C L I N I C S I NP L A S T I C

S U R G E R Y

Clin Plastic Surg 34 (2007) 575–583

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The LeFort I Transmaxillary Approachto Skull Base TumorsSaswata Roy, MD, MSa,*, Pravin K. Patel, MDb, Tadanori Tomita, MDc,d

- History- Indications- Surgical approach

PreparationThe exposureThe osteotomy

Skull base exposureReconstructionPostoperative management

- Complications- Summary- References

This article discusses the surgical approach usingthe LeFort I and its variations to the extracranialskull base for removal of craniocervical lesionsfrom the sphenoid to the fourth cervical vertebrabetween the carotids. Clival lesions with superiorand inferior extension and nasopharyngeal lesionscan be accessed by this transmaxillary approach(Fig. 1). This exposure provides a good angle ofview for clival lesions that extend superiorly behindthe sella turcica.

History

In 1859, von Langenbeck [1] described the horizon-tal maxillary osteotomy, and in a case report in 1861he described the removal of fibroids of the pterygo-palatine fossa [2]. In 1867, Cheever [3] used the vonLangenbeck approach for removal of a tumor of thenasopharynx in two patients. In one patient whohad an angiofibroma, he performed a unilateral hor-izontal maxillary osteotomy, and in the other pa-tient, who had a histologically undiagnosedtumor, he used a bilateral horizontal osteotomy to

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approach the mass [3,4]. In 1893, Lanz [5] describedan approach developed earlier by Kocher in whichthe upper lip is divided and the maxillary palate issectioned along the midline, thus further extendingthe von Langenbeck exposure (Fig. 2). In 1898Partsch [6] described mobilization of the maxillafor access without the need to divide the lip. In1901, LeFort [7] described the classic lines of frac-tures from which the controlled surgical procedureseventually derived their nomenclature. The key dif-ference from present practice was the pterygoid hor-izontal fracture in LeFort’s original descriptionversus the surgical vertical separation of the ptery-goid plate that was developed years later. In 1907,Pincus described inferior displacement of themaxilla for removal of a nasopharyngeal polyp. Asuccession of surgeons (Wassmund, Axhausen,Steinkamm, Gillies, Rowe, Dingman, Harding, Cu-par, Obwegeser, Hogeman, Willmar, and Pfeiffer)contributed to the development of osteotomy for ac-cess to tumors and for mobilization to correctmalocclusion. This history ahs been describedelegantly by Drommer [8]. By the end of the

a Mayo Clinic Center for Facial Anomalies and Cranial Base Surgery, Division of Otolaryngology, NemoursChildren’s Clinic, Jacksonville, FL, USAb Division of Plastic Surgery, Children’s Memorial Hospital, Chicago, IL, USAc Division of Pediatric Neurosurgery, Children’s Memorial Hospital, Chicago, IL, USAd Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA* Corresponding author.E-mail address: roymd@mac.com (S. Roy).

ts reserved. doi:10.1016/j.cps.2007.05.013

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twentieth century, the LeFort I type osteotomy and itsvariations became the procedure of choice for accessto tumors of the skull base [9–21]. Today, certain le-sions that are intrasellar (pituitary tumors, cranio-pharyngiomas, Rathke’s cysts) and involve theupper third of the clivus (chordomas) are best ap-proached endoscopically. When more extensive ex-posure is needed, however, the transmaxillary

Fig. 1. Dotted red line outlines the region of the na-sopharyngeal and skull base accessible by LeFort Itype transmaxillary approach.

approach gives best access to the clival lesionswith superior and inferior extension and to moder-ately sized nasopharyngeal lesions. This exposureprovides a good angle of view for clival lesionsthat extend superiorly behind the sella turcica.

