Le Fort III and Le Fort II Osteotomies

David D. Vu, PharmD, DDS, MD a, Paul S. Tiwana, DDS, MD, MS a,b,c,*

KEYWORDS
 Le Fort III osteotomy  Le Fort II osteotomy  Midfacial hypoplasia  Nasomaxillary hypoplasia

KEY POINTS
 The Le Fort III osteotomy is a technique used in managing midfacial hypoplasia as often seen in syndromic patients.
 The subcranial Le Fort III is the classic solution to total midfacial hypoplasia.
 The modified Le Fort III is used where the nasal subunit is not involved.
 The Le Fort II osteotomy is well-suited for nasomaxillary hypoplasia, where there is less involvement of the orbits and
zygomas.

Introduction
Le Fort III osteotomy
The aesthetic stigmata and functional impairments associated
with craniofacial and maxillofacial deformities have long
challenged surgeons in the management of deficiencies of the
middle third of the face. The French anatomist Rene Le Fort
published his classic treatise on the description of common
fracture patterns in the middle facial third in 1901.1 The
ensuing World Wars produced horrendous mass casualties that
steered facial reconstructive surgeons like Kazanjian2 in their
efforts to manage injuries of the middle third of the face.
Building on the knowledge and skill borne by these conflicts, Sir
Harold Gillies was the first surgeon to publish an attempt at
mobilization of the midface in the management of a patient
with craniofacial dysostosis.3 The procedure was unsuccessful
and was abandoned by Gillies. Subsequently, Longacre4
attempted reconstruction of the midface in patients with
craniosynostosis by autogenous rib grafting. This procedure did
nothing to address the functional impairments associated with
total midface deficiency and, furthermore, resorption of the
grafts occurred. The long-term stability of the reconstruction
from an aesthetic standpoint was questionable. In 1967, the
pioneering efforts of Tessier5e13 revolutionized management of
a
Division of Oral & Maxillofacial Surgery, Department of Surgery,
Parkland Memorial Hospital, University of Texas Southwestern Medical
School, 5201 Harry Hines Boulevard, CS3.104, Dallas, TX 75235, USA
b
Division of Oral & Maxillofacial Surgery, Department of Neurolog-
ical Surgery, Parkland Memorial Hospital, University of Texas South-
western Medical School, 5201 Harry Hines Boulevard, CS3.104, Dallas,
TX 75235, USA
c
Pediatric Oral & Maxillofacial Surgery, Childrens Health, 1935
Medical District Drive, Dallas, TX 75235, USA
* Corresponding author. Division of Oral & Maxillofacial Surgery,
Department of Surgery, Parkland Memorial Hospital, University of Texas
Southwestern Medical School, 5201 Harry Hines Boulevard, CS3.104,
Dallas, TX 75235.
E-mail address: paul.tiwana@utsouthwestern.edu
the patient with total midface deficiency. His landmark pre-
sentations and publications describing the mobilization of the
entire middle face through the concept of combined intra-
cranial and extracranial approach in a safe and consistent
manner was groundbreaking. Modifications and extensions of
this concept by Tessier and others have produced surgical
techniques that have provided relief of functional impairments
and facial aesthetics to the benefit of the patient with severe
midface deficiency. The first known performance of this sur-
gery in the United States was undertaken by Dr Robert V.
Walker in 1967, shortly after Tessiers presentation in Rome at
Parkland Memorial Hospital in Dallas, Texas (Fig. 1).
Le Fort II osteotomy
There is a paucity of literature on the Le Fort II osteotomy when
compared with the Le Fort III osteotomy. Although the Le Fort III
osteotomy is a high-level craniofacial disjunction with the po-
tential to move the entire midface forward, useful for total
midface hypoplasia (such as the patient with Crouzon syn-
drome),14 the Le Fort II osteotomy addresses nasomaxillary hy-
poplasia in which the central face is more retruded than the orbits
and zygomas. This may be seen, for instance, more commonly in
Apert syndrome. Typically, these patients may present with a
Class III malocclusion, decreased Sella, Nasion, A point,14 a short
nose, and a vertically deficient midface. The Le Fort II osteotomy
thus addresses the nose and maxilla, in contrast to nose, maxilla,
orbits, and cheeks in the Le Fort III osteotomy.
Based on 30 years of experience, Lakin and Kawamoto
delineate the types of nasomaxillary hypoplasia that may
benefit from a Le Fort II osteotomy, including lateral naso-
maxillary deviation, noncleft nasomaxillary hypoplasia, cleft
nasomaxillary hypoplasia, anteroposterior displacement in
binder syndrome, and posttraumatic defects. In the case of
lateral nasomaxillary deviation, patients experience asym-
metric hypoplasia with nasal deviation to the right or left.
Patients with lateral nasomaxillary deviation in this series
included those with unilateral coronal synostosis, hemifacial
microsomia, and Romberg disease.
Steinhauser14 summarized the variations in the Le Fort II
osteotomy, including the anterior Le Fort II as described by

