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.

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***BSSO

Teeth were brushed with Betadine and rinsed with saline irrigation. A K-wire was placed at the nasofrontal junction and the reference vertical height to maxillary incisor bracket was measured. Occlusal interferences were removed with a round diamond bur. Next, attention was turned to the patient's right mandibular vestibule. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the inferior border of the mandible. Dissection then proceeded medially with a #9 elevator to expose the medial lingual surface of the mandibular ramus. The inferior alveolar nerve was identified and protected with a Seldin retractor. Next a reciprocating saw was used to make the sagittal osteotomy. Following this, wooden handle osteotomes were used to mobilize the proximal and distal segments of the mandible taking care to ensure mobility of the inferior border as well as the lingual surface. The sagittal split was completed without complication and the inferior alveolar nerve was dissected out of the proximal segment.  A periosteal elevator was used to extract tooth #32 from inside the split – rongeurs were used to remove the dental follicle.  The inferior border of the proximal/distal segment of the mandible was then stripped free of its soft tissue attachments. The surgical site was then copiously irrigated and packed off with moist gauze. Attention was then turned to the patient's left mandibular vestibule where an identical type procedure was carried out.

Again, a #15 blade was used to make a BSS type incision. Incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator dissection carried inferiorly and posteriorly to expose the entire inferior border of the mandible. Dissection then proceeded medially with a #9 elevator to expose the medial lingual surface of the mandibular ramus. The inferior alveolar nerve was identified and protected with a Seldin retractor. Next a reciprocating saw was used to make the sagittal osteotomy. Following this, wooden handle osteotomes were used to mobilize the proximal and distal segments of the mandible taking care to ensure mobility of the inferior border as well as the lingual surface. The sagittal split was completed without complication and the inferior alveolar nerve was identified to be in the distal segment. A periosteal elevator was used to extract tooth #17 from inside the split – rongeurs were used to remove the dental follicle. The inferior border of the proximal/distal segment of the mandible was then stripped free of its soft tissue attachments The surgical site was then copiously irrigated and packed off with moist gauze.

Next using a prefabricated intermediate occlusal stent the patient was placed in maxillomandibular fixation using 26-gauge wire loops and J-wires. Afterwards, the proximal and distal segments were noted to be free of interference and the mandibular condyles were noted to be easily seated in their most superior and posterior position, taking care not to seat them with too much pressure. Both sides were then accessed with a trocar system, first making a small nick incision on the cheek and then inserting a trocar through to the intraoral surgical site. Finally, both proximal distal segments were fixated using 3x KLS bicortical screws at the superior border.  The patient was then released from maxillomandibular fixation.  It was noted that the patient was biting easily into the splint without any interferences or slides and then without the splint in place the occlusion was noted to be stable and reproducible without slides or interferences. The midlines were noted to be on at this point.

***Inverted L

Teeth were brushed with Betadine and rinsed with saline irrigation. A K-wire was placed at the nasofrontal junction and the reference vertical height to maxillary incisor bracket was measured. Occlusal interferences were removed with a round diamond bur. Next, attention was turned to the patient's right mandibular vestibule. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the entire inferior and posterior border of the mandible. Next, attention was turned to extract the fully bony impacted tooth #32. Using a 702 fissure bur, bone was removed and the tooth was sectioned and subsequently delivered with elevators and forceps. The entire extraction socket was copiously irrigated with sterile saline. Dissection then continued to proceed medially with a #9 elevator and a notched toe-in retracted was placed on the coronoid process. Next a baur retractors was placed at the inferior border. A prefabricated drill guide was adapted over the angle of the mandible.  This was then accessed with a trocar system, first making a nick incision with a #15 blade and then placing the trocar with a cheek retractor to aid in visualization. Proximally and distal screw holes were then pre-drilled.  Next, the horizontal cut of a mandibular inverted L osteotomy was made using a reciprocating saw.  Then, the vertical cut was made with an oscillating saw, leaving a small area of mandible intact. Once finished, the drill guide was removed and a pre-bent KLS reconstruction plate was placed at the angle of the mandible.  The proximal portion was fixated bicortical screws.  Following this the vertical osteotomy was completed with the oscillating saw.  The surgical site was then copiously irrigated and packed off with moist gauze.

