Le Fort III Osteotomy

[Chadpreet_]

Instant ascension but holy shit

 

[dsheppa]

Lefort iii is fucking terrifying

 

[Deleted member 52566]

thanks for the tutorial, cant wait to perform it on myself!

 

[Soychadcell]

Le Fort III is an invasive surgery that advances the maxillary bone and zygomatic bones forward and upwards inorder to correct craniofacialdystrophy.

A Le Fort III fracture includes fracture of the nasofrontal junction, bilateral fractures through the area of the frontozygomatic suture, and probable fractures of the zygomatic arch. These fractures are also referred to as craniofacial dysjunction.

Due to its counterparts, Le Fort I and II, Le Fort III is special because of its ability to advance not only the lower part of the maxilla, but also the upper maxilla and zygomactic bones, which Le Fort I, Double jaw surgery, Bimax and any other maxilla osteotomy are unable to achieve as they only advance the lower part of the maxilla, resulting in increased recessed orbitals, upper maxilla, zygomactic bones and a monkey face look: typically what boxers look like with a mouthguard in.

Le Fort III typically gets treated on deformed patients, people with crouzon syndrome especially. However it can be done on non-deformed patients, but as of now there are only a few surgeons in the world willing to do it, but this should increase in the years to come.

Examples of Le Fort III before and after:

View attachment 260574

This example is Le Fort III + advancement of the mandible

However this is Le Fort III without advancement of the mandible:

View attachment 260509
View attachment 260511

As you can see the result is not as aesthetically pleasing as the first example. This is why it is ABSOLUTELY necessary to advance the mandible with Le Fort III via BSSO and Genioplasty.

Approach:

All of these fractures can be approached by coronal incision.

A second option includes a combination of bilateral upper-eyelid incisions to treat the fracture at the frontozygomatic suture, combined with a glabellar incision to approach the nasofrontal area if the surgeon is confident regarding the reduction and chooses not to plate the zygomatic arch fractures.

A third option is to include a combination of upper-eyelid incisions, combined with a glabellar incision, combined with a preauricular approach to plate the zygomatic arch. This combination also avoids performing a coronal incision.
A glabellar incision may be particularly desirable in an elderly patient who commonly has frown lines in the area of the glabella, or in a patient who wears glasses, where the frame of the glasses may help to cover up the glabellar incision.
If present, existing lacerations may also be used. The ethmoidal approach is not recommend.

View attachment 260538


3. Reduction
Arch bars and mobilization

First, arch bars are secured to the dentition.
After exposure of the fracture segments by adequate approaches, the fractures have to be mobilized to enable reduction and fixation.

View attachment 260541


Reduction instruments - Use of Rowe disimpaction forceps

The Rowe disimpaction forces are side specific. They allow precise 3-D movement of fracture fragments of the centrally impacted midface or maxilla.
Note: Special attention has to be given to the patient’s individual fracture pattern so that the use of these instruments does not result in significant shearing at the skull base or orbit. Otherwise, severe complications such as blindness can occur.


View attachment 260543

Special attention has to be paid regarding the correct placement of the Rowe disimpaction forceps so that the upper anterior dentition is not harmed.
The maxillary fracture is completely mobilized and an attempt should be made to make the fragment as passive as possible. This may require an up-down and side-to-side movement of the forceps.


View attachment 260545


Reduction instruments - Use of bone hooks

According to regional preferences and various schools of teaching, different bone hooks are used for fracture reduction in the lateral midfacial area.

Reduction hook (Stromeyer hook)

The Stromeyer hook (Georg Friederich Louis Stromeyer, Hannover, Germany, 1804-1876) is very versatile for transoral and transcutaneous reduction of lateral midfacial fractures. Its main indication is to reduce zygoma or zygomatic arch fractures.
In selected cases the Stromeyer hook can also be used for manipulating the Le Fort complex by hooking the tip of the instrument inside the piriform aperture and pulling downwards and anteriorly. This technique is called downfracture procedure in Le Fort osteotomies.