Atlas Oral Maxillofacial Surg Clin N Am 24 (2016) 1525

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http://dx.doi.org/10.1016/j.cxom.2015.10.007 oralmaxsurgeryatlas.theclinics.com
16 Vu & Tiwana

Fig. 1 (AeD) The first Le Fort III osteotomy was performed at Parkland Memorial Hospital by Dr Robert V. Walker. Patient is seen here
decades after her initial surgery. Note the characteristic syndactyly.

Converse15 in 1971, the pyramidal Le Fort II described by Indications

Henderson and Jackson in 1973, and the quadrangular Le Fort II
osteotomy described by Kufner in 1971. The latter excludes the Le Fort III osteotomy
nasal skeleton, and is thus used in patients with a maxillary
zygomatic deficiency, and normal nasoethmoid projection. The
Skeletal facial deformities can be repetitive patterns of
osteotomies of the quadrangular variant share characteristics
deformity affecting the different functional and aesthetic
of both Le Fort I and Le Fort II patterns and do not represent a
subunits of the facial hard and soft tissues. Their only common
classic Le Fort II. The anterior Le Fort II includes an osteotomy
feature is the degree of variable expressivity within each
through the palate at the level of the bicuspid, thus creating an
subtype of anomaly.19e22 Although numerous procedures exist
alveolar gap with advancement.
for the management of the various craniofacial malformations
As can be expected, access to the bony skeleton requires a
in the middle third of the facial skeleton, only the subcranial
combination of incisions. Access to the maxilla is standard via
Le Fort III osteotomy23 addresses the nose, orbits, cheeks, and
vestibular incisions. For access to the nasofrontal region and
maxilla. However, specific limitations apply to the use of this
medial orbit, direct cutaneous incisions over the nasal
surgical maneuver. The bony structures of the middle facial
bridge were previously used. The trap door inverted V-Y by
third are in contiguity with the cranial base superiorly. Trans-
Converse is one such example.16 Perhaps more aesthetic in-
gression of this natural barrier is indicated in the surgical
cisions in this area are now hidden in the eyelids via a medial
correction of some craniofacial anomalies, if the presenting
upper blepharoplasty incision or lower transconjunctival
deformity includes excessive interorbital distance or there is
approach.17 Wedgewood18 describes an approach in which
significant aberration of the supraorbital/forehead subunit. In
rhinoplasty incisions (transfixion, intercartilaginous) are
these instances, consideration should be given to using a
combined with the intraoral incision to expose all osteotomy
combined intracranial and extracranial approach, such as
sites with a similar goal of minimizing cutaneous scarring.
facial bipartition or monobloc osteotomy.24 In addition, sub-
For broad access, a bicoronal may be combined with the
cranial Le Fort III osteotomy does not address the 3-dimen-
intraoral incision, although it arguably carries significantly
sional vertical slanting of the facial halves or the convex arc of
greater morbidity.
Le Fort III and Le Fort II Osteotomies 17

