QUADRANGULAR LEFORT 1 OSTEOTOMY? HIGH LEVEL LEFORTS?

[Lazlo]

Hi,

now before anyone lays in with the charge that this is irrelevant to most people, I would contend it is in fact NOT irrelevant at all. Most, if not all A/G patients receive some form of
HA augmentation to their suborbital or undereye/cheekbone areas either to compensate for the shifting of the maxilla AND/OR for cosmetic enhancement.
 A quadrangular lefort 1 is a lefort 1 (again with all incisions done from the inside) but is modified to include the malr/suborbital/zygoma regions. In other words, the maxilla and part of the cheekbones are moved
forward rendering the need for HA paste or other implants either less or unnecessary.

I'm not sure but it may be this procedure is usually used for patients with more severe midfacial hypoplasia (e.g. crouzen's syndrome etc.), I'm actually not even sure about that, but it does seem to be used
to increase cheekbone/suborbital eminence. I've been researching it and while all reports suggest it is a safe and doable operation, I haven't seen any before/after pics.
Again, this is NOT a lefort II where the incision is made above the nose, the quadrangular lefort 1 is done intraorally and the nose is not affected. Here's a description of the procedure and an abstract, if anyone has
any more info I would appreciate it, especially pics. The main surgeon on this paper, E E Keller is head of maxillofacial surgery at the Mayo clinic. And I will inquire about having a consultation with him.
I haven't seen before and after pics of it yet though, so if anyone could help me out that would be great!

http://www.sciencedirect.com/science/article/pii/027823919090171W

[CK]

yeah, that's a 4 piece lefort right? i think it is a pretty common technique for AG surgeries if it is double jaw. i would bet - but don't know for sure - that most people who have upper jaw surgery with them require cheeck augmentations because the advancements are so great in terms of pure movement. i believe a 4-piece is necessary to insert the hydroxyapatite. not sure how common it is among other surgeons.

[Lazlo]

yeah, that's a 4 piece lefort right? i think it is a pretty common technique for AG surgeries if it is double jaw. i would bet - but don't know for sure - that most people who have upper jaw surgery with them require cheeck augmentations because the advancements are so great in terms of pure movement. i believe a 4-piece is necessary to insert the hydroxyapatite. not sure how common it is among other surgeons.

actually i don't think that's what a quadrangular lefort 1 is, but i might be wrong, let me try and find a diagram and paste.

[CK]

actually i don't think that's what a quadrangular lefort 1 is, but i might be wrong, let me try and find a diagram and paste.

i dont know how else a surgeon could access the cheekbones through the mouth without a 4 piece.

[Lazlo]

i dont know how else a surgeon could access the cheekbones through the mouth without a 4 piece.

oh that might involve four cuts, but i think that can be done independently of a four piece lefort.

So a quadrangular lefort 1 osteotomy looks like this --scroll down to the third row of dual images entitled (lefort 1 high osteotomies). The third column shows the where the surgical cuts are made --along the line of the traditional lefort 1 --under the nasal base, but around it the cuts are made high, just under the suborbital region --so this whole complex is advanced, i.e. the suborbital and cheekbone area in addition to the maxilla. If you click on the video it will animate to show you the soft tissue movement involved.

Pros of this: can be performed intraorally, no external incisions/scars, does not affect the nose, can address deficient cheekbones and undereye area WITHOUT the use of silicone or medpor implants.
Cons: Is it riskier? I don't know really. There is some talk I've heard that cutting near the orbital rim is dangerous due to the orbital nerve. But the studies I've cited suggest that the orbital nerve remains unaffected. In addition in the 54 patients all had satisfactory outcomes. Can it be performed on anyone with midface hypoplasia? I don't see why not? Especially if you're a candidate for bi-max anyway?

So that's all I have on this now, would love to know more.

http://www.zib.de/vis-long_projects/cas/cas-gallery.html

[Sharptoys]

Out of curiosity, have you actually read the papers, or only the abstracts?

[Lazlo]

Out of curiosity, have you actually read the papers, or only the abstracts?

I have read the chapters in two max fac textbooks through google books where they describe both the quadrangular lefort 1 osteotomy in great depth
AND one article has a more extensive abstract, but no I have been unable to find a full article. I will consult with Keller though about this and I'm consulting with Schendel next month.
Schendel's secretary already told me he performs the malar osteotomy.

[Lazlo]

Out of curiosity, have you actually read the papers, or only the abstracts?

ps if you find the full papers, i would love to read them.

[Sharptoys]

I have read the chapters in two max fac textbooks through google books where they describe both the quadrangular lefort 1 osteotomy in great depth
AND one article has a more extensive abstract, but no I have been unable to find a full article. I will consult with Keller though about this and I'm consulting with Schendel next month.
Schendel's secretary already told me he performs the malar osteotomy.

