Le Fort III distraction using rotation advancement of the midface in patients with cleft lip and palate.

Abstract

Sir: We read the article by Drs. Hettinger, Hanson, and Denny on Le Fort III distraction for patients with cleft lip and palate with interest. The authors conclude that a Le Fort I procedure targets the occlusion alone and that a Le Fort III procedure is the only way to obtain malar and nasal correction in select cleft lip–cleft palate patients with severe malar deficiency. Although the authors show excellent results using their technique, we respectfully disagree that a Le Fort III procedure is required to correct maxillary hypoplasia in any simple cleft lip–cleft palate patient. Conceptually and anatomically, the simple cleft lip and palate, a Tessier no. 1 or 2 cleft without cranial extension, does not involve the orbital rim, lateral orbital wall, or zygoma. Clinically, the morbidity involved in a Le Fort III distraction, such as the need for blood transfusion, the need for multiple operations, and the potential for temporal hollowing, outweighs the benefits in this subset of patients. We agree that, in some patients, the severity of maxillary hypoplasia may cause a concave facial profile with malar flattening. However, we have found that a high Le Fort I advancement, including the zygomatic body, advances the zygomatic/malar region, nasal base, and nasal spine adequately while correcting the malocclusion (Fig. 1).1 In contrast, a Le Fort III advancement brings the lateral orbit, orbital rim, and entire nose forward. Unlike patients with craniofacial dysostoses, such as Apert or Crouzon syndrome, cleft lip–cleft palate patients do not have exorbitism, and movement of the orbit is not warranted and may cause enophthalmos, which is difficult to correct, although no cases of enophthalmos were reported in this study. When a Le Fort III procedure is required in a skeletally mature patient with craniofacial dysostosis, advancement at both the Le Fort I and Le Fort III levels is frequently required to address differential hypoplasia in that more advancement is required at the Le Fort I level. When Le Fort III distraction advancement is performed in a growing patient, orbital/malar correction is the goal, rather than occlusion. The authors argue that they achieved a desired counterclockwise rotation with significantly more advancement at the dentoalveolar level than at the nasion level, analogous to a Le Fort I/III procedure. This is only possible if the advancement was quite small or if the occlusal plane was extraordinarily steep such that the rotation actually leveled the occlusal plane. Although helpful in internal midface distraction, perioperative elastics would likely only impact the advancement at the nasion level and actually limit additional rotation advancement at the occlusion. The most likely explanation, in our opinion, is that an open bite is being created and orthodontic compensations, such as upper incisor proclination, occur. Finally, it would be beneficial in the study to separate skeletally mature patients from growing patients because the therapeutic goals and treatment strategies are different. In the skeletally mature patient, it is important to achieve a class I occlusion, whereas in a growing patient, overcorrection into a class II occlusion is the goal.Fig. 1: Preoperative (above, left and above, center) and postoperative (below, left and below, center) photographs of a skeletally mature patient who underwent a high Le Fort I advancement including the body of the zygoma. Preoperative (gray lines) and postoperative (black lines) lateral cephalometric tracings are depicted on the right. (From Kumar A, Gabbay JS, Nikjoo R, et al. Improved outcomes in cleft patients with severe maxillary deficiency after Le Fort I internal distraction. Plast Reconstr Surg. 2006;117:1499–1509.)PATIENT CONSENT Parents or guardians provided written consent for use of the patient’s images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Justine C. Lee, M.D., Ph.D. James P. Bradley, M.D. Division of Plastic and Reconstructive Surgery University of California, Los Angeles Los Angeles, Calif.