rotation of the face as seen in some of patients with cranio-
facial dysostosis, which can only be adequately managed with
facial bipartition osteotomy.25
This is not to suggest that within the context of an extra-
cranial procedure the Le Fort III osteotomy is inflexible, rather
the opposite is true. Modifications of the Le Fort III osteotomy,
such as Kufner operation (modified Le Fort III), are possible and
can be used to address deformities that do not involve the
nasal subunit26 (Fig. 2). Stability of these procedures in both
syndromic and nonsyndromic patients has been studied.27,28
Thoughtful consideration by the surgeon must be given to
addressing the presenting dysmorphology, with the intention of

Fig. 2 (AeF) A 19-year-old male patient presenting with severe midface deficiency. Note the sclera show. Preoperative facial and
occlusal views. (GeL) Eight-month follow-up. Postoperative facial and occlusal views after modified Le Fort III osteotomy.
18
improving the aesthetic and functional concerns of the patient,
while taking into account the potential complications and
benefits inherent with the use of an intracranial approach.
Management of the skeletally immature patient requires sur-
gical intervention based on the complex balance between the
long-term stability of the correction and more immediate
functional, psychological, and aesthetic demands of each pa-
tient. As with all facial reconstructive procedures, patient
selection is critical to successful outcome.
Craniofacial dysostosis
The craniofacial dysostosis syndromes (eg, Apert, Crouzon,
Pfeiffer, Saethre-Chotzen, and Carpenter) are characterized
by sutural involvement that not only includes the cranial vault
but also extends into the skull base and midfacial skeletal
structures.29 Although the cranial vault and cranial base are
thought to be the regions of primary involvement, there is also
significant impact on midfacial growth and development. In
addition to cranial vault dysmorphology, patients with these
inherited conditions exhibit a characteristic total midface
deficiency that must be addressed as part of the staged
reconstructive approach. Although there is some similarity
between the pattern of facial growth and development in
these patients, there is a high degree of variable expressivity
seen in each patient regardless of syndrome. This must be
taken into account when planning and executing surgical
correction of these deformities.30e36 If the nasal subunit is
normal or excessive preoperatively, further advancement of
the nose will lead to a less than aesthetic result. Therefore,
the surgeon must give consideration to subtotal midface
advancement via modified Le Fort III osteotomy or consider a
quadrangular Le Fort II osteotomy in this situation.
Midface deficiency
The role of the human face is significant in a both direct and
indirect fashion for reasons other than purely aesthetic con-
siderations. This is secondary to the highly evolved and
specialized functions of the face in vision, breathing, speech
production, smell, and hearing, among a few. Total midface
deficiency, to include the orbits, nose, zygomas, and maxilla,
can occur in both syndromic and nonsyndromic individuals. In
patients with syndromal craniofacial dysostosis, in addition to
potential neurologic deficits, there is often variable fusion of
the lesser sutures of the skull base.37e39 This commonly results
in abnormal ophthalmologic findings, including exorbitism,
exotropia, orbital dystopia, and ptosis secondary to lack of
orbital depth and diameter, as well as prolapse of the ethmoid
sinuses through the medial orbital walls. The severe occlusal
discrepancies found in this group of patients is characterized
by generalized hypoplasia of the maxilla, transverse defi-
ciency, class III malocclusion, and apertognathia. All of these
abnormalities contribute to impact speech articulation errors
and mastication. In addition, cleft palate, when present, can
produce velopharyngeal incompetence. The severe retrusive
position of the midface also can interfere with nasal breathing
and produce chronic nasal obstruction. Varying degrees of
orbital hypertelorism (OHT) may or may not be present. The
extent to which this is present strongly influences the type of
surgical correction required for midface deficiency.
The presence of midface deficiency does not mitigate the
coexistence of other facial skeletal abnormalities, such as
Vu & Tiwana
mandibular excess and retrogenia. In addition, there are often
irregularities of the forehead, as well as frontal bossing. The
nasal length can be short and projection may be deficient.
However, there are many circumstances in which nasal pro-
jection is normal or even excessive, which then mandates
subtotal midface advancement. Deficiency in orbital depth and
diameter produces exorbitism and an excessive amount of
sclera may be present. Ptosis of the lids and lateral canthal
dystopia are usually present. When high levels of midface
deficiency exist, the subcranial Le Fort III osteotomy or a
modification thereof should be considered.