View attachment 260548

For zygoma reduction the tip of the Stromeyer hook is inserted transcutaneously. The curvature of the Stromeyer is held between the index finger and the thumb. The tip of the hook is then inserted about 4 cm below the lateral canthus either directly through the skin or following a limited stab incision.

View attachment 260549

After controlled positioning of the instrument, the hook is placed below the fracture segment and reduction can be obtained by pulling in the necessary vector. Care has to be taken so that the direction of pull on the hook is not changed, causing dislocation of the hook which could result in injury to the orbit or soft tissues.

View attachment 260550


Reduction instruments - Use of threaded reduction tool

The threaded reduction tool (Carroll-Girard technique) might be helpful to 3-D position the midface.
The tip of the tool is self-drilling which generally requires no predrilling, but support of the mobile fragment is required to withstand the force resulting from the insertion of the instrument.
The T-handle allows excellent manipulation of a solid bony structure like the zygoma, in a Le Fort III fracture. Insertion of the threaded reduction tool is usually done after limited stab incision.


View attachment 260551


4. Fixation
General considerations

According to the quality and stability of the reduction, the final decision is made regarding the number of plates and screws, and the design of the plates.
Generally, for Le Fort III fractures, plate fixation is applied to the fractures at the zygomatic arch, the frontozygomatic area, and the nasofrontal junction.
Fixation usually starts at the most reliably reduced buttress, always considering any fracture line in all three dimensions. If reduction is satisfactory, the first plate can be fixed by filling an adequate number of screws into the plate holes. Due to the specific patient injury patterns, provisional fixation with a limited number of screws may be indicated (in special cases, even temporary wire fixation might be considered). Final fixation must include two screws per fracture side.

The remaining buttresses are similarly addressed.
Complete reduction and fixation of the Le Fort fractures should take place before addressing the internal orbital wall fractures.

If there are any significant orbital fractures that require fixation or plating, these are performed after complete reduction and stabilization of the Le Fort III fracture.

View attachment 260553

First plate
In the case shown, the first plate is applied to the right lateral orbital buttress. According to the fracture morphology, a plate of appropriate profile, shape, and length is selected and contoured using bending pliers.
The plate is positioned with appropriate instruments (eg, forceps, plate holders, gauze packer). The first hole is drilled (a drill bit with a stop may be used) next to the fracture line in the frontal process of the zygoma and a screw is inserted.

View attachment 260554


Second screw in first plate
After drilling, the second screw is inserted next to the fracture line on the opposite side of the fracture.


View attachment 260556


Insertion of remaining screws
If reduction is satisfactory at the other fracture lines, the remaining screws are inserted (at least two screws per fracture fragment).

Alternatively, these two screws can be inserted after all other plates have been applied.

Insertion of remaining screws
If reduction is satisfactory at the other fracture lines, the remaining screws are inserted (at least two screws per fracture fragment).
Alternatively, these two screws can be inserted after all other plates have been applied.

View attachment 260560

Contralateral frontozygomatic buttress

In the illustrated case the contralateral frontozygomatic buttress is fixed in the same manner.

View attachment 260558

Additional plates (if required)

For isolated Le Fort III fractures, bilateral frontozygomatic fixation may be sufficient; more commonly, additional points of fixation are needed.

Nasofrontal plate(s)
Depending on the fracture pattern, one or two appropriate plates are applied. In this illustrated case, an inverted Y-plate is used for further reduction and stability at the nasofrontal fracture.

View attachment 260561

Zygomatic arch plate
If stability of the specific patient’s fracture morphology requires additional fixation, plates can be applied to the zygomatic arches in order to reestablish these sagittal buttresses.

Plate fixation normally uses straight plates. As with other fractures, at least two screws should be placed on each side of the fracture line, when possible. The number, length, and size of screws vary according to patient anatomy.
In case of a fracture of the zygomatic arch near the temporal bone, screw fixation (position screw or lag screw) may be considered. Care has to be taken to choose the correct implant dimension and length so that the neighboring structures are not harmed. The use of drill bits with a drill stop should be considered in this area.


