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Paranasal incision as an access for maxillary osteotomy
J. Cranio-Max.-Fac. Surg. 16 (1988) J. Cranio-Max.-Fac. Surg. 16 (1988) 359-361 © Georg Thieme Verlag Stuttgart • New York
Paranasal Incision as an Access for Maxillary Osteotomy
359
Summary A new approach for osteotomy of the maxilla through a paranasal incision is described. Advantages and indications are discussed. Key words Paranasal incision - Maxillary osteotomy
Karl Hollmann, Michael Rasse Maxillo-Facial Surgery Clinic (Head: Prof. S. Wunderer, M. D., D. M. D.), University of Vienna, Austria Submitted 1 0 . 1 1 . 8 7 ; accepted 1 2 . 2 . 8 8
Introduction
With the intention of preserving the blood supply to the fragments and considering various indications, different approaches for osteotomy of the maxilla have been described. Cohn Stock (1921), Converse and Shapiro (1952), Wunderer (1962) and others used a palatal approach. Exposure of the bone through the oral vestibule was chosen by Wassmund (1935 [vertical incision]) and Cupar (1954 [horizontal incision]), Casson et al. (1974) combined a vestibular approach with bilateral intercartilaginous incisions and a transfixation incision, calling it the "Midface degloving procedure". Surgical access to more cranially situated areas of the maxilla or the facial skeleton is also gained by skin incisions, e. g. the bitemporal incision, incisions at the nasal base (Converse et al., 1970; Henderson and Jackson, 1973) or a lower eyelid approach. We would like to describe another simple approach for osteotomy of the maxilla.
Fig. 1
Paranasal incision exposing piriform aperture.
Method The incision is made in the alar sulcus of the nose (Fig. 1). It can be combined with additional palatal incisions of all kinds. The incision may extend cranially as far as is defined by the anatomical sulcus. Caudally and medially it reaches the nasal sill. With this incision and by elevating the soft tissues, access can be gained to the piriform aperture. The incision further permits a subperiosteal mobilization of the soft tissues dorsally to the maxillary tuberosity and cranially to the frontal processes of the maxilla. By using this approach the bone can also be exposed for osteotomy along the lateral wall of the nasal cavity and the nasal floor and along the caudal part of the nasal septurn. If the maxillary tuberosity is to be separated from the pterygoid plates, an additional buccal or palatal incision in the retromolar area is needed. For palatal osteotomies we use incisions in the tuberosity area. Discussion and Conclusions
The above described approach to the maxilla offers several advantages. In the case of high Le Fort I osteotomies and high osteotomies at the piriform aperture good exposure
Fig. 2
Implanted miniplate.
360
J. Cranio-Max.-Fac. Surg. 16 (1988)
K. Hollmann, M. Rasse
Fig. 3 Fig.3, Fig.4
Fig. 4
Patient with maxillary deficiency prior to operation.
Fig. 6
Fig. 5 Fig. 5, Fig.6
Patient after maxillary advancement employing paranasal incisions.
of the maxilla is guaranteed. The mucosal lining of the alveolar process and of the oral vestibule can be preserved intact. This prevents fistula formation and reduces the risk of infection of bone grafts. The application of miniplates for stabilizing the maxillary fragments can easily be performed via this approach (Fig. 2). Similarly bone grafts can be inlaid into defects at the site of osteotomy or in cases of palatal clefts respectively t o augment the alveolar process or the facial aspect of the maxilla. Needless to say, the incision can also be used for simultaneous nose or lip correction. Since we have, from a cosmetic point of view, been successful with this type of incision for correction of the posi-
tion and width of the alar wings (laid down by Weir in 1982 for this purpose), we did not hesitate to use it as an approach for osteotomy of the maxilla. Henderson (1980) reports satisfactory cosmetic results even in the case of rather unfavourably situated paranasal incisions at the root of the nose, which he used as an access for Le Fort II osteotomy. Up to the present time, we have operated on 6 patients using the incision described. The first operation was performed in 1981. Since our type of incision is made in a preformed sulcus, scars are hardly noticable (Fig. 3-6). Keloid formation was never seen.
