• #9 Molt periosteal elevator
• #15 Scalpel blade
• Appropriate sutures (4-0 Vicryl sutures, 4-0 chromic gut sutures)
• Curved Mayo scissors
• Double-guarded septal osteotome
• Freer elevator
• Kirschner wire
• Langenbeck (toe-in) retractors (two)
• Local anesthetic with vasoconstrictor
• Mallet
• Needle driver
• Pterygoid chisel
• Round bur
• Safe-edge saw
• Sagittal saw
• Selden retractor
• Spatula osteotome
• Straight osteotome
• Suture scissors
• Woodson elevator

LeFort 1 Osteotomy performed by Marc Oschs

During down fracture of the maxilla, the blood supply is by the ascending pharyngeal artery, the ascending palatine branch of the facial artery and the rich mucosal alveolar network overlying the maxilla. The descending palatine arteries are commonly sacrificed during surgery.
Anatomic studies indicate that the descending palatine artery is commonly sacrificed during Le Fort I disjunction. As a result, the major vascular supply of the mobilized Le Fort segment relies on the ascending palatine branch of the facial artery and the palatine branch of the ascending pharyngeal artery.

1. Osteotomy across the anterior lateral maxillary surface
2. Antero-lateral maxillary walls
3. Nasal septum
4. Lateral nasal walls to the anterior portion of the vertical palatine bone (stopping at the palatine bone to avoid the descending palatine arteries)
5. Pterygoid plates
6. Downfracture of maxilla

• Bleeding during Le Fort I osteotomy and downfracture is usually the result of injury to the terminal branches of the internal maxillary artery including the descending palatine and sphenopalatine arteries. Even after the Le Fort I downfracture, intraoperative injury to the descending palatine vessels may occur as a result of significant maxillary advancement or impaction. Postoperative hemorrhage following maxillary surgery typically presents as epistaxis with bleeding into the anterior and/or posterior nasal cavity. This may occur at any point during the first month after the surgical procedure and may be the result of breakdown of previous clot or necrosis of arterial vessels which were stretched by the surgical movement. An initial “sentinel” episode of brisk bleeding may stop spontaneously giving the false impression that the problem has resolved. Angiography and interventional radiology techniques provide detailed visualization and localization of the source of bleeding. The bleeding vessel may be stopped by embolization without the need to reopen the wound, remove rigid fixation devices, and dismantle skeletal segments. Angiography also allows detailed visualization of the arterial system and detection and management of pseudoaneurysm involving the internal maxillary artery or its terminal branches.
• The pterygoid plexus of veins is located directly posterior and medial to the maxilla. Its location makes it vulnerable to injury during creation of the osteotomy and use of an osteotome for pterygomaxillary disjunction. It is the most common source of intraoperative venous hemorrhage in patients undergoing LeFort I osteotomy. Management of venous hemorrhage from the pterygoid plexus requires packing and application of topical hemostatic agents.
• Segmental surgery for transverse maxillary expansion is associated with the highest rate of relapse following orthognathic surgery. Palatal soft tissue resistance and dental compensations often add to this instability.
• Movement of the maxilla directly affects the lower nasal anatomy and the nasal septum. When the maxilla is advanced and/or superiorly repositioned, the alar base width will increase, nasolabial angle will decrease, and increased superior rotation of the nasal tip is noted. As a result of these changes, the prominence of any dorsal hump will be reduced by the surrounding changes of the lower nasal dorsum.
• Alar base: Widening of the nasal base occurs anytime the maxilla is repositioned anteriorly or superiorly. In order to avoid undesirable nasal widening, a cinch-suture is passed through the transverse nasalis muscle on each side of the alar base of the nose and tied. Some surgeons prefer to pass this suture through the caudal edge of the nasal septum or anterior nasal spine.