Attention was then directed at the left side. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the entire inferior and posterior border of the mandible. Next, attention was turned to extract the fully bony impacted tooth #17. Using a 702 fissure bur, bone was removed and the tooth was sectioned and subsequently delivered with elevators and forceps. The entire extraction socket was copiously irrigated with sterile saline. Dissection then continued to proceed medially with a #9 elevator and a notched toe-in retracted was placed on the coronoid process. Next a baur retractors was placed at the inferior border. A prefabricated drill guide was adapted over the angle of the mandible.  This was then accessed with a trocar system, first making a nick incision with a #15 blade and then placing the trocar with a cheek retractor to aid in visualization. Proximally and distal screw holes were then pre-drilled.  Next, the horizontal cut of a mandibular inverted L osteotomy was made using a reciprocating saw.  Then, the vertical cut was made with an oscillating saw, leaving a small area of mandible intact. Once finished, the drill guide was removed and a pre-bent KLS reconstruction plate was placed at the angle of the mandible.  The proximal portion was fixated using bicortical screws.  Following this the vertical osteotomy was completed with the oscillating saw.  The surgical site was then copiously irrigated and packed off with moist gauze.

Next using a prefabricated intermediate occlusal stent the patient was placed elastic rubber bands. The proximal and distal segments were noted to be free of interference and the mandibular condyles were noted to be easily seated in their most superior and posterior position, taking care not to seat them with too much pressure. The remaining screws were placed in the distal segments of both sides of the custom plates. The patient was then released from maxillomandibular fixation. It was noted that the patient was biting easily into the splint without any interferences or slides.

***Single piece Lefort

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. 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 rongeurs and the reciprocating saw. 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 loop. 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.

***Segmental Lefort

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.

***Genioplasty

Attention then turned to the patient's chin. Approximately 10 cc of 2% lidocaine with 1:100k epinephrine was infiltrated into his anterior mandibular buccal vestibule. Next, the lip was stretched to reveal the underlying fibers of the mental nerve bilaterally. A #15 blade was used to make a genioplasty type incision between these fibers. The incision carried through mucosa and the mentalis muscle. Once the mentalis muscle was excised the dissection turned towards bone, using metzenbaum scissors to dissect downwards. Once bone was reached the periosteum was incised and a #9 periosteal elevator was used to develop a subperiosteal plane from posterior to each mental foramen and then to the inferior border of the mandible.The midline was marked with a reciprocating saw and the saw was used to make a horizontal osteotomy, taking care to place the osteotomy 5 mm inferior to each mental foramen. The chin segment was positioned as planned based on the presurgical planning utilizing 26g wire to position the segment anteriorly.  3 position screws were used to fixate the chin segment.

First, 3-0 PDS was used to position the cartilaginous septum in the midline by fixating it to the ANS.  An alar cinch was also placed with 3-0 PDS. Attention was then turned to closure, starting with a V to Y closure of the maxilla and then closing the incision using 3-0 chromic gut suture in a horizontal mattress fashion. The mentalis muscle was then resuspended with 3-0 vicryl suture in an interrupted fashion. The genioplasty incision was closed with a 3-0 chromic gut suture in running fashion. The remaining intraoral sites were closed with 3-0 chromic gut in a running fashion. Trocar sites were closed with 5-0 nylon suture. The patient's throat pack was then removed from the posterior oropharynx and an oral gastric tube was passed to empty the stomach of its contents. Tegaderms were then removed from the eyes and BSS placed in both of them to wash them free of the lacrilube.  The patient was wiped down with a moist lap and then turned over to the anesthesia team where the patient was awakened from general anesthesia and extubated without complication and returned to the PACU for recovery in stable condition.

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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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