Box 1: Transfacially accessible skull basetumors and lesions

BenignAngiofibromaChondromaChordomaCraniopharyngiomaFibrous dysplasiaMeningiomaNeurofibromaOsteoblastoma,OsteochondromaMeningoceleAneurysmRheumatoid arthritis

MalignantAcinic cell adenocarcinomaAdenocarcinomaAdenoid cystic carcinomaChondrosarcomaChordomaFibrous histiocytomaOlfactory neuroblastomaRhabdomyosarcomaSarcoma

Fig. 2. As originally depicted by Otto Lanz in 1893. A second attempt was made to resect a ‘spindle-cell’ tumorfrom the posterior nasopharyngeal space in a 17 year old. This time under chloroform and morphine, the lip andleft side of the nose was divided, the maxilla was sectioned with a chisel (A), the tumor removed and the maxillafixed with strong silk sutures. The ‘photogramme’ (B) shown at one month without speech hypernasality, intactswallowing mechanism and breathing through both nasal cavities, without mobility to the frontal teeth. Thearticle emphasized the cosmetic and functional approach compared to previous attempts. Lanz felt that the pa-tient survived because of his youth.

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Fig. 3. Red arrows indicate skull base tumors. (A) Chordoma. (B) Juvenile nasopharyngeal angiofibroma expand-ing the pterygopalatine fossa. (C) Fibrous dysplasia lesion of the cranial base. (D) Esthesioneuroblastoma invad-ing the anterior skull base, frontal lobe, nasal cavity and orbit.

Indications

A variety of lesions can involve the mid-skull base;these are summarized in Box 1 (Fig. 3). The deci-sion to operate is complex and varies with the lesionand the individual patient’s situation. It requires anunderstanding of the natural history of the lesion.The results, as would be expected, are better withbenign lesions than with malignancy. Complete re-section is possible when the lesion is well encapsu-lated, slowly growing, and extradural. When theclival dura is involved, it can be removed withoutsignificant injury to the brain stem. In general theprognosis is good and is related to the extent of re-moval at the initial procedure. Recurrence requiringre-exposure creates a difficult situation. When the tu-mors are malignant, without capsule, and aggres-sive, complete resection is rarely possible. Whenthe lesion is malignant, the decision to intervene is

difficult and frequently is made as a measure oflast resort after failure of radiation. The outcomeof surgical, radiation, and chemotherapeutic treat-ment is beyond the scope of this brief article[18–21]. This article focuses only on the technical as-pects of exposure should that be deemed part of thepatient’s management.

Surgical approach

Preparation

Appropriate studies are obtained to establish the ex-tent of the lesion and surgical approach (Fig. 4).Patients who have angiofibroma should undergoangiography and embolization within 48 hours ofsurgery (Fig. 5).

Before the surgical procedure, the authors estab-lish the correct occlusal relationship with an

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Fig. 4. Juvenile nasopharyngeal angiofibroma. (A) CT image. (B) Endoscopic view. (C) Acrylic skull model for sur-gical planning.

indexing acrylic splint. The splint should be fabri-cated so that it includes a posterior transpalatalbar to prevent collapse, and it should be elevatedoff of the palatal mucosa to allow for postoperativeedema. The possibility of malocclusion is discussedspecifically with the patient. In children, parents are

counseled about dental injury and subsequent den-tal development and the potential for adverse mid-facial development.

The patient is intubated transorally, and the oro-tracheal tube is wired circumferentially to the man-dible. The operative field is infiltrated generously

Fig. 5. Angiogram (A) pre-embolization and (B) postembolization in preparation for surgery for resection of theangiofibroma.

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with lidocaine solution containing epinephrine,specifically in the areas of the incision, the pterygo-maxillary recess, the hard and soft palate, the poste-rior-lateral nasopharyngeal wall, and the nasallining. Obtaining vasoconstriction of the nasal lin-ing is critical. The nasal cavity is packed with cotto-noid soaked in 4% cocaine and 1% phenylephrine.In the preparation, it is important to include thescalp for the possible need of a temporalis flap to re-construct the skull base. Additionally, the nasolacri-mal ducts are cannulated if the transverse maxillaryosteotomy is planned above the inferior turbinate.Pressure-equalizing tubes are placed to counter eu-stachian tube dysfunction, which often occurs withlesions involving the posterior choanae and naso-pharynx. The anesthesiologists are asked to planfor hypotensive anesthesia, and agents such asaprotonin can be used when appropriate to helpminimize bleeding.

