital dissection to expose the lateral orbital wall and floor of
the orbit, as well as the inferior orbital rim; and an intraoral approach to
recreate the zygomaticomaxillary fracture and to perform the osteotomy
through the zygomatic arch (FIG 4).
■ In many cases, the surgeon may determine that the safest approach (and
possibly easiest) is to perform a coronal incision for access to the ZF suture,
lateral orbital wall, and the zygomatic arch.

FIG 4 • Incisions: periorbital (subciliary, midlid, and
orbital rim; A), conjunctival-lateral canthotomy (B),
upper eyelid (blepharoplasty and brow; C), and intraoral
(D). We do not recommend the orbital rim and brow

incisions due to unfavorable scars. E. Osteotomy of the
zygomaticomaxillary segment made through the
periorbital and intraoral approaches and the osteotomy
of the zygomatic arch made through the intraoral
incision using a Keen type of approach.
T E C H N I Q U E S
■ The first item the surgeon must address with the patient is the aspect of the
deformity that bothers the patient most and the risks of various treatment
options.
■ Camouflage Corrections
■ The patient may choose more conservative methods of treatment or
camouflage procedures to cover the deformity, without osteotomies to
reposition the zygoma.
■ Enophthalmos or dystopia may be adequately corrected with the use of bone
grafts, cartilage, or porous polyethylene (PPE) or the use of some other filler
in the orbit.
■ Posterior displacement of the malar eminence may similarly be addressed
with a PPE malar implant or a bone graft.
■ In the past, methyl methacrylate and silicone implants were commonly
used.
■ A superior sunken sulcus of the upper eyelid can be addressed with fat
grafting to camouflage the degree of the deformity.
■ A malposition of the lateral canthus can be addressed by repositioning of the
canthus.
■ Correction Requiring Osteotomies
■ Assuming the most difficult case in which the patient prefers an osteotomy
and complete correction of a healed OIF of the ZMC, at the minimum,
periorbital and intraoral exposures are required.
■ Exposure of the ZF suture can theoretically be achieved by performing a

lateral canthotomy/conjunctival incision without a blepharoplasty incision.
The degree of pull on the soft tissues in the cephalad direction results in
both a struggle of retraction and more postoperative periorbital edema than
including an additional lateral blepharoplasty incision.
■ The blepharoplasty incision heals with a well-concealed scar.
■ The authors condemn the use of the lateral brow incision, which does not
provide any better exposure to the ZF suture than does a blepharoplasty
incision and results in an obvious permanent alopecia and part within the
eyebrow that can be permanently noted from across the waiting room.
■ Through the periorbital incision, the globe can be retracted medially to
expose the lateral wall of the orbit and superiorly to expose the orbital floor
and perform the appropriate osteotomies.
■ Similarly, the orbital and intraoral exposure can be used to osteotomize the
inferior orbital rim and the zygomaticomaxillary portion of the midface.
■ Using a Keen-type approach, the intraoral approach can also be used to
perform the osteotomy of the zygomatic arch (see FIG 4E).
■ Patients commonly present with an OIF and multiple problems. A coronal
incision will often facilitate access for the various osteotomies and allows the
surgeon to better visualize when adequate reduction is achieved.
■ In these cases, when a coronal incision is made, a blepharoplasty incision
is not needed.
■ The periorbital incision and intraoral incision are still required.
■ The coronal incision also facilitates the exposure and osteotomy of the
zygomatic arch (TECH FIG 1A).
■ In this case, the patient had significant temporal hollowing from previous
procedures, and PPE has been placed to correct the temporal defect (TECH
FIG 1B).

TECH FIG 1 • A. The coronal approach provides
excellent exposure to much of the zygoma. B. Late
malposition has been repositioned, using a coronal
approach to facilitate exposure of the ZF suture, the
lateral orbital wall, and the zygomatic arch (A PPE
implant has been placed to correct temporal
hollowing.).
■ Reconstruction and Fixation
■ As with a traditional repair of an acute ZMC fracture, following the
osteotomies and repositioning of the zygoma with fixation, a decision needs
to be made as to whether the orbital floor or lateral orbital wall needs to also
be reconstructed using titanium mesh, bone, cartilage, PPE, titanium mesh
plus PPE, bioabsorbables, Silastic sheeting, and/or other less popular
materials.
■ The periorbita often must be mobilized to correct for enophthalmos.
Controversy exists as to the extent of mobilization required to achieve
adequate correction of globe protrusion.
■ In his original publication describing this procedure, Kawamoto3

recommended a complete 360-degree dissection and mobilization of the
periorbita. In a later publication, Longaker and Kawamoto4 suggested that
only the portion of the periorbita attached to the displaced ZMC needed to
be mobilized. The extent of required mobilization remains controversial,
and a perfect esthetic result in a patient with chronic exophthalmos remains
a challenge.
■ The challenges facing the surgeon include scarring of the periorbita.
■ Even with a perfect reduction of the ZMC, it is possible that foreshortening
of the soft tissue of the orbit and the extraocular muscles may prevent the
surgeon from achieving proper globe projection.
■ Although one- or two-point stabilization with plates and screws may be
adequate in acute ZMC repair, because of the degree of scarring and
foreshortening of the soft tissues, three- or four-point fixation is generally
needed for malpositioned ZMC.
■ Navigation and intraoperative imaging may also be very helpful in these
cases, if the technology is available.
PEARLS AND PITFALLS
Preoperative
clinical
documentation
■ Complete eye examination with documentation of limitations
and asymmetries
Preoperative
radiologic
documentation
■ Midface CT with reformatting and 3D reconstruction.
Fiduciaries if navigation techniques are being considered
Camouflage
alternatives
■ Alternatives to osteotomies should be discussed: camouflage
procedures, alternatives for correction of enophthalmos, and
malar augmentation to correct asymmetry.
Mobilization of
the periorbita
■ The periorbita often must be mobilized to correct for
enophthalmos. Controversy exists as to the extent of the
mobilization that must be performed to achieve an adequate
correction of globe protrusion.
Intraoperative
assessment
■ Use of intraoperative imaging or navigation, if available