•.028 K wire at nasion – measure w/ caliper and write it down
•Two medium/large toe in (held by B)
•bovie M1 to M1
•dissect up maxilla buttress to pririform, expose infraorbital nerve, create posterior pocket behind buttress and insert medium toe out
•(Other person repeat other side)
•Segmental dissection prn
•dissect nasal mucosa starting laterally, floor, medial
•(Other person repeat other side then strip tissue off ANS)
•recip saw for horizontal cut (then other side)
•single guarded curved chisel at lateral max sinus wall behind tuberosity
•Spatula chisel posterior sinus wall just medial to single guarded (light tap then remove both chisels)
•curved chisel at pterygoid plates (inf, ant, med)
•keep finger on palate
•First insert chisel then remove the toe out
•(Other person repeat other side)
•single guarded straight chisel at lateral nasal wall
•go 30 mm posteriorly, below inf turbinate, change in bone when reach palatine bone
•Each person does contralateral, hold suction in nose so you can always visualize the ball/guard
•double guarded chisel at septum (vomer, finger in the mouth on jct of soft and hard palate)
•push down on anterior maxillary teeth w/ fingers, then with J-stripper/hook
•Freer to elevate the sinus floor and evaluate fracture
•roe disimpcation forceps to down fracture
•medium hemoclip for desc palatine vessels, bovi along bone side after clipping
•remove posterior medial and lateral interferences with rongeur and back biting kerrison
•Sonopet and chisels for segmental palatal cuts prn
•IMF (rotate mand up and back w/ condyles seated)
•Re measure vertical
•remove additional anterior interferences
•L plates x4
•closure:
•nasal cinch (at alar base)
•V-Y (to prevent lip shortening)
•vestibular, running

⁃bovie 1M 1M, stay in unattached gingiva because otherwise its going to be a bitch to close
⁃peel with broad end of periosteal, go all the way up
⁃laterally when you get across ZMC, use the sharp end to make a pocket, slide on bone with peropsteal broad end
⁃use a toe out to retract this tissue laterally. if you violate the periostrum, buccal fat will come out
⁃strip ANS, bovie off ans
⁃dissect nose. use periosteal, freer slide on bone, go back like 3 cm laterally and inferiorly.
⁃lefort cut
⁃use single guarded and straight chisel, tap
⁃then both come out. use suctionn the nose, use single guarded ball in nose
⁃be sure when you use the single guarded, seat it flat against that bone
⁃use curved to hit pteryoid. finger goes in the mouth
⁃double guarded, put finger in mouth
⁃finger pressure should break it
⁃then use j hook
⁃use rowe disimpaction
⁃hemoclip x2 on descending palatine. clip hard! bovie to bone, buzz it good. artery goes one way
⁃rongeurs to take interfereces or back biting kerrison

when bending plates – 1.5 thickness L plates. Use needle driver x2. make sure you dont bend over the hole, you can’t use it unless the gap is so big that you HAVE to bend it. think about the orientation for you to bend it
⁃usually 3 or 4 mm screws

•fracture 1 and 2
•Stryker imf
•Dental extras
•Dental extraction kit
•Leibinger kit
•Sonopet (BSSO, LF segmental)
•Core drill
•Bovie with Colorado tip
•.028 K wire (LF)
•Medium hemoclips
•24 and 26 G wires

Incision to bone pm to pm with vertical releases.
Peel
Sweep back and forth to get behind the buttress.
Need to be able to fit a toe in
Periosteal pocket in nose. Sweep little by little the entirety of your exposure before you do the lateral wall and floor of nose
Use bovie take off ans attachment
Dissect your segmental osteotomy
Use obwegaser to tent the tissues down
Put in cutting guide
Use oscillating saw
Make sure guide is seated
If not using a guide, score the cortex
Will need spatula chisel to go all the way down
Lefort cut with recip
Single guarded facial surface seat with the sharp end
Lateral nasal wall
Curved osteotome finger in mouth at hamulus
Double guarded
May need to use mayo scissor to cut septum
j hook to pull it down
B does the Sonopet to make the island and you use the Sonopet to connect to his cuts
Rowe forceps airplane left and right
When plating, don’t make your bend right next to the hole because it is more stress and may cause the bone and plate to break. Give it some room
Cut extra holes off the field
Midface usually 3 mm to 4 mm holes
When closing 3-0 prolene alar cinch
Feel it with your fingers or show it coming out that you grabbed nasalis
V y – run it then dive it underneath the stitch to grab midline
Running chromic gut must have noneadted movements. Load your needle as you pass it and rotate it around.