Le Fort II osteotomy
The Le Fort II osteotomy may be used to address the same
population of patients as described previously, but perhaps
with a focus on those patients with a more pronounced hypo-
plastic nasomaxilla. That is, the nose and maxilla are the
components addressed surgically, rather than nose, maxilla,
orbits, and cheeks all at once, as with the Le Fort III.
Patients with lateral nasomaxillary deviation (for instance in
unilateral coronal synostosis, hemifacial microsomia, or Rom-
berg disease) benefit from asymmetric osteotomies with
movement in multiple vectors. Advancement addresses retru-
sion, whereas lateral pendulum type movement helps correct
occlusal canting. Rotation about a vertical axis also aids in
correcting deformities. These patients have greater malar
deficiency on the side to which the nose is rotated, thus
osteotomies on this side are lateral to infraorbital foramen.
The osteotomy on the contralateral side is medial to the
infraorbital foramen. When the mobilized nasomaxilla is
rotated to the contralateral side, this increases the bulk of the
deficient side while simultaneously minimizing decreases in
bulk of the cheek on the contralateral side.17
For the patient with a retruded noncleft hypoplastic naso-
maxilla, bilateral osteotomies medial to the infraorbital fora-
men allow advancement to address the deficient areas.17
It is important to note that a spectrum of anomalies occurs,
and most patients have varying degrees of nasomaxillary
hypoplasia, combined with orbital and malar retrusion. These
patients may thus benefit from a combination of approaches
with differential movement of various components (usually
greater movement of the central midface), possibly in unison
with distraction.40e42 For instance, monobloc advancement of
the forehead and orbits may be combined with the Le Fort II
osteotomy, to address deficiencies in each area. Similarly,
zygomatic repositioning may be combined with the Le Fort II
osteotomy.42,43 The central midface may be then be moved
differentially, such as with advancement, vertical elongation,
or sagittal rotation as necessary, while allowing appropriate
movements of the forehead, orbits, or zygomas. This results in
improvement of not only frontal views, but also birds and
worms views.
Technique
Naso-endotracheal intubation with a reinforced tube exiting
inferiorly and across the cheek is preferred. The tube is
secured with suture to the membranous septum and columella.
Because intermaxillary fixation is necessary to establish the
projection of the middle face, oral intubation is less desirable
and should be avoided unless the splint can be modified to
accommodate the position of the tube. The length of the
Le Fort III and Le Fort II Osteotomies
endotracheal tube must be sufficiently below the level of the
vocal cords to prevent unintended dislodgement during mid-
face disimpaction and advancement.
A corneal shield may be used to secure the eyelids after
ophthalmologic lubricant is placed. An alternative is to place
tarsorrhaphy sutures bilaterally. The hair is protected from the
field through draping. The incision line is infiltrated with 2%
lidocaine with 1:100,000 epinephrine to control bleeding dur-
ing dissection in the maxillary vestibular area and in the region
of the lower eyelid incisions. The face and oral cavity are then
prepared with the Betadine scrub. The entire operative field is
straight, exposing the oral cavity, eyes, ears, forehead, and
scalp posterior to the planned incision (if the coronal approach
is used).
A decision must be made to use coronal incision, trans-
conjunctival incisions, or inferior lid incisions. Subcranial Le
Fort III osteotomy is carried out through coronal incision access
to allow for osteotomy across the central midface. It can be
combined with periorbital approaches to permit access to the
orbital floor regions bilaterally to facilitate osteotomy of these
regions. Similarly, the pyramidal Le Fort II osteotomy can be
carried out with or without a coronal incision.
If modified Le Fort III osteotomy is used, surgical access can
be achieved either through incisions as described previously or
through bilateral periorbital incisions combined with an oral
(vestibular) approach.
With the coronal approach, an incision is made from the mid
auricular area of the scalp across the top of the head to the
opposite side. The incision is carried through the layers of the
scalp to the pericranium. Hemostasis is achieved with bipolar
cautery and a flap is elevated in the bloodless supraperiosteal
plane until a point approximately 2 cm behind the supraorbital
rim is reached. At this point, an incision is made through the
periosteum and the dissection continues under the periosteum
to expose the supraorbital rims, nasal bones, lateral orbital
rims, zygomas, and infraorbital regions bilaterally. The supra-
orbital nerves are freed by releasing them from the supraor-
bital foramina bilaterally. Next the periorbital dissection is
performed subperiosteally, being careful not to detach the