View attachment 260562

Check occlusion

After internal fixation has been completed, MMF is released and the occlusion checked.

View attachment 260566

Pitfall: malocclusion
If an open bite and/or Class III tendency occurs when checking the occlusion, one or both mandibular condyles were malposed in posterior and/or inferior direction. In such cases, it is necessary to remove the bone plates, reapply MMF, and passively reposition the maxillomandibular complex again, assuring the condyles are properly seated. Bone plates are again applied and the occlusion verified.

The reason for a malocclusion may be the fact that the condylar heads were not positioned correctly in their respective glenoid fossae when securing MMF (as illustrated).


View attachment 260564



Recovery/Aftercare:


Postoperative positioning
Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.


Nose-blowing
To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following orbital fracture repair.

Medication
The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.
• Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.

Ophthalmological examination
Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:

• Vision (except for alveolar ridge fracture, palatal fracture)
• Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture)
• Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Globe position (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.

Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.

Postoperative imaging
Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.

Diet
Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.

Clinical follow-up
Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.
With patients having fracture patterns including periorbital trauma, issues to consider are the following:

• Globe position
• Double vision
• Other vision problems

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:

• Problems of dentition and dental sensation
• Problems of occlusion
• Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)

Le Fort III Pricing:

The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS.

While a staggering $47,333 is a lot, this would not be the final price if you also got a BSSO and genioplasty, which is absolutely necessary as stated before. The total price would be around $65,000.

If you are interested in this surgery, the most likely place would be to get it in Europe, USA, or Pakistan.

Sounds like you get fucked up for life for 60k+

 

[iam good boy]

Le Fort III is an invasive surgery that advances the maxillary bone and zygomatic bones forward and upwards inorder to correct craniofacialdystrophy.

A Le Fort III fracture includes fracture of the nasofrontal junction, bilateral fractures through the area of the frontozygomatic suture, and probable fractures of the zygomatic arch. These fractures are also referred to as craniofacial dysjunction.

Due to its counterparts, Le Fort I and II, Le Fort III is special because of its ability to advance not only the lower part of the maxilla, but also the upper maxilla and zygomactic bones, which Le Fort I, Double jaw surgery, Bimax and any other maxilla osteotomy are unable to achieve as they only advance the lower part of the maxilla, resulting in increased recessed orbitals, upper maxilla, zygomactic bones and a monkey face look: typically what boxers look like with a mouthguard in.

Le Fort III typically gets treated on deformed patients, people with crouzon syndrome especially. However it can be done on non-deformed patients, but as of now there are only a few surgeons in the world willing to do it, but this should increase in the years to come.

Examples of Le Fort III before and after:

View attachment 260574

This example is Le Fort III + advancement of the mandible

However this is Le Fort III without advancement of the mandible:

View attachment 260509
View attachment 260511

As you can see the result is not as aesthetically pleasing as the first example. This is why it is ABSOLUTELY necessary to advance the mandible with Le Fort III via BSSO and Genioplasty.

Approach:

All of these fractures can be approached by coronal incision.

A second option includes a combination of bilateral upper-eyelid incisions to treat the fracture at the frontozygomatic suture, combined with a glabellar incision to approach the nasofrontal area if the surgeon is confident regarding the reduction and chooses not to plate the zygomatic arch fractures.

A third option is to include a combination of upper-eyelid incisions, combined with a glabellar incision, combined with a preauricular approach to plate the zygomatic arch. This combination also avoids performing a coronal incision.
A glabellar incision may be particularly desirable in an elderly patient who commonly has frown lines in the area of the glabella, or in a patient who wears glasses, where the frame of the glasses may help to cover up the glabellar incision.
If present, existing lacerations may also be used. The ethmoidal approach is not recommend.

View attachment 260538


3. Reduction
Arch bars and mobilization

First, arch bars are secured to the dentition.
After exposure of the fracture segments by adequate approaches, the fractures have to be mobilized to enable reduction and fixation.