Postoperative
ophthalmologic
assessment
■ Postoperative monitoring of vision and movement of the globe.
POSTOPERATIVE CARE
■ Postoperative care after addressing a late malposition of the ZMC is similar to
that of acute treatment of the ZMC, with greater concern to ensure that the
patient does not develop an orbital compartment syndrome.
■ Performing a forced duction test at the end of the case and confirming that the
patient’s vision has not been compromised in the postoperative period is
important.
■ Keep the head of the bed maximally elevated to help decrease edema.
■ The use of nonsteroidal anti-inflammatories should be encouraged. Many
surgeons also use steroids in the perioperative phase to help with inflammation,
pain, and swelling.
■ The growing danger of excessive use of narcotics in North America needs to
be addressed.
■ Antibiotic use in the perioperative phase is common but with little evidence.
■ The use of ice packs may be beneficial for pain and swelling in the immediate
postoperative period.
OUTCOMES
■ An improved or perfect repositioning of the zygoma is the goal. However, a
perfect correction of enophthalmos and other chronic soft tissue asymmetries
may be impossible to correct perfectly.
COMPLICATIONS
■ Failure to adequately correct the malpositioned ZMC
■ Failure to adequately correct soft tissue asymmetries
■ Postoperative diplopia, dystopia, and blindness
REFERENCES
1. Wilde F, Lorenz K, Ebner AK, et al. Intraoperative imaging with a 3D C-arm
system after zygomatico-orbital complex fracture reduction. J Oral Maxillofac
Surg. 2013;71:894-910.
2. Gellrich NC, Schramm A, Hammer B, et al. Computer-assisted secondary

reconstruction of unilateral posttraumatic orbital deformity. Plast Reconstr
Surg. 2002;110:1417-1429.
3. Kawamoto HK. Late posttraumatic enophthalmos: a correctable deformity?
Plast Reconstr Surg. 1982;69:423-432.
4. Longaker MT, Kawamoto HK. Evolving thoughts on correcting posttraumatic
enophthalmos. Plast Reconstr Surg. 1998;101:899-906.

65
CHAPTER
Correction of Le Fort I
Fracture
Ananth S. Murthy
DEFINITION
■ The maxilla forms most of the middle third of the facial skeleton. It is attached
to the zygomatic bone and nasoethmoid area.
■ There are a series of vertical and horizontal buttresses to absorb energy during
impact by alternating thick and thin structures of the bones.
■ Le Fort I fractures occur above the apices of the dental roots, continue across
the base of the maxillary sinus, and extend to the pterygoid process.
ANATOMY
■ The maxilla forms portions of the orbit, nasal cavity, and oral cavity.
■ It contributes to the stability of the face by interacting with the cranium to
form buttresses (FIG 1).
■ Nasofrontal buttress: Medially with nasal bones and glabella (frontal bone)
■ Zygomatic buttress: Laterally with the zygoma, which further articulates with
the frontal bone, sphenoid, and temporal bone
■ Pterygomaxillary buttress: Posteriorly with sphenoid
■ Four processes: Frontal, zygomatic, palatine, and alveolar
■ During childhood, the maxilla acts as a tooth bank. As permanent teeth erupt
and sinuses form, the anterior wall becomes thin and the alveolar segment
becomes thick. With aging, as permanent teeth exfoliate, the alveolar segment
resorbs and recedes.
■ The infraorbital nerve passes through the infraorbital canal in the anterior
maxilla and supplies sensation to the upper lip and lateral portion of the nose.
■ Fractures of the maxilla are caused by direct impact; pattern and distribution
vary depending on magnitude and direction of force.

■ Le Fort I fractures usually occur in combination with other maxillary and/or
facial fractures (FIG 2).
PATHOGENESIS
■ The most common cause is a frontal impact.
■ The victim is usually thrown forward, striking the midface against an object,
for example, the dashboard or steering wheel of a car.
■ Displacement of the maxilla is generally posterior and inferior. Pterygoid
musculature aids in this direction of displacement.
■ Because of this displacement, premature contact of molars often results in an
anterior open bite.
■ Untreated fractures will result in maxillary retrusion and decreased facial
height and malocclusion.
FIG 1 • A series of vertical and horizontal buttresses

(alternating thick and thin structures of the bones) that
absorb energy during impact.
FIG 2 • Le Fort I fractures occur above the level of the
dental apices, across the maxillary sinus.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Mobility of maxillary dentition is the hallmark of a maxillary fracture.
■ Force applied by grasping the anterior portion of the maxilla with the thumb
and index finger elicits mobility of the maxilla. Integrity of the palate should
be assessed in cases of segmental or split palatal fractures.
■ Epistaxis, ecchymosis, and edema are seen.
■ There is midface retrusion, and malocclusion is present.
■ There may be hematoma and lacerations of the buccal mucosa.
■ Evaluation for other fractures of the face, especially nasal fractures, should be
performed, as isolated fractures of the maxilla are rare.
IMAGING
■ Computed tomography (CT) scan is required for diagnostic examination of the
maxilla. Axial cuts are best to demonstrate fractures of the maxilla.
■ Three-dimensional (3D) reconstructions aid in assessing symmetry and
displacement of the maxilla (FIG 3).

FIG 3 • CT scan showing Le Fort I maxillary fractures.
Note the posterior impaction of the maxilla due to the
trauma. Often segmental fractures (arrows) and loss of
dentition (asterisks) are also seen.
SURGICAL MANAGEMENT
■ Timing of surgery depends on the severity of injury.
■ Open, unstable fractures with hemorrhage will need emergent care.
■ Closed fractures with displacement and malocclusion should be treated
within a week of injury.
■ Initial treatment should be directed toward airway control, hemostasis, and
maxillomandibular fixation.
■ When comminuted fractures are present along with oronasal hemorrhage, and
unstable midface, then, tracheostomy should be performed to obtain airway
control.
■ If endotracheal intubation is done, it should be converted to a nasotracheal
airway so MMF can be pursued.
■ The simplest and most effective way to reduce a maxillary fracture is to place
the patient in occlusion with maxillomandibular fixation.

■ Arch bars are useful because Le Fort fractures are usually accompanied by
dentoalveolar fractures.
■ Interdental wiring, dental bonding, and use of occlusal splints with quick-
curing acrylic resins are also helpful in cases of displaced or missing teeth.
■ The goals of treatment should be to re-establish midfacial height and
projection, along with occlusion.
■ Critical buttresses should be visualized, and the maxilla reduced for accurate
alignment of these buttresses.
■ Plate and screw fixation is necessary for control of fractures and fracture
fragments.
Preoperative Planning
■ Risks of tooth loss and malocclusion should be discussed with the patient.
Preoperative occlusion should be determined by questioning patient or
caretaker.
■ Preoperative CT scans are imperative for diagnosis and planning. Intraoral
exam to determine any dentoalveolar injury is important.
■ If severe malocclusion is present with multiple fractures of the maxilla, then
preoperative dental impressions along with model surgery and an occlusal
splint may assist in obtaining maxillomandibular fixation.
■ Arch bars/MMF systems, 26-G stainless steel wires, lidocaine with
epinephrine, periosteal elevators, intraoral retractors, Rowe forceps, bone
hooks, and 1.0 to 1.5 mm midface titanium plating systems will be needed.
■ Loupe magnification with headlight assists with visualization.
Positioning
■ Supine positioning with the head toward the anesthesia team allows access
from both sides of the patient to the buccal sulcus and maxilla.
■ Nasotracheal intubation is necessary, as MMF will be required. If fractures are
unstable with oronasal hemorrhage, a tracheotomy should be considered.
Approach
■ A buccal sulcus approach is the best way to visualize the maxilla.
■ Preoperative injection with a local anesthetic plus epinephrine assists in
hemostasis.
■ A lip retractor, such as an Orringer retractor, aids with the exposure.