medial canthus and to dissect behind the lacrimal apparatus.
Remaining under the periosteum during the facial dissection is
critical to preserve facial nerve function.
If transconjunctival incisions are used, release of the inferior
limb of the lateral canthus and dissection to the bone of the
inferior orbital rim is accomplished. Extension of the incision on
the lateral periorbital skin is necessary for soft tissue release.
Alternatively, an inferior lid incision could be used to achieve
similar operative exposure. Dissection along the inferior orbital
rim posteriorly to the infraorbital fissure is required to identify
the anatomic landmark. Subperiosteal dissection is then carried
over the anterior orbital rim to identify the infraorbital fora-
men. Once all of the tissues are dissected and protected from
the mid facial skeleton, the osteotomy commences. These
osteotomies must be conducted methodically by the surgeon to
minimize hemorrhage and to allow for access to control
excessive hemorrhage during the operation.
Subcranial Le Fort III osteotomy
The initial osteotomy is conducted vertically through the
zygomatic arch with a reciprocal saw. The soft tissues are
protected by placing a channel retractor below the zygomatic
arch. The frontozygomatic suture is identified and an osteotomy
19
is begun to separate the lateral orbital wall from the suture area
inferiorly to the infraorbital fissure at a depth of approximately
1 cm from the orbital rim. A drill with a small fissure burr is then
used to section the floor of the orbit from the infraorbital fissure
medially and directed behind the lacrimal apparatus. The
wound is then packed and the attention is directed to the nasal
frontal area.
The frontonasal suture is identified and the level of the
cribriform plate should be confirmed radiographically to be
above the nasal frontal junction. If the plate is lower than this
junction, the procedure should be modified to be certain that
the osteotomy is inferior to the cribriform plate or consider-
ation should be given to formal craniotomy to protect the
intracranial contents. Similarly, the anterior extent of the
temporal lobes should be identified radiographically before
the lateral orbital rims are cut, especially in patients with
Apert syndrome where the temporal lobes can be located more
anteriorly within the lateral orbital rims.
Once this procedure is completed bilaterally, the wounds
are packed, and the scalp flap is returned to its original posi-
tion. The oral cavity is entered and the tissue over the poste-
rior maxilla is injected with 2% lidocaine with 1:100,000
epinephrine. The posterior wall of the maxilla and pterygoid
plates are then approached through the 2 horizontal sub-
periosteal incisions. Subperiosteal dissection to the pterygoid
plates and superiorly to the infratemporal fossa exposes the
area of the midface, which must be sectioned next. The
pterygoid plate is sectioned at the posterior maxillary wall
junction from the pterygoid plate superiorly to the infraorbital
fissure region. Remaining subperiosteal is critical to limit the
possibility of hemorrhage from the internal maxillary artery
and its terminal branches. These wounds are then packed and
the scalp flap is reflected again to expose the osteotomies from
above.
The final osteotomy is the separation of the vomer. This is
done with a thin osteotome placed at the nasofrontal osteot-
omy and directed inferiorly and posteriorly. Care must be
exercised to remain anterior to the skull base. Modified Rowe
disimpaction forceps are the inserted in the nose and intra-
orally through the maxillary incision onto the bone of the nasal
floor. Downward force with adequate head stabilization and
care to minimize the risk of endotracheal tube displacement
begins the process of mobilization. The previously placed su-
ture to secure the naso-endotracheal tube must be assigned an
assistant to guard its position during the mobilization process.
Adequate mobilization of the facial skeleton is critical for
success. Downward, anterior, and rotary motion is necessary to
completely free the face. Care that all osteotomy sites are
moving similarly will reduce the chances of inadvertent frac-
tures especially of the zygoma. Recutting areas of resistance is
sometimes necessary and important.
Once the middle face is adequately mobilized, it should be
advanced to the predetermined position, using the pre-
fabricated occlusal splint as a reference. A vertical reference
should also be used to control the face height. Sometimes this
requires the placement of a pin in the outer cortex of the
frontal bone in the area of the frontal sinus. Intermaxillary
fixation wires are then applied.
Bone plate stabilizations are placed at the zygomatic and
lateral orbital rim regions. Additional plating takes place at the
nasofrontal region. Bone defects are filled with grafts har-
vested from the cranium or ilium. Additionally, autogenous
bone is almost always used to further contour and refine the
morphology of the facial skeleton. It is an exception to perform
20 Vu & Tiwana