The exposure

The exposure required depends on the location andsize of the lesion as well as on the involvement ofsurrounding structures. The anterior cranial basecan be exposed through multiple approaches: trans-maxillary, facial degloving, and transoral. Thechoice of approach or approaches depends on thelesion and the operative field of view necessary forthe resection. Additionally segmentation of themidface can be done in a variety of ways, dependingon the need for exposure and on the blood supplyof the elements. The exposure must be plannedcarefully by a multispecialty team (neurosurgery,otolaryngology, plastic surgery, and oral and maxil-lofacial surgery) to minimize complications fromtechnical miscalculations.

Transoral approachThe transoral approach is best for small midlinechordomas of the lower third of the clivus extend-ing to C3-4 region. After the palate is injectedwith a vasoconstricting agent, the uvula is split inthe midline; this splitting adequately exposes thelower clivus and the floor of the sphenoid sinus.The incision can be extended laterally to 4 to 5mm of the teeth and followed anteriorly past themucoperiosteum of the hard palate. The palatineneurovascular bundle is ligated on the side of great-est exposure. Once the bony palate is exposed, a drillcan be used to remove enough bone to achieve ad-equate exposure of the upper clivus.

Facial degloving (transmaxillary approach)Facial degloving exposes the midfacial skeletonwithout any visible scars. An upper gingivolabialsulcus incision is made well above the attached gin-giva. The maxilla, zygoma, orbital rim,

pterygomaxillary recess, and nasal piriform are ex-posed fully. When needed, intercartilaginous andtransfixion rhinoplasty incisions are combinedwith bilateral sublabial incisions. Soft tissues ofthe nose are elevated from the bony-cartilaginousjunction (Fig. 6).

Planning of the osteotomyThe osteotomy then can be planned depending onthe exposure needed (Fig. 7). The LeFort I can be ex-tended to include the zygoma and orbital rims, tovarying degrees, to access the tumor fully. Addition-ally it can be combined with a midline split of thesoft palate to translocate each side laterally to allowcentral access. A median labiomandibulotomy anda ‘‘mandibular swing,’’ detaching the pharynx fromthe base of the skull and incising the eustachiantube, can be added for further exposure. Thus thisapproach provides access to large anterior cranialbase tumors with lateral infratemporal fossa exten-sions and to tumors of the lower clivus and anteriorcervical spine.

Plate registrationWhen the exposure is complete, the planned LeFortI type and its extended osteotomy is marked witha pencil. Miniplates then are adapted to the medialnasomaxillary and lateral zygomatic-maxillary but-tresses (Fig. 8). The authors prefer to use 2.0-mmminiplates that are easily adaptable to the surfacecontours. The adaptation must be perfect. Thesefour plates then are fixed with a single screw holeon either side of the planned osteotomy. Addition-ally a plate is adapted across the midline at thebase of the anterior nasal spine in preparation fora palatal split. The plates then are removed andlabeled appropriately. In children, the osteotomyshould be placed as superior as possible to minimizeinjury to the developing permanent dentition.

The osteotomy

A LeFort I osteotomy is performed with a reciprocat-ing saw. The lateral nasal wall and septum are

Fig. 6. Extensive exposure with degloving of the mid-face and nose for access).

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Fig. 7. Access to the skull base can be achieved through a LeFort I type osteotomy with or without a palatal split(A) or any one of a number of variations depending on the extent of the lesion and need for exposure (B).

osteotomized with guarded osteotomies, and thepterygomaxillary fissure is separated with a curvedosteotome. The LeFort I fragment then is downfrac-tured with finger pressure and mobilized with dis-impaction forceps (Fig. 9). Further exposure canbe achieved by sectioning the single-piece maxillabetween the central incisors using a combinationof a fine burr, a thin interdental osteotome, and areciprocating saw. Each half of the maxilla then isretracted laterally. The conventional LeFort I typeosteotomy can be varied to extend from above theinferior turbinate to include the zygoma. The lacri-mal duct should be cannulated at the time of

Fig. 8. To restore the anatomy and occlusion, platesare adapted at the medial and lateral buttresses priorto sectioning the maxilla.

surgery to maintain its integrity with the upper levelosteotomy.