T E C H N I Q U E S
■ Exposure and Reduction
■ A lip retractor is placed and occlusion is assessed. A throat pack is placed.
■ A buccal sulcus incision is made with a 10-mm cuff above the gingival
border. When making the incision, avoid injury to the parotid duct, which is
usually present at the level of the maxillary first molar.
■ Using cautery, perpendicular dissection is directed toward the maxilla.
■ Subperiosteal dissection is then performed with a Joseph elevator.
■ The maxilla is exposed from the piriform/anterior nasal spine medially to the
orbital rim superiorly (the infraorbital foramen and contents are visualized),
the maxillary tuberosity laterally, and the zygoma superolaterally.
■ A curved periosteal elevator can be used to dissect around the maxillary
tuberosity hugging the bone until the pterygomaxillary fissure is reached by
the tip of the elevator.
■ Avoid disrupting the buccal fat pad with lateral dissection; fat within the
operative field becomes a nuisance during the case.
■ All fractures are visualized. If vertical fracture lines are present between
tooth roots, or alveolar fractures present, these are addressed first.
■ Interdental wires can help align the vertical fractures.
■ Rowe disimpaction forceps can be used to position the maxilla (TECH FIG
1).
TECH FIG 1 • A and B. The use of Rowe forceps to

reduce maxillary fractures.
■ Maxillomandibular Fixation
■ Arch bars are then placed on the maxillary and mandibular dentition; 26-
gauge stainless steel wires are preferred.
■ MMF is achieved by placing wire loops around the arch bars.
■ After MMF, attention is turned to the maxilla. The fractures along the
nasomaxillary and the zygomaticomaxillary buttresses are visualized. These
are aligned. If there are greater than 5 mm gaps, they should be filled with a
bone graft.
■ Six-hole L-shaped plates work well for fixation.
■ Monocortical drilling at 8000 RPM with copious irrigation is needed.
■ Screws of 4 to 5 mm are typically adequate for fixation.
■ Three screws on each side of the fracture are optimal.
■ The horizontal portion of the L-plate is affixed just above the dental roots (or
between them), and the vertical portion is used to secure it to the stable
portion of the maxilla or zygoma (TECH FIG 2).
■ After medial and lateral buttresses are secured bilaterally, MMF should be
released and occlusion tested. If normal occlusion and range of motion are
present, then closure can be commenced.
TECH FIG 2 • Plating schema for Le Fort I fractures. It

is important to reduce the fractures and fixate them.
Plates must be bent to accommodate the curvature of
the buttresses.
■ After thorough antibiotic irrigation, the buccal sulcus is closed from a lateral
to medial progression. Interrupted 4-0 Vicryl sutures are placed in a
composite fashion so that the muscle and mucosa of the buccal sulcus are
closed together in a watertight fashion.
■ After removal of the throat pack, an orogastric tube is placed and suctioned,
prior to extubation.
PEARLS AND PITFALLS
Dissection
■ Gentle dissection near the maxillary tuberosity prevents piercing
into the buccal fat pad and the nuisance of subsequent fat herniation
into the surgical field.
MMF
■ If fractures are segmental and/or severely displaced, expose the
fractures, followed by open reduction and pre-emptive alignment
using wire. Then, MMF can be pursued successfully followed by
internal fixation.
■ Leave MMF bars/screws for a few weeks after confirmed
functional occlusion.
Malocclusion
■ If malocclusion is noted (initially as lack of cuspid contact),
elastics should be instituted.
Gaps
■ Gaps in the critical buttresses larger than 5 mm should be grafted
with bone.
POSTOPERATIVE CARE
■ If used alone, MMF should be instituted for 4 weeks. If internal fixation is
performed, MMF is not required.
■ A nonchew diet is instituted until the bone is healed. Typically, this means
liquids for the first week, followed by blended food for 6 to 8 weeks.
■ Oral hygiene is critical. Chlorhexidine mouthwash helps maintain good oral
hygiene.

■ Nasal cleansing with saline sprays assists in clearing clot and exudate after
surgery. Nose blowing is prohibited for 3 weeks, as the increased pressure may
lead to epistaxis.
■ Perioperative antibiotic for 24 hours is recommended, along with
postoperative pain management.
■ Orthodontic referral is recommended for guided elastics if malocclusion is
suspected.
■ Physical therapy for jaw mobilization aids in recovery of function.
COMPLICATIONS
■ Hemorrhage can be managed with ligation, packing, and MMF.
■ If hemorrhage is not controlled with these measures, interventional radiology
referral for embolization may be necessary.
■ Airway can be managed based on severity.
■ Intubation postoperatively may be indicated, especially if MMF is
maintained.
■ Tracheostomy may be necessary if nasal intubation is not possible due to
extensive trauma.
■ Anesthesia of the cheek. This is usually secondary to traction and should
return over the first 8 to 12 weeks.
■ If the infraorbital nerve has been severed or avulsed, permanent anesthesia
will result if not repaired.
■ Dehiscence of buccal sulcus incision may occur. Meticulous oral care is
necessary.
■ If plates are exposed, continue oral care till bone healing is noted.
■ Hardware may be removed after healing is confirmed radiographically.
■ Instability, not exposure, causes infection and malunion.
■ If multiple lacerations are noted along the gingiva, be careful to preserve a
vascular cuff at the buccal sulcus incision.
■ The mucosa should be preserved centrally and not incised to preserve
vascularity.
■ If compromised, gingival necrosis/retraction can be noted postoperatively.
■ Postoperative infections are rare despite the continuity and involvement of
oral/nasal cavities and maxillary sinuses. Infections may occur in the face of
pre-existing sinusitis, or dental infection.
■ If sinusitis is suspected, traditional methods of treatment are recommended.

■ If dental abscess is suspected, tooth extraction may be required.
■ Malocclusion may present at several time points. If malocclusion is seen after
release from MMF and with articulation of the mandible, it is necessary to
remove and replace internal fixation.
■ If normal occlusion is obtained intraoperatively, and malocclusion is seen
within the first 4 weeks postoperatively, then MMF can be reinstituted.
■ After 4 weeks, guided elastics are recommended.
■ After 8 weeks, when union across the fracture is expected, reosteotomy at the
Le Fort I level and fixation is necessary.
REFERENCES
1. Markowitz BL, Manson PN. Panfacial fractures: organization of treatment.
Clin Plast Surg. 1989;16(1):105-114.
2. Gruss JS, Mackinnon SE, Kassel EE, Cooper PW. The role of primary bone
grafting in complex craniomaxillofacial trauma. Plast Reconstr Surg.
1985;75(1):17-24.
3. Manson PN, Hoopes JE, Su CT. Structural pillars of the facial skeleton: an
approach to the management of Le Fort fractures. Plast Reconstr Surg.
1980;66(1):54-62.
4. Manson PN. Some thoughts on the classification and treatment of Le Fort
fractures. Ann Plast Surg. 1986;17(5):356-363.