this operation and not use bone grafts to further contour
the face. All bone grafts must be wedged or adequately sta-
bilized with screws to prevent displacement and to enhance
revascularization.
If Le Fort I osteotomy is combined with the Le Fort III pro-
cedure, it is done through 2 horizontal mucosal incisions,
preserving an anterior pedicle to the independently mobilizing
maxilla. Stabilization with bone plates and autogenous bone
grafts are also used.
It is emphasized that all osteotomies are conducted with
copious irrigation. At the completion of surgery, thorough
irrigation of all surgical sites is done. Resuspension of the
lateral canthus and temporalis muscle is done with 3-0 resorb-
able suture. Superior and posterior suspension of the deep
layers of the flap should also be done with resorbable suture to
minimize dead space and to encourage reattachment of the
superficial musculoaponeurotic layer. Drains are usually not
placed. The scalp is closed in 2 layers, with 3-0 polyglycolate in
deeper tissues and 3-0 chromic gut in the hair-bearing regions.
The oral tissues and operative site are irrigated and closed with
3-0 chromic gut suture. A forced duction test of the globe is
done bilaterally to ensure eye mobility (Fig. 3AeL).
Modified Le Fort III osteotomy
The frontozygomatic suture is identified and an osteotomy is
begun to separate the lateral orbital wall from the suture area
inferiorly to the infraorbital fissure at a depth of approximately
1 cm from the orbital rim, splitting the vertical body of the

