Le Fort I Osteotomy with placement of Distractor

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Author: Nikhil Kamath
Published:
Specialties: Craniofacial and Pediatric Plastic Surgery, Plastic Surgery
Schools: Arkansas Children's Hospital, University of Arkansas for Medical Sciences
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Basic Info

Our patient is a 20 year old boy with severe maxillary hypoplasia with a history of bilateral cleft lip and palate. We performed a maxillary advancement with distraction osteogenesis.

Nikhil Kamath, BS

Aaron Smith, MD

Michael S. Golinko, MD

Kumar Patel, PA-C

Advanced

Procedure

Le Fort I Osteotomy with Distractor

The patient was laid supine after successful nasal endotracheal intubation. Maxillary exposure was gained through mucosal incision from 1st premolar to 1st premolar. A 5mm  gingivobuccal cuff is maintained. The maxilla is degloved with a number 9 periosteal elevator. Care is taken to identify infraorbital nerve on each side.The mucosa is lifted from the periform appature using a Penfield 1. The posterior foot plate is fitted bilaterally prior to osteotomy. This distractor body is parallel and confirmed to both be in an appropriate vector. The maxilla is marked for osteotomy. Reciprocating saw is used lateral to medial taking extra caution over the thin walled maxillary sinus. Olive osteotome is used to separate mucosa from the posterior palate. Kowamoto osteotome is used at pterygomaxiallary junction. Ribbon Osteotome is used to complete posterior wall osteotomies and complete the maxilla down fracture. Once the maxilla is confirmed to be completely free, fixation of anterior and posterior foot plates is finalized. The distractor bodies are turned to begin distraction osteogenesis. The gingovobuccal incision is closed with running 3-0 chromic suture. The patient was extubated in good condition

Indications

Severe maxillary hypoplasia (>10mm of advancement required)

Contraindications

No absolute contraindications, but conventional fixed advancement remains the standard of care in patients of skeletal maturity with mild to moderate maxillary hypoplasia.

Instrumentation

Setup

-Reciprocating saw
-Penfield 1
-Various osteotomes

Preoperative Workup

-Orthodontic preparation
-Low dose craniofacial CT scan with 3D reconstruction
-Virtual surgical planning
-Sterolithic skull model used to modify distractor footplates

Anatomy and Landmarks

Infraorbital nerve, infraorbital foramen, maxillary sinus, zygomatic process, anterior nasal spine, alveolar process, palentine process, periform aperture

Advantages/Disadvantages

Benefits over conventional Le Fort I advancement:
-helpful in cleft lip/palate population with poor bone quality and scaring from previous surgery
-lower risk of disharmony than combined maxillary advancement with mandibular setback
-skeletal maturity not required for distraction osteogenesis
-relative long-term stability in pts who have failed traditional advancement
-decreased relapse rate compared to the conventional advancement

Complications/Risks

-Infection/bleeding
-Horizontal relapse (risk highest within 6 months of consolidation)
-Decreased ANB angle in patients who have not reached skeletal maturity
-Negative effect on velopharyngeal competence

Disclosure of Conflicts

None

Acknowledgements

Arkansas Children's Hospital Department of Pediatric Craniofacial Plastic Surgery

References

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4219915/
https://www.ncbi.nlm.nih.gov/pubmed/14704578

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