Le Fort III

Anaesthesia and Preparation

1) Oroendotracheal intubation is preferred, and the tube is secured with wire adjacent to the
incisal edge of the mandibular central incisors/ molar dentition with interdental wiring/
sutured into the labiomental fold.
2) However, if maxillomandibular fixation is required, nasoendotracheal intubation is
preferred.
3) Hypotensive anesthesia is recommended, with a mean arterial pressure between 50 and
60 mm Hg
4) Tarsorrhaphy sutures are placed bilaterally with 6-0 nylon for ocular protection
5) The head and neck region is then prepared and draped in a sterile fashion. Sterile towels
are stapled/sutured into position for optimal exposure. (Bi coronal incision)
6) The chest and ilium can also be prepared in case there is a necessity to harvest
interpositional bone/cartilage onlays.
7) The occlusal wafer is wired into the maxilla.
Coronal approach
1) A coronal incision is preferred. Lidocaine (2 %) with epinephrine (1:80,000) is injected in
the proposed site of incision to facilitate hemostasis.
2) The incision is to be placed well within the hairline toward the vertex but anterior enough
to allow adequate exposure of the temporozygomatic region, bearing in mind that the
coronal incision needs to be extended slightly in a preauricular or post auricular direction
for additional exposure.
Flap Reflection
1) The initial dissection of the anterior scalp flap is in a supraperiosteal plane, with an
incision made through the periosteum (pericranium) approximately 2 cm above the
supraorbital ridges.
2) The supraorbital nerve may require release from its bony canal with a 2 mm osteotome.
3) Careful sequential subperiosteal dissection allows visualization and exposure of the nasal
dorsum, lateral orbital rims, anterior maxilla, and zygomatic arches.
4) A tunneling technique is used to achieve exposure of the nasal bones, medial canthal
tendons (MCTs), superior aspect of the lacrimal fossa, and medial and inferior orbital
margins
5) In most cases, medial dissection is carried within the orbit down to the nasolacrimal
groove, without disruption of the MCTs.
6) Circumferential subperiosteal dissection around the orbit should allow mobilization of the
periorbita so that the inferior orbital fissure is clearly visualized and the osteotomy may
be located approximately 10 mm inside the orbital margin.
7) A tunnel should generally be created connecting the medial and lateral subperiosteal
dissection.

8) The zygomatic arch and temporal fossa are exposed in a bilateral fashion by division of
the deep temporal fascia approximately 5 cm superior to the arch and is reflected
inferiorly while maintaining attachment to the coronal flap.
9) The soft tissue envelope is progressively reflected off the lateral orbital rim and zygoma
toward the maxilla via gentle stretching using periosteal elevators.
10) Throughout the flap reflection, bone is used as a guide to prevent injury to the
frontotemporal branch of the facial nerve.

Osteotomies
1) The first osteotomy is the zygomatic osteotomy via a vertical cut at the body of the
zygoma using a reciprocating saw.
2) It is designed so that it extends from the bottom of the zygoma, splitting the lateral orbital
rim in half and extending superiorly to end slightly above and medial to the
frontozygomatic suture.
3) The identical osteotomy on the contralateral side should be made parallel to the first
osteotomy and ideally perpendicular to the vector of distraction (ie,Frankfort horizontal
plane).
4) With careful globe protection, the lateral orbital wall osteotomy is initiated 10 mm behind
the lateral orbital rim via a reciprocating saw through the inferior orbital fissure,
extending superiorly to meet the initial osteotomy superior to the frontozygomatic suture
5) From the inferior orbital fissure via a supratemporal fossa approach, the posterior wall of
the maxillary sinus is cut posteriorly and inferiorly (via an osteotome) or posteriorly and
superiorly (via a reciprocating saw) from the superior half of the pterygomaxillary
junction.
6) After both right and left lateral osteotomies are completed, attention is directed to the
medial osteotomies.
7) Prior to initiating the horizontal nasal osteotomy, as well as the subsequent separation of
the bony nasal septum from the anterior cranial base, coronal computed tomographic
scans are reviewed to verify the position of the cribriform plate.
8) The horizontal osteotomy extending over the nasal bones is completed 5 mm inferior to
the nasofrontal suture via a reciprocating saw in a direction posterior-inferior and
superior to the MCTs and nasolacrimal apparatus
9) Attention is then turned to the medial orbital osteotomies. After finishing the nasal bone
cut posterior to the lacrimal fossa, the direction of the osteotomy is behind and parallel to
the posterior lacrimal crest as it moves toward the inferior orbital fissure; a 6 mm
osteotome is generally used to complete this step.
10) The nasal septal osteotome is used to separate the nasal septum from the cranial base.
11) The direction of the osteotome is parallel to the base of the skull and directed toward the
posterior nasal spine as palpated transorally.
12) The inferior half of the pterygomaxillary junction is separated bilaterally using a curved
pterygoid osteotome approach via the temporal fossa . An alternative approach would be
via an intraoral route with a limited vestibular incision bilaterally.

Mobilization
1) Maxillary disimpaction forceps are applied to mobilize the midfacial segment until the
planned distance is reached and the maxilla is comfortably in the final desired occlusal
position. This is achieved with gentle rocking and traction. Initally, one should ensure
that the midface is moving in one piece by inspection. Care must be taken to avoid excess
traction on the orbital neurovascular structures or excessive unilateral traction on the
zygomas, resulting in fracture.
Plating
1) The maxilla and mandible are placed in rigid imf.
2) Bone grafts can be inserted in the resulting gaps in the orbital walls, nasofrontal angle
and the pterygo- maxillary area , while onlay bone grafts are placed on the zygomatic
complex.
3) Fixation is done at the fronto-nasal suture, bilaterally at the lateral orbital rims and the
zygomatic arches.