Surgeon(s): ***

‍Assistant Surgeon(s):  ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts:  Correct x2

‍Indications: ​***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

Attention was then drawn to the patient's maxilla. 10cc of 1% lidocaine with 1:100,000 epinephrine was injected.  An incision was made approximately 5 mm from the mucogingival junction using a #15 blade.  Incision was carried out through mucosa and then down to bone.  Using a #9 periosteal elevator the maxilla was then stripped in a subperiosteal fashion to expose the entire piriform rims and zygomatic buttresses.  Next a Woodson elevator was used to dissect the nasal mucosa and release the nasal septum from the maxilla. A #9 periosteal elevator was placed behind the piriform rim to protect the nasal mucosa.  Toe in retractors were then used to expose the posterior lateral maxillary wall.  A reciprocating saw was then used to complete a Lefort 1 osteotomy bilaterally. The Woodson elevator was then used to dissect and retract the attached gingiva between the maxillary canine and lateral incisor teeth.  Using a sagittal saw, interdental cuts were made between these teeth connecting to the Lefort osteotomy. Next acute curved osteotomes were used to fracture the pterygoid plates and a double guarded osteotome was used to separate the septum from the maxilla.  Finally, a single guarded osteotome was used to separate the piriform buttress and the maxilla was downfractured.  Both descending palatine arteries were quickly identified and hemostasis was achieved with bovie electrocautery.  A combination of periosteal elevator and rongeurs were used to extract teeth #1, 16 from above with the maxilla downfractured.  All posterior bony interferences were removed with a reciprocating saw and next the interdental cuts were continued over the entire posterior bony maxilla using a reciprocating saw, placing the osteotomies approximately 1/3 of the distance off of the medial wall of the maxillary sinus. Once completed the maxilla was gently segmented using a straight osteotome. The inferior turbinates were then removed with a Kelley clamp and scissors. The inferior nasal septum was then trimmed with scissors.

Next, a prefabricated final occlusal stent was wired to the patient's maxilla using 26 gauge J-wires and wire loops. The segmental osteotomies were then bone grafted using autogenous graft from the mandibular osteotomy. Next, the patient was placed into maxillomandibular fixation again using 26 gauge wires and elastics. The maxilla was adjusted to allow for excellent bony contact. The maxilla was fixated using KLS L-plates at the nasomaxillary buttresses using 5mm monocortical screws and then L-plates at the zygomaticomaxillary buttresses.

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The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

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