Transmucosal Pterygomaxillary Separation in the Le Fort I Osteotomy.

Abstract

Sir: We read with great interest the article entitled “Transmucosal Pterygomaxillary Separation in the Le Fort I Osteotomy” by Susarla et al.1 In this article, the authors introduced an innovative transmucosal tuberosity osteotomy approach with a far shorter incision and more reliable safety profiles. We think highly of the alternative transmucosal approach and agree that it saves the need to operate through the vestibular access, thus minimizing the tearing of soft tissue from maxillary tuberosity osteotomy. However, it appears to us that shortening the incision from molar-to-molar to canine-to-canine remains a matter of debate. First, a shorter incision with a broader labiobuccal pedicle may not provide additional beneficial effects. The authors thought that reducing the length of the incision would decrease the risk for nonunion or aseptic necrosis after surgery, especially in patients with complex maxillary tissue conditions. However, Nelson et al. quantified the blood flow after Le Fort I osteotomy and found a 95 percent decrease of blood flow in the attached gingiva and 89 percent in the alveolar bone after ligation of the descending palatine vessels.2 Based on this finding, we believe that the principle lies in the protection of palatal pedicles with intact descending palatine vessels for prevention of postoperative ischemic necrosis, whereas the role of the labiobuccal gingiva, in our humble opinion, is supplemental. Although the shortened incision may partially improve the blood supply, its effect is minimal compared to the palatal pedicle, the major nutrient supply of separated maxillary bones.3 From the experience of our center and records in the literature,4 ischemic complications are rare in operations with conventional incisions, when palatal pedicles are well preserved. To address the possible controversy, we reckon that a randomized controlled study might be necessary to verify the association between the length of incision and postoperative ischemic complications and other adverse events. Second, we are confused about the practicality of shorter incisions, fearing the extra inconvenience it would bring to the operation. In more detail, we are wondering whether the shorter incision would limit surgeons’ actions and narrow the surgical field, which may result in prolonged operation duration and increased blood loss, especially for novice surgeons. Meanwhile, when performing submucosal osteotomy, the shorter incision would result in increased mucosal tensions because the opening of the incision is more limited, thereby impeding further movement of the osteotome or resulting in accidental tearing, or even irregular incisional ruptures. In addition, the shorter incision would add extra inconvenience to segmental osteotomy in procedures such as vertical osteotomy, mobilization, and fixation. Therefore, it is our opinion that decisions on the incisional length should be individualized and condition-oriented. In conclusion, we thank the authors for their innovative work in advancing the surgical technique for one of the most critical steps in Le Fort I osteotomy. Considering the extra inconvenience and the indecisive role in recovery, it seems not worthwhile to reduce the length of the incision and to increase the operation difficulty and duration. We expect further investigations that will provide more information in the future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this communication. Zhaojian Wang, M.D.Xiaoshuang Guo, M.D.Xiaolei Jin, M.D.16th DepartmentPlastic Surgery HospitalChinese Academy of Medical SciencesPeking Union Medical CollegeBeijing, People’s Republic of China