Modified Le fort III osteotomy: A simple solution to severe midfacial hypoplasia

Abstract

Purpose: There are multiple conditions that may affect the development of the middle third of the face and with varying degrees of severity. The surgical treatment alternatives for major midfacial sagittal deficiencies consist in Le Fort I, II, or III with conventional osteotomies or with distraction osteogenesis (DO). Both techniques have advantages and disadvantages that should be evaluated specifically in each case. The aim of this report is to present a group of patients with severe hypoplasia of the middle third of the face, with different origins, and their treatment with a Modified Le Fort III osteotomy and distraction osteogenesis, using a minimally invasive surgical approach.

Materials and methods: The surgical technique was performed in a group of patients with severe hypoplasia of the middle third of the face, through a transconjunctival approach with lateral canthotomy and a trans-oral approach. The osteotomy consisted of a Le Fort III without the nasofrontal component. A rigid external distractor (RED) type II or internal distractor was installed. The amount of distraction, surgical time, blood loss, and complications were evaluated.

Results: A total of 7 patients underwent operation, 5 men and 2 women with an average age of 20.8 (range 11-41) years; 3 patients with Crouzon syndrome, 2 with Pfeiffer syndrome, 1 patient with cleft lip and palate sequel, and 1 with a severe non-syndromic class III. The average follow-up was 3.14 years. All patients achieved stable occlusion without postoperative changes, positive overbite and overjet, without relapse in the skeletal position. The average advancement was 14.7 (+/- 4.07) mm, in 1.1 incisors, and 15.2 (+/- 3.19) in point A. The average time of surgery was 2.78 (+/- 0.64) hours, with an average blood loss of 240 (+/- 48.6) ml. Four patients required a rhinoplasty in a secondary surgery.

Conclusion: This technique shows a surgical approach with low morbidity, short surgery time, and low blood loss. It allows optimal resolution of severe hypoplasia of the middle third of the face with longterm stability. It avoids the use of grafts and osteosynthesis material. By not including the nasal pyramid in the osteotomy design, the size, position, and nasofrontal angle in patients with adequate facial balance is maintained. If nasal correction is necessary, a second surgery may be done. In cases of asymmetrical hypoplasia of the middle third, this osteotomy shows great versatility and can be done unilaterally and/or simultaneously combined with other distractions.