Paranasal Incision as an Access for Maxillary Osteotomy Editorial Note We consider the incision described superfluous in most cases. We furthermore think that it has more disadvantages than advantages and should be avoided as much as possible especially because of the external scar. H. P.F. References
]. Cranio-Max.-Fac. Surg. 16 (1988)
Henderson, D.: In: Bell et al. (Eds.): Surgical correction of dentofa-
cial deformities, Vol 2. Saunders, Philadelphia-London-Toronto-Mexico City-Rio de Janeiro-Sydney-Tokyo 1980 Henderson, D., L I. Jackson: Naso-maxiUary hypoplasia: the LeFort II osteotomy. Br. J. Oral Surg. 11 (1973) 77 Wassmund: Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer, Bd. I, Leipzig 1935 Weir, R.F.: On restoring sunken noses. N. Y. Med. J. 65 (1982) 44-9 Wunderer, S.: Die Prognathieoperation mittels frontal gestieltem Maxilla-Fragment. Osterr. Z. Stomatol. 39 (1962) 98
Casson, P. K , P.C. Bonnano, J.M. Converse: The midface degloving
procedure. Plast. Reconstr. Surg. 53 (1974) 102 Cohn Stock, H.: Die chirurgische Immediatregulierung der Kiefer,
speziell der chirurgischen Behandlung der Prognathie. Vjschr. Zahnheilkd. 37 (1921) 320 Converse, J.M., H. H. Shapiro: Treatment of developmental malformations of the jaws. Plast. Reconstr. Surg. 10 (1952) 473 Converse, J.M., S.L. Horowitz, A.J. Valauri, D. Mintendon: The treatment of nasomaxillary hypoplasia. A new pyramidal nasoorbital maxillary osteotomy. Plast. Reconstr. Surg. 45 (1970) 527 Cupar, J.: Die chirurgische Behandlung der Form- und Stellungsverfinderung des Oberkiefers. Osterr. Z. Stomatol. 51 (1954) 565
3 61
Prof. K. Hollmann, M. D., D. M. D. Klinik fiir Kiefer- und Gesichtschirurgie der Universitdt Wien 9 Alser Strafle 4 A-1090 Wien Austria Dr. M. Rasse, M.D. Klinik fiir Kiefer- und Gesichtschirurgie der Universitdt Wien 9 Alser Strafle 4 A-1090 Wien Austria
Paranasal Incision as an Access for Maxillary Osteotomy
359
Summary A new approach for osteotomy of the maxilla through a paranasal incision is described. Advantages and indications are discussed. Key words Paranasal incision - Maxillary osteotomy
Karl Hollmann, Michael Rasse Maxillo-Facial Surgery Clinic (Head: Prof. S. Wunderer, M. D., D. M. D.), University of Vienna, Austria Submitted 1 0 . 1 1 . 8 7 ; accepted 1 2 . 2 . 8 8
Introduction
With the intention of preserving the blood supply to the fragments and considering various indications, different approaches for osteotomy of the maxilla have been described. Cohn Stock (1921), Converse and Shapiro (1952), Wunderer (1962) and others used a palatal approach. Exposure of the bone through the oral vestibule was chosen by Wassmund (1935 [vertical incision]) and Cupar (1954 [horizontal incision]), Casson et al. (1974) combined a vestibular approach with bilateral intercartilaginous incisions and a transfixation incision, calling it the "Midface degloving procedure". Surgical access to more cranially situated areas of the maxilla or the facial skeleton is also gained by skin incisions, e. g. the bitemporal incision, incisions at the nasal base (Converse et al., 1970; Henderson and Jackson, 1973) or a lower eyelid approach. We would like to describe another simple approach for osteotomy of the maxilla.
Fig. 1
Paranasal incision exposing piriform aperture.
Method The incision is made in the alar sulcus of the nose (Fig. 1). It can be combined with additional palatal incisions of all kinds. The incision may extend cranially as far as is defined by the anatomical sulcus. Caudally and medially it reaches the nasal sill. With this incision and by elevating the soft tissues, access can be gained to the piriform aperture. The incision further permits a subperiosteal mobilization of the soft tissues dorsally to the maxillary tuberosity and cranially to the frontal processes of the maxilla. By using this approach the bone can also be exposed for osteotomy along the lateral wall of the nasal cavity and the nasal floor and along the caudal part of the nasal septurn. If the maxillary tuberosity is to be separated from the pterygoid plates, an additional buccal or palatal incision in the retromolar area is needed. For palatal osteotomies we use incisions in the tuberosity area. Discussion and Conclusions
The above described approach to the maxilla offers several advantages. In the case of high Le Fort I osteotomies and high osteotomies at the piriform aperture good exposure
Fig. 2
Implanted miniplate.