Fig. 3 (A) An 11-year-old child with Crouzon syndrome. Preoperative facial and occlusal views. (B) An 11-year-old child with Crouzon
syndrome demonstrating total midface deficiency. Preoperative facial view and procedure illustration. Right panel.
Le Fort III and Le Fort II Osteotomies 21

Fig. 3 (continued) (C) Facial and 3-dimensional computed tomography (CT) scan views before subcranial Le Fort III osteotomy. Note:
Skull defects from previous cranio-orbital decompression (by another surgeon). (D) Intraoperative view demonstrating nasofrontal
osteotomy. (E) Bone grafts rigidly fixed across 15-mm osteotomy gap at nasofrontal junction. (F) Intraoperative view demonstrating left
orbital osteotomy. (G) Bone grafts rigidly fixated across 17-mm osteotomy gap at zygomatic arch.

zygoma as inferiorly as possible. Here again, care must be exer-
cised to identify the temporal lobes to prevent injury. A drill with
a small fissure burr is then used to section the floor of the orbit
from the infraorbital fissure and directed back across the inferior
orbital rim onto the anterior surface of the maxilla medial to
the infraorbital nerve foramen and lateral to the lacrimal
apparatus.
The oral cavity is entered and the posterior wall of the
maxilla and pterygoid plates are then approached through the
circumvestibular subperiosteal incision. Subperiosteal dissec-
tion to the pterygoid plates and superiorly to the infra-
temporal fossa exposes the area of the midface, which must
be sectioned next. The pterygoid plate is sectioned at the
posterior maxillary wall junction from the pterygoid plate
superiorly to the infraorbital fissure region. Remaining sub-
periosteal is critical to limit the possibility of hemorrhage from
the internal maxillary artery and its terminal branches. These
wounds are then packed. Dissection superiorly along
the buttress to expose the inferior aspect of the vertical
zygomatic osteotomy is then performed. Completion of the
zygomatic osteotomy with a reciprocating saw can be
necessary. A straight osteotome is then used to section the
posterior maxilla superiorly to the infraorbital fissure
superiorly. Identification of the anterior vertical maxillary
osteotomy medial to the infraorbital foramen with ex-
tension of the osteotomy further medially and inferiorly
through the pyriform rim while protecting the nasal mucosa is
next.
22
Fig. 3 (continued) (H) Three-dimensional CT scan views after subcranial Le Fort III osteotomy and repair of anterior skull defects with
resorbable mesh and hydroxyapatite bone cement. (I) Preoperative and 6-month postoperative facial views after subcranial Le Fort III
osteotomy and repair of anterior skull defects.
The final osteotomy is the separation of the vomer, which is
sectioned from the nasal crest in the same fashion as for Le
Fort I osteotomy. Modified Rowe disimpaction forceps are then
inserted in the nose and intraorally through the maxillary
incision onto the bone of the nasal floor. Once again, adequate
mobilization of the facial skeleton is critical for success with
attention paid to keep in the endotracheal tube secured.
Recutting areas of resistance is often necessary and important
with this procedure as well.
Once the middle face is adequately mobilized, it should be
advanced to the predetermined position, using the pre-
fabricated occlusal splint as a reference. A vertical reference,
such as a Kirschner wire in the nasofrontal region, should also
be used to control the face height. Intermaxillary fixation wires
are then applied.
Bone plate stabilizations are placed at the zygomatic,
lateral orbital rim, and maxillary pyriform regions bilaterally.
Bone defects are filled with grafts as described previously and
wedged or fixated into place.
Resuspension of the lateral canthus is done with 3-0 resorb-
able suture. The oral tissues and operative site are irrigated and
closed with 3-0 chromic gut suture. The transconjunctival
Vu & Tiwana
incisions are closed with 6-0 fast resorbing gut suture. The
corneal shields or tarsorrhaphy sutures are removed and forced
duction of the globe is done bilaterally to ensure eye mobility.
Pyramidal Le Fort II osteotomy
The frontonasal suture is identified and the level of the crib-
riform plate should be confirmed radiographically to be above
the nasal frontal junction. If the plate is lower than this
junction, the procedure should be modified to be certain that
the osteotomy is inferior to the cribriform plate or consider-
ation should be given to formal craniotomy to protect the
intracranial contents. The osteotomy is carried out trans-
versely with the blade directed away from the cribriform plate.
It is continued down the medial wall of the orbit below the
medial canthal attachment across the upper part of the
lacrimal groove to the posterior lacrimal crest. A drill with a
small fissure burr is then used to section the floor of the orbit
directed behind the lacrimal apparatus toward the infraorbital
canal laterally. A chisel may be used to join the 2 cuts if
needed. The osteotomy is then continued down the anterior
Le Fort III and Le Fort II Osteotomies 23

Fig. 3 (continued) (J) Preoperative and 6-month postoperative occlusion. (K) Preoperative and 6-month postoperative facial views. (L)
Preoperative and 6-month postoperative facial views. (From [B] Bell WH. Surgical correction of dentofacial deformities. vol. 1. Phila-
delphia: WB Saunders; 1980. p. 655. Figure 9-89; with permission.)