66
CHAPTER
Correction of Le Fort II
Fracture
Nataliya Biskup and John van Aalst
DEFINITION
■ Le Fort II is a midface fracture pattern that classically involves the critical
vertical facial buttresses:
■ Nasofrontal
■ Zygomaticomaxillary
■ Pterygomaxillary (pathognomonic component of all Le Fort fractures)
ANATOMY
■ The fracture starts at the zygomaticomaxillary buttress, extends through the
inferior orbital rim and orbital floor to the nasofrontal buttress, and then travels
posteriorly to involve the pterygomaxillary junction (FIG 1).
■ The level of fracture across the nose is variable, ranging from as high as the
nasofrontal suture to as low as the nasal cartilages.

FIG 1 • Approaches for exposure of the maxilla for
reduction and plating for Le Fort II fracture.
■ The attached pterygoid muscles exert a posterior and downward pull on the
maxilla leading to an anterior open bite with class III occlusal relationship.
■ Fractures may be bilateral or unilateral, may be combined with other Le Fort
fractures, and often may be a component of a pan-facial injury.
■ Medial and inferior orbital walls and nasoethmoid fractures are commonly
associated fractures. If the fracture traverses the lacrimal fossa, it may involve

the lacrimal system.
PATHOGENESIS
■ Le Fort II fractures result from high-velocity, blunt trauma, such as motor
vehicle collisions.
■ Patients will often report being thrown forward striking the midface against an
object such as a steering wheel.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ In addition to diffuse facial edema, malocclusion, periorbital ecchymoses, and
epistaxis are often present.
■ Mobility of the maxilla is a hallmark clinical finding.
■ Step-offs along the inferior orbital rim may be palpable.
■ The key points of examination are as follows:
■ Rule out cervical spine injury.
■ Evaluate ocular/orbital injury (vision, pupils, extraocular movement).
■ Assess cranial nerve V2 (sensation over cheek, lateral nose, and upper lip).
■ Evaluate occlusion. The expected occlusion is class III with an anterior open
bite with premature posterior tooth contact.
IMAGING
■ Maxillofacial CT with 3D reconstruction is the standard for diagnosis and
preoperative planning. Fluid in the maxillary sinus is the most reliable indicator
of maxillary fractures.
EPIDEMIOLOGY
■ Most patients are males in their 30s involved in motor vehicle collisions.1
■ Among patients with maxillary fractures, the incidence of Le Fort I, Le Fort II,
and Le Fort III fracture is 16% to 55%, 14% to 24%, and 13%, respectively.
■ Over half (57%) of the Le Fort fractures are combinations of the three; 89%
coexist with other fractures in the maxillofacial region.2
■ The incidence of associated serious eye injury is 9% and traumatic optic
neuropathy 20%, and the rate becomes significantly higher for more complex
fractures.2,3
■ Patients with Le Fort II fractures have higher injury severity scores and are
more likely to need intensive care unit admission and immediate operative
intervention (similar to patients with Le Fort III fractures and unlike patients

with Le Fort I injuries).4,5
NONSURGICAL MANAGEMENT
■ Observation is indicated in:
■ Patients with nondisplaced fractures, premorbid, unchanged occlusion, and
willingness to comply with strict soft, no-chew diet
■ Edentulous patients with minimal displacement
■ Unstable patients
■ Closed treatment with arch bars and guiding elastics is indicated in patients
with minor malocclusion who can be reduced by closed maxillary disimpaction
and manipulation.
SURGICAL MANAGEMENT
■ Open treatment is indicated in patients with displaced fractures or
malocclusion or those unable to comply with diet modification.
Preoperative Planning
■ Rule out cervical spine injury prior to surgical correction of the facial fracture.
■ Obtain ophthalmologic evaluation to rule out globe/retinal injury as
intraoperative manipulation may exacerbate the injury.
Positioning
■ Use nasotracheal intubation to facilitate verifying occlusion during fracture
reduction.
■ If nasotracheal intubation is contraindicated, place the endotracheal tube
through retromolar space; if this is not possible and other lacerations are
present, use submental or submandibular intubation.6
Approach
■ Make an upper gingivobuccal sulcus incision from first premolar to first
premolar, leaving a residual cuff of mucosa for final closure.
■ Apply cautery directly onto maxilla the full length of the incision (TECH FIG
1).
■ Use a Freer elevator to develop subperiosteal plane. Avoid injury to the
infraorbital nerve, which exits the maxilla 1 to 2 cm below the inferior orbital
rim.
■ If needed, open the orbital rim via eyelid incision, either transconjunctival or

transcutaneous. If transconjunctival approach is chosen, make an incision with
Bovie along the inferior fornix, well away from the tarsus. Use Bovie cautery
directly onto the bone. If fracture extends medial along the rim, use a
transcutaneous incision. Make an incision in the lower lid crease with a no. 15
blade. Raise a skin and orbicularis flap until arriving at the inferior orbital rim.
■ Develop a subperiosteal plane to expose the infraorbital rim. Extend this
approach medially via a transcaruncular approach to expose medial wall
fractures if present.
■ Use glabellar or coronal incisions for exposure of the nasofrontal junction, if
needed.
■ Close the gingivobuccal sulcus incision with 3-0 Vicryl simple interrupted.
Close transcutaneous eyelid incision with 5-0 Prolene or 5-0 fast gut.
Transconjunctival incisions do not need to be closed. If a lower lid incision is
made, apply Frost stitch for 5 to 6 days postoperatively.
T E C H N I Q U E S
■ Reduction
■ Restore the fractured midfacial buttresses: the zygomaticomaxillary (ZM),
pterygomaxillary, and nasomaxillary (NM).
■ Apply Erich arch bars with 26-gauge wire.
■ Expose fractures and debride callus with small curette or rongeur.
■ Reduce fractures.
■ Muscular attachments to the pterygoid plates and posterior maxilla distract
the maxilla posteriorly and resist reduction and fixation.
■ Use Rowe disimpaction forceps, “Stromeyer” hook, Tessier retromaxillary
mobilizers, or channel retractors to passively mobilize the maxilla (TECH
FIG 1).
■ If maxilla cannot passively be mobilized, placement of maxillomandibular
fixation (MMF) can unseat the condyles such that when MMF is released,
the condyles seat back into fossa, and a class III malocclusion occurs.

