Your Questions
Your Questions
Q: Dr. Eppley, I had a LeFort 1 osteotomy done two years ago and I’m looking for a revision as it was done poorly. For the first surgery, I only had rubber bands and was allowed to remove them after the first week for meals. (soft food) However, I’ve read of many cases whereby the patient is completely wired shut for weeks. Why do some patients have such strict fixation while others don’t? Would not getting wired shut lead to a greater chance of relapse or a poorer outcome?
A: Historically, LeFort 1 osteotomies were done using wire bone fixation and the need to use maxillomandibular fixation (jaws wired together) to hold the bone in place as it heals. Since the late 1980s and early 1990s, LeFort osteotomies have been held into place using plates and screws thus obviating the need for wiring the jaws shut after surgery for six weeks to allow the bones to heal.
While I have no idea what type of bony movements were done with your LeFort 1 osteotomy, your after care with temporary rubber bands suggest that you had plate and screw fixation. If properly done the use of plate and screw fixation would create a comparative result to wiring the jaws shut for six weeks. In theory long-term stability would be improved with the plate and screw fixation technique. The risk of a malaligned bite after a LeFort 1 osteotomy with the jaws wired shut for six weeks, as uncomfortable and historic as that is, has a lower risk than that if rigid plate and screws fixation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask, in a Lefort 1 osteotomy, is it possible to lengthen the nose along with that part of the maxilla. Part of my problem with my midface is a nose that is short vertically compared to the distance between eye to eye horizontally. So is it possible to lengthen the nose within the Lefort 1 osteotomy? I am asking because I saw this Lefort 1 osteotomy example, and wanted to know if the bone grafts also applied to lengthening the nose vertically? And if so, by how much?
A: While diagrams and actual LeFort I osteotomy down fractures (vertical lengthening) do show the pyriform aperture (nasal base) being opened up and/or bone grafted, this will not vertically lengthen the nose. The shape of the external nose is largely controlled by the cartilaginous support system. (septum, upper and lower alar cartilages) This to vertically lengthening the nose cartilage grafts must be placed on TOP of the existing cartilage support. Nothing done underneath it will lengthen the external nose shape. In fact, vertical lengthening of the midface will actually create a relatively greater deficiency of the nose, more of a potentially saddle dorsal line appearance rather than the opposite effect which you desire.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For purely cosmetic reasons, I wanted to know if it was possible to lengthen my midface by performing a 1-2mm dual sided vertical ramus distraction of the mandible? Also a 1-2mm LeFort 1 osteotomy vertical elongation similar to the fashion of that provided in the attached photo that had featured the osteotomy and bone grafts. And if so, what would be the likely maximum cost after taxes and hospital bills?
A: What you are seeking is vertical elongation of the maxillomandibular complex. If all that is needed is a few millimeters of vertical lengthening of the maxilla and mandible, there would be no reason to undergo any form of distraction. This can be done by using conventional orthognathic surgery operations such as a LeFort 1 osteotomy with interpositional bone grafting and a sagittal split osteotomy of the mandible. I would not do a LeFort 2 osteotomy as this is associated with an incraesed difficult factor that requires a coronal scalp incision to complete. Whatever aesthetic benefits that may come from a LeFort 1 osteotomy vs a LeFort 2 osteotomy, the added surgical risks and effort are not worth it. Such bimaxillary orthognathic surgery will cost in the range of $40,000 to $50,000 to undergo.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 21 years old. In March I have planned some maxillofacial surgeries. Currently I have a chin implant large anatomical. I have a problem in my maxillary prognathism which is vertically long. A maxillofacial doctor also diagnosed me with micrognathia. I have no problems with my bite. My upper jaw is too long like my upper lip. Then I realized I needed an upper lip lift and a Lefort 1 osteotomy. The only plastic surgeon I have seen thinks I need a upper lip lift (remove 6-7 mm) but the problem is that I have a gummy smile. My question is what is best to do first? And how long should I wait to do them?
A: With a vertically long maxilla and an overlying long upper lip, it is an interesting question as to which one should be done first. If I make the assumption that you really need both bone and soft tissue shortenings, whichever one is done first will leave you with an increased aesthetic deformity before the second stage correction. In these situations, it is always best to do the underlying foundational change first. Because the bone surgery is more involved and may change what is eventually done in the amount of upper lip lifting, the LeFort impaction procedure should be done first. Once the bone level is set then the upper lip lift can be done based on the position of the lip to the maxillary anterior teeth. Also dependent upon how long your upper lip is and how much vertical maxillary shortening is needed, it is also possible to both together…but using only a conservative upper lip reduction as more can be done later if needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had a Le Fort I osteotomy to correct my bite, which it did. Despite the upper jaw movement my midface still appears flat. I was told to look toward having cheek and paranasal implants to correct my profile.
A: A LeFort osteotomy only affects the face at the upper jaw/upper tooth level, otherwise known as the maxilla. If the maxilla is brought forward (LeFort advancement) it can change the anterior nasal spine and the base of the nose, opening up the nasolabial angle and providing some paranasal augmentation. But it takes a significant movement forward to make those changes. But it will never provide any cheek or zygomatic enhancement as the level of the bone movement is way below these bone structures.
Secondary midface augmentation will require cheek and paranasal implants to achieve increased midface fullness/projection. When the degree of midfacial fullness is recognized before the LeFort procedure, the implants can be placed at the same time. But they can also be done afterwards as a secondary procedure. This would also provide an opportunity to remove the metal plates and screws that were initially placed to hold and heal the LeFort osteotomy. Four implants are used to create both lower (paranasal) and upper (cheek) midfacial augmentation.
Dr. Barry Eppley
Indianapolis, Indiana