maxilla, well past the infraorbital foramen. The osteotomy
may be lateral or medial to the foramen, depending on the
specific asymmetry addressed. The wound is then packed.
Once this procedure is completed bilaterally, attention is
directed intraorally. Two percent lidocaine with 1:100,000
epinephrine is injected. A circumvestibular incision is made,
and subperiosteal dissection is completed superiorly and pos-
teriorly to expose the anterior maxilla and zygomaticomaxillary
buttress, and to gain access to the pterygoid plates and infra-
temporal fossa. The anterior vertical maxillary osteotomy is
identified from this incision. A horizontal osteotomy with a
reciprocating saw is completed in similar fashion to a Le Fort I
osteotomy, but terminating at the level of the vertical
osteotomy completed previously. The pterygoid plates are
separated in standard fashion using sharp curved osteotomes.
The final osteotomy is the separation of the vomer. This
is done with a thin osteotome placed at the nasofrontal
osteotomy and directed inferiorly and posteriorly. Care must
be exercised to remain anterior to the skull base. Modified
Rowe disimpaction forceps are then inserted in the nose and
24
intraorally through the maxillary incision onto the bone of the
nasal floor. Downward force with adequate head stabilization
and care to minimize the risk of endotracheal tube displace-
ment begins the process of mobilization. The previously
placed suture to secure the naso-endotracheal tube must be
assigned an assistant to guard its position during the mobili-
zation process.
Adequate mobilization of the facial skeleton is critical for
success. Downward, anterior, and rotary motion is necessary to
completely free the face. Care that all osteotomy sites are
moving similarly will reduce the chances of inadvertent frac-
tures. Recutting areas of resistance is sometimes necessary
and important.
Once the middle face is adequately mobilized, it should be
advanced to the predetermined position, using the pre-
fabricated occlusal splint as a reference. A vertical reference
should also be used to control the face height. Sometimes this
requires the placement of a pin in the outer cortex of the
frontal bone in the area of the frontal sinus. Intermaxillary
fixation wires are then applied.
Bone plate stabilizations are placed at the anterior maxilla.
Additional plating takes place at the nasofrontal region. Bone
defects are filled with grafts harvested from the cranium or
ilium. Additionally, autogenous bone is almost always used to
further contour and refine the morphology of the facial skel-
eton. It is an exception to perform this operation and not use
bone grafts to further contour the face. All bone grafts must be
wedged or adequately stabilized with screws to prevent
displacement and to enhance revascularization.
Steroids and antibiotics
Steroids and antibiotics are always used with the first dose
administered on intubation and before the commencement of
surgery. High-dose intravenous steroid is given intravenously
every 4 hours throughout surgery and for the first 24 hours after
surgery. Before leaving the operating room, a further dose of
intramuscular slow-release steroid is administered. A weight-
appropriate dosage of cephalosporin is also administered
intravenously every 4 hours during surgery and for the first
24 hours. Oral antibiotics are continued for 10 days.
Postoperative care
A nasogastric tube is carefully inserted at the completion of
surgery and it is kept to low suction overnight. Extubation at
the completion of surgery is usual. Typically, the airway is
improved as a result of surgery and there is little reason for
prolonged intubation following this surgery. Early during the
postoperative course, ambulation and oral intake are encour-
aged. Nose blowing, Valsalva maneuvers, and so forth are
discouraged. Nasal packing is never performed, although drip
pad usage is common. Nasal sprays with vasoconstrictors for
congestion are used for 2 weeks. Diet is restricted to a soft
nonchew consistency for approximately 6 weeks. Guiding
elastics are useful to reduce patient discomfort and control the
occlusion.
Visual disturbance, including diplopia, is uncommon,
although all patients must be warned before surgery. Anosmia
is also uncommon, but informing the patient of this possibility
is prudent. Altered sensation to the cheeks, lateral nose,
gingiva, and palate are common and patients must be
Vu & Tiwana
counseled accordingly. Facial nerve injury should not occur,
especially with subperiosteal dissection.
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