TECH FIG 1 • Instruments used in reduction of
maxilla. From left to right: Rowe disimpaction forceps,
Stromeyer hooks, Tessier retromaxillary mobilizer,
channel retractors.
■ Fixation
■ Once adequate reduction is obtained, fixate the maxilla.
■ Two points of fixation are most common; however, the number of fixation
points can vary from one to three depending on the degree of comminution
and displacement of the fractures.
■ Start plating at the most reliably reduced buttress (TECH FIG 2A).
■ At the zygomaticomaxillary buttress, the greatest masticatory force is
exerted; thus, use a larger caliber 1.5 or 2.0 mm L or straight plate.
■ Some Le Fort II fractures can be adequately reduced and plated at the ZM
buttress only.
■ Place leg of plate along the most lateral portion of the ZM buttress as it has
the thickest bone.
■ Place foot of plate along the alveolar bone taking care to avoid tooth roots.
■ In comminuted fractures, use longer plates in addition to smaller, shorter
plates to reduce small fragments.
■ At the inferior orbital rim, the forces are weaker and soft tissue is thinner;
use a lower profile plate, such as a 1.2 mm, to avoid palpability.

■ Rarely is plating at the nasofrontal area needed, as closed reduction of this
fracture is often adequate.
■ If plating is deemed necessary, use low-profile straight, Y, or X plates.
■ Use additional plates or mesh in comminuted fractures (TECH FIG 2B).
TECH FIG 2 • A. Most common plating configuration
for noncomminuted Le Fort II fractures, includes
plating of nasomaxillary/orbital rim and
zygomaticomaxillary buttresses. B. Plating
configuration used for comminuted Le Fort II fractures;
shorter low-profile plates or a single sheet can be
used to bridge bone defects.
■ Completion
■ Following fracture fixation, release MMF and verify occlusion.
■ Passively open and close the mandible to see whether maximal
intercuspation occurs and whether wear facets of the maxillary/mandibular
dentition reference one another.
■ Given that the maxilla is reduced by referencing its occlusion with the
mandible, accurately reduce any mandible fractures and restore the posterior
mandibular height and width.
■ Recognize any simultaneous palatal fractures, as this is critical to restoring
accurate facial width.
■ Reapply MMF depending on stability of reduction and restoration of

occlusion.
■ Explore the orbital floor and medial orbital wall, if indicated, as Le Fort II
fractures often involve fractures of these areas.
■ Depending on degree of fracture displacement, reduction and fixation of
these fractures may be indicated after plating the Le Fort II fracture.
PEARLS AND PITFALLS
Preoperative
■ Evaluate ocular/orbital injury.
■ Rule out cervical spine injury.
Technique
■ Passive mobilization of maxilla is critical to prevent class III
malocclusion.
■ Rowe disimpaction forceps should be used with caution to avoid
significant shear at the skull base and orbit and to prevent injury to
the anterior maxillary dentition.
■ Following surgery, immediately evaluate globe mobility and rule
out entrapment with a forced duction test and check pupil symmetry.
POSTOPERATIVE CARE
■ Vision and light perception should be monitored for 24 hours after reduction.
■ Patient should elevate head of bed, apply ice, and avoid nose blowing for 4 to
6 weeks.
■ Strict oral hygiene with gentle tooth brushing and non–alcohol-based
mouthwash should be performed. Patients should have soft no-chew diet for 4
to 6 weeks.
■ Postoperative antibiotics are recommended for 1 day after surgery. Antibiotics
beyond this have not been shown to decrease infection rates.7
■ Smoking and alcohol use should be avoided.
■ Duration of MMF is variable from 2 to 6 weeks, depending on fracture
stability after reduction, establishing occlusion, and amount of fracture
comminution.
OUTCOMES
■ Patients with more complex comminuted Le Fort fractures report more
limitations due to physical and emotional problems.

■ Approximately 70% of patients with Le Fort II fractures are able to return to
work.
■ Commonly, these patients report dissatisfaction with facial appearance and
score higher on Social Avoidance and Distress scales.8,9
■ Other self-reported symptoms include visual problems, alteration in smell,
difficulty with mastication, breathing, diplopia, and epiphora.10
COMPLICATIONS
■ Early
■ Midface fractures may result in significant bleeding, which can be controlled
by nasopharyngeal packing, manual fracture reduction, and/or angiographic
embolization.11
■ Airway obstruction may occur due to edema and posterior displacement of
fracture fragments.
■ Though more rare than in mandible fractures, infection can occur, especially
in patients with pre-existing sinusitis or obstruction of the maxillary sinus
drainage tract.
■ Extreme care must be exercised with reduction of the maxilla as excessive
force and down fracture may propagate fractures and lead to blindness.
Cerebrospinal fluid leak, though rare, can also occur.
■ If the maxilla cannot be passively repositioned into appropriate reduction,
consider a Le Fort I osteotomy to restore premorbid occlusion.12
■ Late
■ The most common long-term complications include persistent infraorbital
nerve paresthesias (22%); malocclusion (20%), most of which resolved with
application of MMF; and orbital complications including diplopia (8%) due to
extraocular muscle injury and epiphora due to nasolacrimal duct injury.10
■ Others include devitalization of teeth, nonunion, malunion, plate exposure,
changes in facial appearance, and nasal airway obstruction. Delayed union is
more likely to occur in comminuted fractures. Malunion often requires Le
Fort I osteotomy to correct.10
REFERENCES
1. Kochhar A, Byrne PJ. Surgical management of complex midfacial fractures.
Otolaryngol Clin North Am. 2013;46(5):759-778.
2. Chen WJ, Yang YJ, Fang YM, et al. Identification and classification in LeFort
type fractures by using 2D and 3D computed tomography. Chin J Traumatol.

2006;9(1):59-64.
3. Amrith S, Saw SM, Lim TC, Lee TK. Ophthalmic involvement in cranio-
facial trauma. J Craniomaxillofac Surg. 2000;28(3): 140-147.
4. Motamedi MH. An assessment of maxillofacial fractures: a 5-year study of
237 patients. J Oral Maxillofac Surg. 2003;61(1): 61-64.
5. Oliveira-Campos GH, Lauriti L, Yamamoto MK, et al. Trends in LeFort
fractures at a South American trauma care center: characteristics and
management. J Maxillofac Oral Surg. 2016;15(1):32-37.
6. Lee SS, Huang SH, Wu SH, et al. A review of intraoperative airway
management for midface facial bone fracture patients. Ann Plast Surg.
2009;63(2):162-166.
7. Soong PL, Schaller B, Zix J, et al. The role of postoperative prophylactic
antibiotics in the treatment of facial fractures: a randomised, double-blind,
placebo-controlled pilot clinical study. Part 3: LeFort and zygomatic fractures
in 94 patients. Br J Oral Maxillofac Surg. 2014;52(4):329-333.
8. Manson PN, Clark N, Robertson B, et al. Subunit principles in midface
fractures: the importance of sagittal buttresses, soft-tissue reductions, and
sequencing treatment of segmental fractures. Plast Reconstr Surg.
1999;103(4):1287-1306
9. Girotto JA, MacKenzie E, Fowler C, et al. Long-term physical impairment
and functional outcomes after complex facial fractures. Plast Reconstr Surg.
2001;108(2):312-327.
10. Steidler NE, Cook RM, Reade PC. Residual complications in patients with
major middle third facial fractures. Int J Oral Surg. 1980;9(4):259-266.
11. Bagheri SC, Holmgren E, Kademani D, et al. Comparison of the severity of
bilateral LeFort injuries in isolated midface trauma. J Oral Maxillofac Surg.
2005;63(8):1123-1129.
12. Ellis E. Passive repositioning of maxillary fractures: an occasional
impossibility without osteotomy. J Oral Maxillofac Surg. 2004; 62(12):1477-
1485.

