Am I A Good Candidate For A LeFort II Midface Osteotomy?

Q: Dr. Eppley, I’m currently undergoing orthodontic treatment for a Lefort I + SARPE surgery in the future. I have a class 3 malocclusion. This surgery should help (though not completely fix my bite). The lower portion of my maxilla is very narrow, and my mandible has shifted and become asymmetric so that my molars connect. However, it’s really my entire maxilla which is quite recessed, and not just the lower portion. I have a very/flat recessed eye area as well (hardly any cheekbones). I’m concerned that a lefort 1 is not addressing the whole problem, and really won’t do much to help me cosmetically. I have been researching lefort 2 as an alternative, but can hardly find any surgeons who perform this operation in the USA. Since I came across your site in my search, I was wondering if this is something you offer. Thanks for your time.

A: When the entire midface is recessed a Lefort I osteotomy, as you have correctly surmised, will provide an incomplete aesthetic correction. By only addressing the dentoalveolar part of the problem the nasal base is primarily aesthetically improved. Anatomically a LeFort III osteotomy provides the most complete correction. (although limited to the sagittal plane) 

While more anatomically complete there are quite a few differences (tradeoffs) between a LeFort I and III osteotomies. The latter requires eyeid incisions (technically a coronal scalp incision is more ideal) and osteotomies across the orbital floor and cheek areas. These invariably heal with irregularities and some palpable bony stepoffs. In contrast the LeFort I is a far more aesthetic operation with an intraoral approach only with no evident bony stepoffs.

While LeFort procedures above the I level may be appealing in diagrams, there are aesthetic tradeoffs with their use that are not obvious in such drawings and should be very carefully considered and undertaken with caution. There is a reason they are primarily used in younger syndromic patients with more substantative bony deformities.

While these LeFort II and III procedures can be done in the highly motivated patient a more prudent and effective approach is to employ both a LeFort I osteotomy with custom midface implants above it, either done concurrently or staged.

Dr. Barry Eppley

Indianapolis, Indiana