Q: Dr. Eppley, I suffer from midfacial hypoplasia. I am currently scheduled to undergo a modified LeFort III and I anticipate undergoing bimaxillary advancement in the future. I am fully aware of the risks associated with the procedure.
I have considered going for the ‘camouflage’ approach, consisting of implantation, and thus I am drawn to you given your experience and presence. What will be crucial in making my decision is whether there is anything that customized implantation can achieve in the upper midface that a modified LeFort III procedure cannot, and vice versa. Initially I was curious as to whether the soft tissue response would be different. Is there anything that you can envisage an osteotomy involving the upper midface achieving that a custom implant cannot?
The main point of my email though is with regard to something more specific. My surgeon informs me that the cut will be made in the lateral orbital wall above the lateral canthus. The lateral orbital wall will be moved forward,along with the lateral canthus. This is important to me because my lateral canthus is very far back relative to my medial canthus and the anterior surface of the eyeball. In fact, this is probably my most pressing aesthetic concern. So my surgeon assures me that it is solveable. However, if there is another way of achieving this aim without undergoing a risky procedure such as a modified LeFort III, I would be eager to undergo it.
Which brings me onto my question. I know that it is possible to replicate more anterior projection of the lateral orbital rim with implants. What I would love to know is whether the lateral canthus may be brought forward in the way that it would with an osteotomy? Perhaps through disattachment of the lateral canthus and replacement in another part of the newly constructed lateral orbital rim?
Another brief question that I have is with regards to the appearance of the lateral orbital rim without movement of the lateral canthus. I struggle to envisage how the lateral orbital rim would appear if it is given anterior projection past the position of the lateral canthus. Would the lateral canthus become invisible in this situation or how would it appear?
Thank you for your time.
A: In short, you have correctly surmised that the position of the lateral canthus inside the lateral orbital rim can be repositioned either onto the bone or onto an implant rim. (lateral canthoplasty) One would certainly not choose a modified LeFort III procedure if that issue was the primary objective of the surgery. As there is an easier way to accomplish that goal.
Be aware that in the execution of any form of a LeFort III ostetotomy the later canthus has to be detached and then reattached once the bone is moved. It does not really ‘move’ with the bone as it comes forward
Whether you should do the LeFort procedure or onlay implants depends on how much forward movement of the midface/rims you need to accomplish your aesthetic goals and what other midface needs are to be addressed.
Dr. Barry Eppley