67
CHAPTER
Correction of Le Fort III
Fractures
Joseph Lopez and Amir H. Dorafshar
DEFINITION
■ Le Fort III type fracture lines classically transverse the horizontal and vertical
buttresses of the face, separating the face from the base of the skull.
■ Also known as craniofacial disjunction, Le Fort III type fracture lines extend
specifically from the lateral and medial orbital walls to the nasofrontal region
and the zygomatic arches (FIG 1).
ANATOMY
■ The facial skeleton is composed of several bones: maxilla, mandible, lacrimal,
nasal, palatine, vomer, zygomatic, and inferior nasal concha bones.
■ The maxilla constitutes the middle third of the face and contains the maxillary
sinus.
■ The maxilla and the surrounding bones compose an important system of
buttresses that provide mechanical support to the face.
■ These buttresses include the lateral orbital wall, zygomatic arch, nasofrontal,
and lateral and medial maxillary buttresses.
■ The medial and lateral maxillary buttresses are better known as the
nasomaxillary buttress and zygomaticomaxillary (ZMC) buttress, respectively
(FIG 2).
■ These buttresses (ie, nasofrontral, zygomatic arch, zygomaticofrontal, lateral
orbital wall) are critical for bony alignment and stabilization after fractures.
■ The main fracture line of Le Fort III type fractures extends from the bridge of
the nose through the nasofrontal process, the medial and lateral walls and floor
of the orbits, the zygomaticofrontal processes, and the zygomatic arches.
■ The nasal septum is also fractured, and the maxilla is separated from the

pterygoid plates.
■ The maxilla is highly vascularized. The largest branch of the external carotid
artery, the internal maxillary artery, supplies the midface.
■ Sensation to the maxillary teeth, nasal cavity, sinuses, and facial skin overlying
the maxilla is supplied by the second branch of the trigeminal nerve
(infraorbital nerve).
■ The infraorbital foramen is located 5 to 10 mm below the infraorbital rim in
line with the medial limbus of the pupil.
PATHOGENESIS
■ All maxillary fractures, including Le Fort III type, are a result of high-energy
frontal or lateral impacts to the face.
■ When force is exerted on the maxilla and the surrounding bones, the force is
dissipated in such a way that the globe and brain are protected from injury,
resulting in characteristic fracture patterns.
■ Maxillary fractures are categorized using the Le Fort system.
■ Le Fort I and II type fractures are less complex maxillary fractures (and are not
discussed here). Le Fort III type fractures are the most complex maxillary
fractures and are often the result of high-energy facial injuries.
■ Le Fort III type fractures usually present in a mixed pattern with other Le Fort
type fractures often present (eg, Le Fort I and II).
■ Le Fort III type fractures often present with other facial fractures such as
mandible, ZMC, or naso-orbital-ethmoid (NOE) fractures.
■ Le Fort III type fractures are often also associated with cervical spine and skull
base fractures. These fractures may be associated with airway compromise,
facial bleeding, and neurological injuries.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ All initial trauma evaluations should consist of an assessment of airway,
breathing, and circulation (ie, A, B, Cs).
■ A proper primary and secondary survey should be performed in all patients
with suspected facial trauma.
■ Because Le Fort III type fractures are the result of high-energy trauma,
patients can often present with other life-threatening injuries such as
intracranial bleeding or penetrating trauma.
■ After the patient is stabilized, a complete history should be obtained (often
from a family member or witnesses given that Le Fort III type fractures are

associated with neurological injuries or loss of consciousness). The following
questions should be considered:
■ When and where did the accident occur?
■ What are the specifics of the injury (ie, object, speed, direction)?
■ Was there loss of consciousness?
■ Does the patient have the following symptoms:
■ Loss of vision?
■ Hearing changes?
■ Malocclusion?
■ Altered sensation?
■ Difficulty moving eyes?
■ Pain with jaw movement?
■ A complete review of system should be obtained including allergies,
medications, previous surgeries or medical conditions, and tetanus
immunization history.
■ A thorough history can be instrumental in guiding the CMF surgeon to specific
injury patterns.
FIG 1 • Craniofacial disjunction/Le Fort III type fracture

in a 28-year-old healthy male after a high-impact motor
vehicle collision. A. Le Fort III type fractures are typified
by fracture lines across the bilateral lateral orbital walls
and nasofrontal junctions (red arrows). B. Left
zygomatic arch and zygomaticofrontal suture fracture
(blue arrows). C. Right zygomaticofrontal junction
fracture (green arrow). D. Stabilization achieved by
reduction and fixation of the nasofrontal junction,
bilateral orbital walls, and zygomaticofrontal junctions.
E,F. Fixation of bilateral zygomaticofrontal fractures.
■ Assess the head and neck region for the following:
■ Soft tissue asymmetry or skeletal deformities: Le Fort III patients often
present with elongated faces or malar depression.
■ Ear canals and tympanic membrane for traumatic injuries (ie,
hemotympanum, etc.) or CSF leaks
■ Nasal area for epistaxis, CSF rhinorrhea, swelling, septal deviation or
hematoma, and nasal airway obstruction
■ Orbit for entrapment, ecchymosis, edema, or subconjunctival hemorrhage
■ Dentition for malocclusion, mobility of teeth, prosthetics, or
mandibular/maxillary displacement during teeth contact: Le Fort III type
fractures can present with malocclusion.
FIG 2 • 3D reconstructions created from CT
maxillofacial coronal (A), axial (B), and sagittal (C)
images of a 19-year-old healthy man with a Le Fort III

type fracture pattern after falling 15 ft. The purple lines
display the nasomaxillary buttresses, and the aqua lines
display the zygomaticomaxillary buttresses.
■ Oral mucosa for swelling, lacerations, open fractures, or other pathology
■ Occlusion for overjet, overbite, or open bite
■ Neurovascular examination
■ Cranial nerves
■ Assess for paresthesia in the distribution of the infraorbital nerve.
■ Palpation of the head and neck region for:
■ Step-offs, crepitus, clicking, or popping of the midface, nasal, frontal, and
mandibular regions
■ Swelling or tenderness along buttress lines
■ Instability of the midface or maxillary mobility
■ Stability of the canthal attachments
IMAGING
■ Patients suspected of having Le Fort III type or other maxillary fractures
should undergo computed tomography (CT) to evaluate the fracture patterns
and the need for treatment:
■ CT scans should be reviewed in the coronal, axial, and sagittal planes with
particular attention to the buttresses to determine severity and types of
fracture lines.
■ 3D reconstructions can often be useful for teaching purposes and for virtual
surgical planning (FIG 2).
SURGICAL MANAGEMENT
■ The two most important indications for surgical intervention of maxillary
fractures are malocclusion and instability:
■ Given the complexity of Le Fort III type fractures, almost all Le Fort III type
fractures present with malocclusion or instability that require surgical
management.
■ Other relative indications for Le Fort III type surgical management include
uncontrolled bleeding and airway stabilization:
■ Because Le Fort III type fractures are associated with extensive soft tissue
injury and swelling, nasal and oral airflow can be compromised.