View attachment 260541


Reduction instruments - Use of Rowe disimpaction forceps

The Rowe disimpaction forces are side specific. They allow precise 3-D movement of fracture fragments of the centrally impacted midface or maxilla.
Note: Special attention has to be given to the patient’s individual fracture pattern so that the use of these instruments does not result in significant shearing at the skull base or orbit. Otherwise, severe complications such as blindness can occur.


View attachment 260543

Special attention has to be paid regarding the correct placement of the Rowe disimpaction forceps so that the upper anterior dentition is not harmed.
The maxillary fracture is completely mobilized and an attempt should be made to make the fragment as passive as possible. This may require an up-down and side-to-side movement of the forceps.


View attachment 260545


Reduction instruments - Use of bone hooks

According to regional preferences and various schools of teaching, different bone hooks are used for fracture reduction in the lateral midfacial area.

Reduction hook (Stromeyer hook)

The Stromeyer hook (Georg Friederich Louis Stromeyer, Hannover, Germany, 1804-1876) is very versatile for transoral and transcutaneous reduction of lateral midfacial fractures. Its main indication is to reduce zygoma or zygomatic arch fractures.
In selected cases the Stromeyer hook can also be used for manipulating the Le Fort complex by hooking the tip of the instrument inside the piriform aperture and pulling downwards and anteriorly. This technique is called downfracture procedure in Le Fort osteotomies.

View attachment 260548

For zygoma reduction the tip of the Stromeyer hook is inserted transcutaneously. The curvature of the Stromeyer is held between the index finger and the thumb. The tip of the hook is then inserted about 4 cm below the lateral canthus either directly through the skin or following a limited stab incision.

View attachment 260549

After controlled positioning of the instrument, the hook is placed below the fracture segment and reduction can be obtained by pulling in the necessary vector. Care has to be taken so that the direction of pull on the hook is not changed, causing dislocation of the hook which could result in injury to the orbit or soft tissues.

View attachment 260550


Reduction instruments - Use of threaded reduction tool

The threaded reduction tool (Carroll-Girard technique) might be helpful to 3-D position the midface.
The tip of the tool is self-drilling which generally requires no predrilling, but support of the mobile fragment is required to withstand the force resulting from the insertion of the instrument.
The T-handle allows excellent manipulation of a solid bony structure like the zygoma, in a Le Fort III fracture. Insertion of the threaded reduction tool is usually done after limited stab incision.


View attachment 260551


4. Fixation
General considerations

According to the quality and stability of the reduction, the final decision is made regarding the number of plates and screws, and the design of the plates.
Generally, for Le Fort III fractures, plate fixation is applied to the fractures at the zygomatic arch, the frontozygomatic area, and the nasofrontal junction.
Fixation usually starts at the most reliably reduced buttress, always considering any fracture line in all three dimensions. If reduction is satisfactory, the first plate can be fixed by filling an adequate number of screws into the plate holes. Due to the specific patient injury patterns, provisional fixation with a limited number of screws may be indicated (in special cases, even temporary wire fixation might be considered). Final fixation must include two screws per fracture side.

The remaining buttresses are similarly addressed.
Complete reduction and fixation of the Le Fort fractures should take place before addressing the internal orbital wall fractures.

If there are any significant orbital fractures that require fixation or plating, these are performed after complete reduction and stabilization of the Le Fort III fracture.

View attachment 260553

First plate
In the case shown, the first plate is applied to the right lateral orbital buttress. According to the fracture morphology, a plate of appropriate profile, shape, and length is selected and contoured using bending pliers.
The plate is positioned with appropriate instruments (eg, forceps, plate holders, gauze packer). The first hole is drilled (a drill bit with a stop may be used) next to the fracture line in the frontal process of the zygoma and a screw is inserted.

View attachment 260554


Second screw in first plate
After drilling, the second screw is inserted next to the fracture line on the opposite side of the fracture.


View attachment 260556


Insertion of remaining screws
If reduction is satisfactory at the other fracture lines, the remaining screws are inserted (at least two screws per fracture fragment).

Alternatively, these two screws can be inserted after all other plates have been applied.

Insertion of remaining screws
If reduction is satisfactory at the other fracture lines, the remaining screws are inserted (at least two screws per fracture fragment).
Alternatively, these two screws can be inserted after all other plates have been applied.