360
J. Cranio-Max.-Fac. Surg. 16 (1988)
K. Hollmann, M. Rasse
Fig. 3 Fig.3, Fig.4
Fig. 4
Patient with maxillary deficiency prior to operation.
Fig. 6
Fig. 5 Fig. 5, Fig.6
Patient after maxillary advancement employing paranasal incisions.
of the maxilla is guaranteed. The mucosal lining of the alveolar process and of the oral vestibule can be preserved intact. This prevents fistula formation and reduces the risk of infection of bone grafts. The application of miniplates for stabilizing the maxillary fragments can easily be performed via this approach (Fig. 2). Similarly bone grafts can be inlaid into defects at the site of osteotomy or in cases of palatal clefts respectively t o augment the alveolar process or the facial aspect of the maxilla. Needless to say, the incision can also be used for simultaneous nose or lip correction. Since we have, from a cosmetic point of view, been successful with this type of incision for correction of the posi-
tion and width of the alar wings (laid down by Weir in 1982 for this purpose), we did not hesitate to use it as an approach for osteotomy of the maxilla. Henderson (1980) reports satisfactory cosmetic results even in the case of rather unfavourably situated paranasal incisions at the root of the nose, which he used as an access for Le Fort II osteotomy. Up to the present time, we have operated on 6 patients using the incision described. The first operation was performed in 1981. Since our type of incision is made in a preformed sulcus, scars are hardly noticable (Fig. 3-6). Keloid formation was never seen.
Paranasal Incision as an Access for Maxillary Osteotomy Editorial Note We consider the incision described superfluous in most cases. We furthermore think that it has more disadvantages than advantages and should be avoided as much as possible especially because of the external scar. H. P.F. References
]. Cranio-Max.-Fac. Surg. 16 (1988)
Henderson, D.: In: Bell et al. (Eds.): Surgical correction of dentofa-
cial deformities, Vol 2. Saunders, Philadelphia-London-Toronto-Mexico City-Rio de Janeiro-Sydney-Tokyo 1980 Henderson, D., L I. Jackson: Naso-maxiUary hypoplasia: the LeFort II osteotomy. Br. J. Oral Surg. 11 (1973) 77 Wassmund: Lehrbuch der praktischen Chirurgie des Mundes und der Kiefer, Bd. I, Leipzig 1935 Weir, R.F.: On restoring sunken noses. N. Y. Med. J. 65 (1982) 44-9 Wunderer, S.: Die Prognathieoperation mittels frontal gestieltem Maxilla-Fragment. Osterr. Z. Stomatol. 39 (1962) 98
Casson, P. K , P.C. Bonnano, J.M. Converse: The midface degloving
procedure. Plast. Reconstr. Surg. 53 (1974) 102 Cohn Stock, H.: Die chirurgische Immediatregulierung der Kiefer,
speziell der chirurgischen Behandlung der Prognathie. Vjschr. Zahnheilkd. 37 (1921) 320 Converse, J.M., H. H. Shapiro: Treatment of developmental malformations of the jaws. Plast. Reconstr. Surg. 10 (1952) 473 Converse, J.M., S.L. Horowitz, A.J. Valauri, D. Mintendon: The treatment of nasomaxillary hypoplasia. A new pyramidal nasoorbital maxillary osteotomy. Plast. Reconstr. Surg. 45 (1970) 527 Cupar, J.: Die chirurgische Behandlung der Form- und Stellungsverfinderung des Oberkiefers. Osterr. Z. Stomatol. 51 (1954) 565
3 61
Prof. K. Hollmann, M. D., D. M. D. Klinik fiir Kiefer- und Gesichtschirurgie der Universitdt Wien 9 Alser Strafle 4 A-1090 Wien Austria Dr. M. Rasse, M.D. Klinik fiir Kiefer- und Gesichtschirurgie der Universitdt Wien 9 Alser Strafle 4 A-1090 Wien Austria