■ The main goal of operative management is to re-establish proper occlusion.
■ Timing of surgical management is dictated largely by concomitant injuries.
Preoperative Planning
■ CT scan should be reviewed to determine the correct combination of
approaches.
Positioning
■ The patient is positioned supine on the operating table with a shoulder roll to
facilitate neck extension.
■ Neck extension is contraindicated if the patient is suspected to have or has a
spine injury.
■ In these situations, we prefer to defer surgical correction until the neck has
been clinically or radiologically cleared. In extenuating circumstances when
the neck cannot be cleared, or if there is indeed a cervical neck fracture, we
will ask permission from the spine team to proceed with caution by either
using an adapted silicone headrest or two 3-L intravenous solution bags taped
on either side of the patient’s head, to keep the neck in a neutral position
throughout the duration of the surgery.
Approach
■ Because of the complexity of Le Fort III type fractures, exposure often is
achieved with multiple approaches including coronal flaps, lower eyelid
incisions, and upper buccal incisions.
T E C H N I Q U E S
■ Repair With Coronal Flap, Miniplate Fixation,
and Intermaxillary Fixation
Airway Establishment and Exposure
■ After a thorough discussion with the trauma and anesthesia team, the best
method for airway management is determined.
■ Nasal intubation can be accomplished with a standard endotracheal tube or
a nasal RAE tube which is longer and can be more easily secured.

■ Careful attention to skull base fractures is mandatory when using nasal
intubation.
■ If postoperative airway compromise is of great concern, a tracheostomy must
be considered.
■ The face is prepped and draped in sterile fashion.
■ Intermaxillary arch bars or screws should be applied at the outset of the case
to assist with achievement of satisfactory occlusion with anatomical fracture
reduction.
■ A coronal incision is made from the preauricular crease above the pinnae
across the temples to form a gentle curve behind the hairline.
■ 1% lidocaine with 1:100 000 epinephrine can be injected to the incision line
to control bleeding.
■ Raney scalp clips can be applied at the incision for hemostasis. These clips
can cause severe alopecia if left in place for a prolonged period of time,
however. The authors prefer not to apply Raney clips and prefer to obtain
hemostasis of the scalp during the incision.
■ Hair can be held out of the way with elastic bands covered with towels
attached to the scalp.
■ Branches of the superficial temporal artery are clamped and ligated with
suture.
■ A subperiosteal plane is developed, and the scalp and forehead are elevated
over the supraorbital rim (TECH FIG 1).
■ Laterally, the dissection should be developed in the plane just superficial to
the temporalis muscle fascia.
■ The dissection is continued once one reaches the supraorbital rim with
careful attention to preserve the supraorbital and supratrochlear vessels.
■ While the flap is elevated, the periosteum is incised along the
zygomaticofrontal buttress.
■ If the zygomatic arch needs to be exposed, the supratrochlear and
supraorbital vessels and nerves can be released by making osteotomies at the
supraorbital foramina.
■ The nasal bridge fracture can be exposed by elevating the periosteum from
the frontal process of the maxilla and nasal bones. At times, the periosteum
needs to be incised to better expose the nasal bones.
■ To expose the infraorbital rim and lower maxilla, an upper gingival buccal
incision can be made.

Fracture Reduction and Fixation
■ Once all fractures are exposed, the Le Fort III fracture can be reduced with
Rowe disimpaction forceps as needed. However, osteotomies may be needed
to fully mobilize the fractured segment if the midface is impacted and cannot
be disimpacted using the Rowe disimpaction forceps (TECH FIG 2A).
TECH FIG 1 • A coronal incision is made and a
subgaleal (or subperiosteal) plane is developed. The
scalp and forehead are elevated over the supraorbital
rim. Near the supraorbital rim, a subperiosteal plane is
developed (or continued) with careful attention to
preserve the supraorbital and supratrochlear vessels.
Laterally, the dissection should be developed in the
plane just superficial to the temporalis muscle fascia.

While the flap is elevated, the periosteum is incised
along the zygomaticofrontal buttress down to the
zygomatic arch.
TECH FIG 2 • A. Once all fractures are exposed, the
Le Fort fracture can be reduced with Rowe
disimpaction forceps as needed. However,
osteotomies may be needed to fully mobilize the
fractured segment if the midface is impacted and
cannot be disimpacted using the Rowe disimpaction
forceps. B. Once pretraumatic occlusion is achieved
with intermaxillary fixation and all the buttress
fractures are aligned, plating can proceed.
■ Once pretraumatic occlusion is achieved with intermaxillary fixation (IMF)
and all the buttress fractures are aligned, plating can proceed (TECH FIG
2B).
■ Large bone gaps (5–10 mm) should be treated with bone grafts.
■ The most important suture to fixate the lateral orbital walls is at the
zygomaticofrontal junction. A miniplate with at least two holes on each side
of the fracture must be placed with the bone in an adequately reduced
position (TECH FIG 3).

■ If the nasofrontal process is unstable, fine 0.5-mm plates, small interosseous
wires, or 2-0 PDS sutures can be placed to approximate all the fragments.
■ If the orbital rim needs repair, an eyelid exposure can assist in fixating the
reduced orbital segments. The authors’ preferred eyelid approach is the
transconjunctival incision.
■ The coronal flap, upper gingivobuccal, and eyelid incisions are closed in
layers.
■ The patient is placed on perioperative antibiotics for 24 hours and imaging
obtained as needed.
TECH FIG 3 • Le Fort III type fracture in a 25-year-old
man who presented after an assault. A–C. Preoperative
imaging revealed Le Fort III and I type fractures. D–F.
Once pretraumatic occlusion was achieved with
intermaxillary fixation, all the buttress fractures were
aligned, and fixation via plating was performed.

