Le Fort I Approach for Midline Tumors of the Palate

Abstract

Hard palate tumors may arise in the midline without affecting the alveolar ridge. In this cases a Brown class IA maxillectomy must be performed to carry out the tumor resection, preserving the dental arcade and therefore achieving better functional results. 1 The way this maxillectomy is executed is variable depending on the tumor size and the surgeon's preferences. In those tumors developing as endophytic masses with extension into the nasal cavity, it may be difficult to guarantee a deep tumor-free margin if the resection is made through a palatine approach. In this situation, a Le Fort I downfracture approach simplifies the surgical procedure improving the visualization of the entire tumor and the nearby structures, such as the descending palatine artery. In this manner, a complete tumor resection is guaranteed and the potential complications are reduced. At the same time, this procedure enables the reconstruction with a temporal muscle flap that otherwise could not be accomplished in a dentate patient. 2 Once in the operating room, the kind of intubation should be individualized. For unilateral tumors, intranasal intubation is preferred to improve the intraoral visualization and facility tumor resection. Submental intubation represents an effective alternative especially with tumors affecting both nostrils. This technique places the endotracheal tube away from our surgical field and improves the tumor visualization.In the surgical technique, first, a free margin is delimitated on the palatine mucosa reaching the bone layer and a palatine osteotomy is done using an oscillating saw (►Fig. 1). Next, a vestibular maxillary approach is done and microplates are fixed at both sides of the maxilla to guarantee the correct reposition of the maxilla at the end of the procedure. Screws and microplates are removed and a Le Fort I osteotomy is performed. This represent the most critical point of the approach and attention must be directed to the piriform aperture, lateral nasal walls, and the septum in order to make the cuts without entering into the tumor. Preoperative imaging is crucial to determine the intranasal extension of the tumor and decide the level of the Le Fort osteotomy (►Fig. 2). Vertical extension of the tumor determines the most limiting factor and tumors with high intranasal extension may not be candidates for this kind of approach, as the risk of tumor disruption is higher in these cases.Other authors have described endoscopic approach as a useful technique for the resection of midline tumors. 3 Although this may help in the operating room to ensure the correct margin of the resection, we consider it is difficult to accomplish the entire resection with free margins. The Le Fort approach, however, allows the direct visualization of the margins as the osteotomy is performed and warrants a better resection. Instead of endoscopic assistance, intraoperative Keywords ► midline palatal tumors ► maxillectomy ► Le Fort I approach ► temporal muscle flap AbstractMidline tumors of the palate may represent a challe...

Lefort 1 Osteotomy Study of Maxillary Bone in Caprine Skull Model: Comparison of Different Osteotomy Techniques (Piezo Versus Lindemann Bur Versus Manual Chisel)

“…It is also indicated for use in maxillofacial, cranial, and spinal surgeries. 18,19 In this study, we have compared the efficiency of 3 different osteotomy techniques in an experimental caprine skull model.…”

“…In addition, its use in rhinoplasty has been very popular in recent years. It is also indicated for use in maxillofacial, cranial, and spinal surgeries 18,19 …”