You do understand that the "quadrangular lefort 1" is really more of an alternative to the variations of the Lefort 2 or 3, than a normal Lefort 1? It is a very specific operation to correct moderate maxillary hypoplasia with concurrent zygomatic hypoplasia BUT with normal nasal projection. Since the operation keeps the maxillary/zygomatic complex in one piece, mobility and flexibility is limited, and rotation of the occlusal plane--whether for aesthetic or functional reasons--necessitates rotation of the entire fragment.

Feel free to bring it up in the consolation, just make sure you mention it in passing, rather than asking if they'd perform it on you.

What kind of malar osteotomy does Schendel perform? If it's akin to Mommaerts' "sandwich" osteotomy, it may be considerably more applicable to your case.

[Sharptoys]

ps if you find the full papers, i would love to read them.

I just use my university's database. If you know anyone who's currently enrolled, they may also have educational access to Elsevier, among other sites. 

[Lazlo]

You do understand that the "quadrangular lefort 1" is really more of an alternative to the variations of the Lefort 2 or 3, than a normal Lefort 1? It is a very specific operation to correct moderate maxillary hypoplasia with concurrent zygomatic hypoplasia BUT with normal nasal projection. Since the operation keeps the maxillary/zygomatic complex in one piece, mobility and flexibility is limited, and rotation of the occlusal plane--whether for aesthetic or functional reasons--necessitates rotation of the entire fragment.

Feel free to bring it up in the consolation, just make sure you mention it in passing, rather than asking if they'd perform it on you.

What kind of malar osteotomy does Schendel perform? If it's akin to Mommaerts' "sandwich" osteotomy, it may be considerably more applicable to your case.

That's really interesting! Yes, I assumed there might be concerns with the quad lefort 1 in terms of what other movement could be performed. My nasal projection is fine, i need more malar/zygoma projection. I will ask Schendel specifics when I see him. I know very little about this operation but want to learn as much as I can so I can see if it is indeed an option for me. Thanks Sharptoys!

[danny44]

Hello there,
I hope it is okay if I chime in on this conversation. I had a consultation with Dr. Mommaerts today because I wanted cheek augmentation. I did not realize that he did cheek osteotomies. I have read as much as I can and talked to him for a good hour but I am still hesitant to go ahead. My other option is simply getting Hydroxyapatite on the outside of the cheekbone from another surgeon. This seems much less invasive and much safer. I am also concerned about the strength of the cheekbone bone after the osteotomy. He wants to secure the space with a little titanium plate and three screws. Any thoughts or comments on this would be really helpful as I am trying to decide wether or not to go ahead with this or not and from the previous conversation you folks seem fairly knowledgeable.
  Thank you 

[Lazlo]

Hello there,
I hope it is okay if I chime in on this conversation. I had a consultation with Dr. Mommaerts today because I wanted cheek augmentation. I did not realize that he did cheek osteotomies. I have read as much as I can and talked to him for a good hour but I am still hesitant to go ahead. My other option is simply getting Hydroxyapatite on the outside of the cheekbone from another surgeon. This seems much less invasive and much safer. I am also concerned about the strength of the cheekbone bone after the osteotomy. He wants to secure the space with a little titanium plate and three screws. Any thoughts or comments on this would be really helpful as I am trying to decide wether or not to go ahead with this or not and from the previous conversation you folks seem fairly knowledgeable.
  Thank you 

I've been told it achieves unpredictable results, so I really can't advise.

[danny44]

Thanks for replying,
What he told me is that you can't say exactly what is going to look like because you are using the natural cheekbone and projecting it anterolateraly (to the side and forward) and since everyone's natural cheekbones are different there is no standard result. The cosmetic result is not really my concern as it seems like the biggest problem would maybe be that it was too small but any improvement or projection I think would be more aesthetically pleasing, my real concern is the strength of the area afterwards as I am 22 years old and have my whole life ahead of me, I live a very active lifestyle. Do you have any knowledge about this or regarding anything related to osteotomies or bone grafts which is another option that would be done in addition to the screws and titanium plate for securing the space made by the osteotomy
Thanks
Daniel

[Lazlo]

Thanks for replying,
What he told me is that you can't say exactly what is going to look like because you are using the natural cheekbone and projecting it anterolateraly (to the side and forward) and since everyone's natural cheekbones are different there is no standard result. The cosmetic result is not really my concern as it seems like the biggest problem would maybe be that it was too small but any improvement or projection I think would be more aesthetically pleasing, my real concern is the strength of the area afterwards as I am 22 years old and have my whole life ahead of me, I live a very active lifestyle. Do you have any knowledge about this or regarding anything related to osteotomies or bone grafts which is another option that would be done in addition to the screws and titanium plate for securing the space made by the osteotomy
Thanks
Daniel

I don't have any knowledge about long term stability. Of course, even if you were 50 years old that would be a concern, you don't want to walk around feeling you have to guard your face once you've healed. What does Dr. M say?