PEARLS AND PITFALLS
Indications
■ Surgical indications for Le Fort III type fractures are instability
and malocclusion.
Goals
■ Restore normal occlusion.
■ Restoration of facial height, width, and projection.
Approach
■ Given the complexity of Le Fort III type fractures, multiple
approaches are necessary to reduce all fractures lines: these
include the coronal flap, upper gingivobuccal incision, and lower
eyelid incisions.
Technique
■ Place IMF arch bars or screws, expose all the fractures adequately,
disimpact the Le Fort III segment using Rowe forceps or perform
osteotomies to reduce fractures anatomically, place the patient into
IMF, align the zygomaticosphenoid sutures, and fixate at the
zygomaticofrontal and nasofrontal buttresses as required.
Postoperative
diet and care
■ Patients should be placed on a soft diet while in IMF, and use
chlorhexidine mouthwash 3 times per day.
POSTOPERATIVE CARE
■ Following fracture repair, resolution of facial edema may occur quite slowly.
Therefore, postoperative airway compromise is of great concern. A
tracheostomy may be considered preoperatively in severe clinical scenarios.
■ Studies have demonstrated that Le Fort III type fractures, when compared to
other facial fractures, are more likely to require a surgical airway.1
■ IMF is the most common cause of frustration in patients. Proper hardware
management to improve patient compliance and comfort is necessary.
■ During surgery and before discharge, intraoral wires should be examined to
prevent irritation or pressure sores.
■ Arch bar care should be initiated with the use of chlorhexidine mouthwash 3
times per day to prevent bacteria over-colonization.
■ The patient should be placed on soft/puree diet until removal of arch bars. A
scheduled antiemetic regimen can be useful as well.
■ IMF should be kept in place for 1 to 3 weeks.2 IMF can then be replaced with
two elastic bands per side for a total of 6 weeks of treatment. Occlusion
should be monitored throughout this period, and the patient should be placed

in IMF if malocclusion develops.
■ At the end of the 6-week treatment, arch bars can be removed, and
intraoperative assessment of occlusion can be performed at that time.
■ Recently, several studies have examined the course of antibiotics needed after
surgical management of facial fractures. All these studies have demonstrated
that a short course of perioperative and postoperative antibiotics (less than 24
hours) is needed to prevent postoperative infections.3,4
■ Follow-up varies depending on surgeon preference. However, the patient
should not be discharged from follow-up until at least 3 to 6 months
postoperatively to allow adequate assessment of surrounding structures (ie,
dental, ocular, or lacrimal system functions).
OUTCOMES
■ Currently, there is a paucity of data exploring outcomes in patients with Le
Fort III type fractures:
■ However, the handful of studies that have examined outcomes in this unique
patient population indicate that Le Fort III type fractures are highly
debilitating fractures that cause significant morbidity to patients.
■ Bagheri et al.1 examined over 60 patients with Le Fort I, II, and III types who
presented to a single institution over a 13-year period.
■ They found that higher Le Fort injuries are associated with greater severity of
trauma as measured by injury severity scores and have a more frequent need
for surgical airways.
■ Additionally, Le Fort III type patients are more likely to require
neurosurgical interventions and experience vision-threatening ocular trauma.
■ Girotto et al.5 compared the long-term general health status and psychosocial
well-being of patients who suffered Le Fort fractures to patients who presented
to a general emergency ward:
■ These investigators found that increasing Le Fort complexity is associated
with emotional problems and physical impairment secondary to altered social
interaction as a result of the facial trauma.
■ Patients with increasingly complex Le Fort type fractures reported
difficulties with vision, smell, mastication, breathing, and epiphora.
■ These studies suggest that Le Fort III type fractures cause significant
morbidity and limit patient’s potential to achieve productive and active lives.
COMPLICATIONS

■ Immediate complications after Le Fort type fractures involve airway
compromise or bleeding:
■ High-energy facial trauma can result in significant soft tissue swelling that
can obstruct the nasopharynx or oropharynx.
■ Deep or superficial vessel damage can occur secondary to high-energy
maxillary fractures. Ligation or nasal packing can often control the bleeding,
but manual reduction with IMF may also be needed.
■ Subacute complications after Le Fort type fractures typically involve damage
to the surrounding structures such as skull base (or cribriform plate) producing
CSF leaks or lacrimal duct injuries causing orbital cellulitis or dacryocystitis.
■ Infections are prone to occur in patients who present with facial soft tissue
injuries and/or contaminated wounds. Although less common than mandibular
fractures, infections can result in plate exposure and bone graft loss.
■ Infections can often be treated with antibiotics only. However, if associated
with plate exposure or failure, plates and grafts may have to be removed.
■ Nerve injuries can occur as well.
■ Forehead paresthesia can occur with injuries to the supraorbital nerve during
retraction of the orbital tissue or during reduction and fixation of the medial or
lateral orbital rims.
■ Weakness of the forehead or upper eyelid can occur with injuries to the
frontal branch of the facial nerve. This often occurs when applying traction on
the forehead flap.6
■ Blindness can occur following Le Fort II type fractures and results from
severe swelling within the optic canal.7
■ Nonunion or malunion are rare long-term complications following correction
of Le Fort type fractures. They are often secondary to suboptimal surgical
management (ie, fixation) or delayed treatment.
■ Facial asymmetries such as long vs short face, increased width, inappropriate
projection, and malocclusion can occur following improper management.
■ If symptomatic, the fracture sites must be explored and corrected with
possible osteotomies, bone grafts, plates, alloplastic or dental implants, or
further orthognathic surgery.
■ Plates can occasionally be visible or palpable in thin-skinned patients. This can
be avoided by using low-profile plates or using interosseous wires.
REFERENCES

1. Bagheri SC, Holmgren E, Kademani D, et al. Comparison of the severity of
bilateral LeFort injuries in isolated midface trauma. J Oral Maxillofac Surg.
2005;63(8):1123-1129.
2. Coletti DP, Salama A. Caccamese JF Jr. Application of intermaxillary fixation
screws in maxillofacial trauma. J Oral Maxillofac Surg. 2007;65(9):1746-
1750.
3. Andreasen JO, Jensen SS, Schwartz O, et al. A systematic review of
prophylactic antibiotics in the surgical treatment of maxillofacial fractures. J
Oral Maxillofac Surg. 2006;64(11):1664-1668.
4. Soong PL, Schaller B, Zix J, et al. The role of postoperative prophylactic
antibiotics in the treatment of facial fractures: a randomized, double-blind,
placebo-controlled pilot clinical study. Part 3: LeFort and zygomatic fractures
in 94 patients. Br J Oral Maxillofac Surg. 2014;52(4):329-333.
5. Girotto JA, MacKenzie E, Fowler C, et al. Long-term physical impairment
and functional outcomes after complex facial fractures. Plast Reconstr Surg.
2001;108(2):312-327.
6. Otto AJ, Borghouts JM. Orbital corrections with use of alloplastic material.
Mod Probl Opththalmol. 1975;14:641-644.
7. Kallela I, Hyrkas T, Paukku P, et al. Blindness after maxillofacial trauma.
Evaluation of candidates for optic nerve decompression surgery. J
Craniomaxillofac Surg. 1994;22(4):220-225.