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LeFort I Approach

last modified on: Fri, 01/15/2021 - 11:43

The LeFort I Approach

 

Return to: Paranasal Sinus Surgery Protocols

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Juvenile nasopharyngeal angiofibroma
      2. Nasopharyngeal, sphenoid, clivus tumors
        1. Inverting papilloma, Myxoma, adenoma
      3. Pterygomaxillary space tumors
        1. Neuroma
    2. Contraindications
      1. Young children with juvenile dentition
  2. PREOPERATIVE PREPARATION
    1. Additional Preoperative Evaluations
      1. CT scans, MRI, possible angiograms based on tumor type
      2. Panorex dental film to document preoperative occlusion
    2. Consent Inclusions
      1. General risks including bleeding, infection, and reaction to anesthesia
      2. Specific risks including possible nerve injury (cranial nerve V2)
      3. Transfusion
      4. Recurrence with the need for further surgery or adjuvant therapy based on tumor type
      5. Dental numbness, nonunion, tooth injury
      6. Malocclusion
      7. Palate necrosis partial or complete (very rare)
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
        1. Back table x 2
    2. Instrumentation and Equipment
      1. Standard
        1. Minor Instrument Tray, Otolaryngology
        2. Palate-Pharyngeal Tray
        3. Sinus Tray
        4. Nasal Sharp Tray
        5. Bipolar Forceps Trays
        6. Bien Otologic Electric Drill Tray
        7. Hall Micro Sagittal Saw Tray (Pneumatic)
          or
        8. KLS Oto Trauma Implant - Instrument Tray
      2. Special
        1. Rowe disimpaction forceps
        2. Richards double-fork retractors
        3. KLS Free Flap Implant - Instrument Tray
        4. Rhoton Micro Bayo, bipolar forceps, regular tip 8, 5 in x 1 mm
        5. Suction coagulator, 10 Fr
        6. Cautery electrode, ENT/IMA, guarded
        7. Bone wax
        8. Throat pack
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,000 epinephrine
      2. Ocular lubricant ointment, ophthalmic
      3. Balanced salt solution (BSS) 15 ml dropper
    4. Prep and Drape
      1. Intraoral prep
      2. Drape:
        1. Head drape
        2. Towels to square off entire face
        3. Split sheet
    5. Drains and Dressings
      1. Xeroform gauze
    6. Special Considerations
      1. Blood loss may be rapid, have double suctions available.
  4. ANESTHESIA CONSIDERATIONS
    1. General Anesthesia
      1. Tube position: Wired to inferior molars of contralateral side, placed in dental gap to avoid biting during dropdown
      2. Paralysis: Will aid in exposure
    2. Systemic Medication
      1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
      2. Steroids: Decadron 8 mg IV
    3. Positioning
      1. Supine
    4. Estimated Blood Loss
      1. Based on tumor type: 1000 cc (300 to 3000)
      2. Type and cross for 4 units
  5. OPERATIVE PROCEDURE
    1. Pertinent Anatomy
      1. It is important to know the location of dental roots and undescended maxillary teeth.
      2. The internal maxillary artery inters the pterygomaxillary space laterally as it hooks around the neck of the mandibular condyle.
      3. The internal carotid artery will provide a blood supply to the tumor via the maxillary and vidian canal.
      4. The pterygoid plates are attached to the maxilla by a bony bridge just posterior to the maxillary alveolar pad posterior to the third molar.
    2. Nasal and Oral Preparation
      1. Inject local anesthesia (1% lidocaine with 1:100,000 epinephrine) along the upper gingival buccal sulcus and intranasal along the nasal floor, septum, and nasal sidewall.
      2. Nasal packing with Afrin bilaterally
    3. Opening
      1. Incise 1 cm above gum line, from third molar to third molar.
      2. Identify the location of bone cuts above roots of teeth extending from the nasal passage (piriform aperture) to the pterygoid plates.
      3. With the maxilla intact, place bilateral medial and lateral maxillary buttress reconstruction miniplate 1.5 mm (2.0 plate may fit on the posterior buttress in larger children and adult patients), X-, Y-, or L-shaped plates, with ideally at least three screw holes remaining available on each side of the bone cuts (remove). Care must be taken not to bend these plates once removed.
      4. Make bone cuts along maxillary face, septal cuts, lateral nasal wall cuts (inferior to inferior turbinate).
      5. Fracture pterygomaxillary bone union with curved osteotome.
      6. Down fracture lower maxilla with palate using disimpaction forceps.
      7. Place hinged smooth-tipped self-retaining retractors in the maxillary bony opening to retain the down fractured position. Take care not to occlude the transoral endotracheal tube or compress the upper lip in the retractors.
      8. Visualize nasopharynx and pterygopalatine fissures. Complete the septal and lateral nasal wall cuts if needed.
      9. Remove tumor.
    4. Closure
      1. Replate maxilla at completion of operation.
      2. Confirm normal occlusion.
      3. Close wound with interrupted 3-0 vicryl, followed by running 3-0 chromic.
    5. Nasal Packing
      1. Xeroform gauze roll cut into long 1-in-wide strips is packed transnasally into the defect, to include the sphenoid and maxillary sinuses if opened during the surgery.
    6. Drains
      1. None
    7. Dressing
      1. Nasal drip pad
  6. POSTOPERATIVE CARE
    1. General Considerations
      1. Continue antibiotics until packing out
      2. Bedside humidification
    2. Dressings
      1. Change as needed
    3. Monitoring
      1. Palate viability
      2. PO intake
    4. Packing Removal
      1. Postoperative day five to seven
      2. In the operating room in young children
    5. Follow-Up
      1. Weekly follow-up until healing complete and then follow-up based on tumor type.
  7. SUGGESTED READING
    1. Brown, DH. The LeFort I maxillary osteotomy approach to surgery of the skull base. J Otolaryngol. 1989;18:289-292.
    2. Drommer RD. The history of the "LeFort I osteotomy." J Max Fac Surg. 1986;14: 119-122.