View attachment 260560

Contralateral frontozygomatic buttress

In the illustrated case the contralateral frontozygomatic buttress is fixed in the same manner.

View attachment 260558

Additional plates (if required)

For isolated Le Fort III fractures, bilateral frontozygomatic fixation may be sufficient; more commonly, additional points of fixation are needed.

Nasofrontal plate(s)
Depending on the fracture pattern, one or two appropriate plates are applied. In this illustrated case, an inverted Y-plate is used for further reduction and stability at the nasofrontal fracture.

View attachment 260561

Zygomatic arch plate
If stability of the specific patient’s fracture morphology requires additional fixation, plates can be applied to the zygomatic arches in order to reestablish these sagittal buttresses.

Plate fixation normally uses straight plates. As with other fractures, at least two screws should be placed on each side of the fracture line, when possible. The number, length, and size of screws vary according to patient anatomy.
In case of a fracture of the zygomatic arch near the temporal bone, screw fixation (position screw or lag screw) may be considered. Care has to be taken to choose the correct implant dimension and length so that the neighboring structures are not harmed. The use of drill bits with a drill stop should be considered in this area.


View attachment 260562

Check occlusion

After internal fixation has been completed, MMF is released and the occlusion checked.

View attachment 260566

Pitfall: malocclusion
If an open bite and/or Class III tendency occurs when checking the occlusion, one or both mandibular condyles were malposed in posterior and/or inferior direction. In such cases, it is necessary to remove the bone plates, reapply MMF, and passively reposition the maxillomandibular complex again, assuring the condyles are properly seated. Bone plates are again applied and the occlusion verified.

The reason for a malocclusion may be the fact that the condylar heads were not positioned correctly in their respective glenoid fossae when securing MMF (as illustrated).


View attachment 260564



Recovery/Aftercare:


Postoperative positioning
Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.


Nose-blowing
To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following orbital fracture repair.

Medication
The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.
• Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.

Ophthalmological examination
Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:

• Vision (except for alveolar ridge fracture, palatal fracture)
• Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture)
• Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Globe position (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.

Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.

Postoperative imaging
Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.

Diet
Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.

Clinical follow-up
Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.
With patients having fracture patterns including periorbital trauma, issues to consider are the following:

• Globe position
• Double vision
• Other vision problems

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:

• Problems of dentition and dental sensation
• Problems of occlusion
• Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)

Le Fort III Pricing:

The mean costs of treating Le Fort I, II, and III fractures were $25,836, $28,415, and $47,333, respectively. Increased cost was independently associated with younger age, male gender, African-American ethnicity, Le Fort II and III patterns, motor vehicle accident etiology, mechanical ventilation requirement, tracheostomy, ORIF, transfer to an outside facility, and increased LOS.

While a staggering $47,333 is a lot, this would not be the final price if you also got a BSSO and genioplasty, which is absolutely necessary as stated before. The total price would be around $65,000.

If you are interested in this surgery, the most likely place would be to get it in Europe, USA, or Pakistan.

Bro I'm planning to get this surgery who to consult

 

[shabby890]

Bro I'm planning to get this surgery who to consult

giant if you can reach him, i believe he has done aesthetic lefort 3s
eppely
most of the big names

 

[iam good boy]

giant if you can reach him, i believe he has done aesthetic lefort 3s
eppely
most of the big names

Where does that nigga live



@BrahminBoss I'm gonna get lefrot bhaii don't ask me the money

 

[shabby890]

Where does that nigga live



@BrahminBoss I'm gonna get lefrot bhaii don't ask me the money

just get it from Sunil Richardson like Brahminboss

 

[shabby890]

giant if you can reach him, i believe he has done aesthetic lefort 3s
eppely
most of the big names

mb giant has only done lefort 2s
no one will give you it unless you look like a deformed freak

 

[PrinceofDarkness]

holy shit that's an insane change

 

[esoterik]

top 10 surgeries

 

[sergeant blackpill]

when will we get LeFort IV?