A simple, atraumatic technique for the dissection of nasal mucosa during Le Fort I osteotomy

J Oral

Maxlllofac

56x587-688,

Surg 1998

A Simple, Atraumatic Technique for the Dissection of Nasal Mucosa During Le Fort I Osteotomy Kenneth

C. Pinkerton,

DMD, * and James

A. Wimsatt

III, DDSf

1. Initial insertion retrieval string.

of the cottonoid

Preservation of intact nasal mucosa is a fundamental surgical principle in Le Fort I osteotomies. A simple technique is presented for the atraumatic dissection of nasal mucoperiosteum during the procedure, with concomitant hemostasis as well as protection of the nasal mucosa from subsequent instrumentation.

Procedure During subperiosteal dissection for the Le Fort I osteotomy, the piriform apertures are exposed in standard fashion. Initial submucosal dissection is performed with a curved Freer elevator. Care is taken to direct the dissection inferiorly and laterally to avoid perforation into the nasal mucosa. After approximately 5 mm of reflection is accomplished at inferior, medial, and lateral extent of the piriform apertures, 0.5” X 3” cottonoid strip (Codman Surgical Pattie, Johnson Sr Johnson, Inc, Randolph, MA) impregnated with bovine thrombin (5,000 p) is gently inserted and directed toward the bony nasal floor (Fig 1). The cottonoid strip is then advanced gently with the end of the Freer elevator for about 32 mm or until resistance is felt (Fig 2). A similar dissection is performed medially and laterally, and three strips are usually sufficient to accomplish the dissection. Minimal elevation of the nasal mucosa should be done medially, elevating only enough to avoid laceration during nasalcartilage separation from the maxilla. The strips are left in place, protecting the mucosa from

Received from the Department of Oral and Maxillofacial USAF Medical Center, Scott APB, IL. *Formerly, Currently,

Chief, Private

Oral

and Maxillofacial

Practice,

San Marcos,

Surgery,

1305 0 1998

Wonderworld American

and reprint

Dr, Suite Association

303,

marker

and

strip.

Note

requests

San Marcos,

of Oral and Maxillofacial

the radiopaque

sharp instruments while the Le Fort I osteotomy is performed. After downfracture of the maxilla, the surgeon will note a pristine nasal mucosa surface, with the periosteum and pericondrium intact. Care must be taken to remove the cottonoid strips after downfracturing of the maxilla is complete. This is facilitated by using the retrieval string incorporated Into the cottonoid material.

Discussion The maintenance of intact nasal mucoperiosteum during maxillary osteotomies is a well-accepted techis nical standard, but achievement of this standdrd

Surgery,

Scott AFB, IL;

TX.

tljormerly, Assistant Chief, Oral and Maxillofacial APB, IL; Currently, Fellow, Reconstructive Surgery, Miami, FL. Address correspondence

FIGURE

Surgery, Scott University of

to Dr Pinkerton:

TX 786667541. Surgeons

0278.6386/98/56060022$3.00/O

FIGURE

687

2. Insertion

of one

strip completed.

688 not well-documented in the literature. Owing to the tenacious nature of the periosteum and perichondrium associated with the nasal aperture, and the inherent bony and cartilaginous irregularities, the most skilled and well-intended nasal mucosal elevation may result in multiple mucosal tears and perforations. Even with blunt instrumentation, this adverse situation could occur, thus increasing the likelihood of postoperative epistaxis and the possibility of perichondritis associated with cartilage exposure (despite meticulous mucosal closure). This technique not only protects the nasal mucosa, but also the endotracheal tube, which can easily be lacerated by sharp instruments while the osteotomy is being accomplished. Additionally, the surgeon is afforded excellent hemostasisby virtue of the cottonoid strip being impregnated with bovine thrombin. After downfracture of the maxilla, the surgeon is treated to a clean, dry nasal mucoperiosteum, which facilitates visualization and

A PRACTICAL

LE FORT I NASAL DISSECTION

FIGURE 3. View of elevated and lackof bleeding.

mucosa

showing

TECHNIQUE

the clean

dissection

subsequent instrumentation of the surrounding bony and cartilagenous structures (Fig 3). It also affects the postoperative course, as it relates to patency of this airway to maximize patient comfort.