To segment the maxilla, a palatal incision is madefrom the central incisors to the junction of the hardand soft palate. The soft palate is divided at the mid-line and the hard palate with a reciprocating saw.The interdental osteotomy is made with a fine os-teotome. Once completed, each half is then translo-cated laterally (Fig. 10) and maintained witha retractor to expose the nasopharyngeal space fortumor resection (Fig. 11) and the skull base(Fig. 12).

Skull base exposure

An incision then is made from the anterior sphe-noid (basisphenoid) to the foramen magnum

Fig. 9. The Segment downfractured, before splittinginto two halves.

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(basiocciput). The pharyngeal mucosa and muscu-lature are retracted laterally to the limits of thehypoglossal foramina and the petrosphenoid fis-sure. Further exposure can be achieved by extendingthe retromolar incision inferiorly. The surgeon thenhas access from the sphenoid roof to the fourth orfifth vertebra, the infratemporal fossa, the regionbounded by the carotid arteries, and the anteriorrim of the foramen magnum. Resection of the clivusand removal of the tumor then can be accom-plished. The dura is incised or excised, dependingon involvement and the tumor removed.

Reconstruction

Once the tumor is resected, the extent of the defectis evaluated. For a sella turcica or sphenoidal or cliv-al midline defects, the dura must be closed water-tight with a fascial graft. The authors prefer to use

Fig. 10. Each half of the maxilla is laterally rotated toallow access to the clival region.

the temporalis fascia. Even if direct closure is possi-ble, they still prefer reinforcing the closure witha fascia as an overlay. Fibrin then is applied, fol-lowed by a bone graft. The bone graft can be takenfrom the posterior maxillary wall. The posteriorpharyngeal mucosa is approximated; however,when the defect is extensive, the temporalis muscleis used. The maxilla then is reassembled. The twohalves are aligned based on the occlusion usingthe prefabricated occlusal acrylic splint with a pala-tal crosspiece to prevent ‘‘yaw.’’ The preregisteredplates are brought back into the operative fieldand are used to secure the maxilla back in its origi-nal position (Fig. 13). When the holes have beenpredrilled, the authors typically use a larger diame-ter ‘‘emergency’’ screw to secure the plates. The oc-clusion should be checked to ensure that themandible comes passively into the splint.

Next the palate is reconstructed. If the soft palateis divided, it is reapproximated along both the nasaland oral layers with repair of the intervening levatormuscle. The mucosa along the edge of the hardpalatal edge is elevated minimally to allowreapproximation.

Postoperative management

The splint should be left intact for 2 to 3 weeks.Routine oral care for the LeFort I osteotomy isused, and the patient initially is kept on a liquiddiet until adequate oral hygiene can be maintained.The diet then is advanced to a mechanically soft dietand then to a regular diet by 6 weeks after surgery.

Complications

Complications can be extensive. Complicationsspecifically related to the transmaxillary exposurewould include traction injury to the infraorbitalnerve, injury to the dental roots or developing toothbuds, lacrimal duct disruption, avascular necrosis ofthe soft-tissue lining, bone, and teeth, postoperative

Fig. 11. Preoperative (A) and postoperative (B) CT showing the nasopharyngeal tumor resected.

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malocclusion, oronasal fistula, and velopharyngealdysfunction [21]. This morbidity must be balancedagainst the natural history of the unresected lesion.

Summary

In its essence the approach to this region by seg-menting and displacing the maxilla remains un-changed since its initial description. Today,however, better instrumentation (along with endo-scopic approaches) and fixation allow an efficientexposure and eliminate the need for external skinincisions (Weber-Fergusson) in a subset of patients.When more extensive exposure is needed, the prin-ciples of disassembling the cranio-orbital region ofTessier for congenital deformities is used.

Fig. 13. Reassembly of the facial skeleton using pre-reg-isteredfixationand a palatalocclusal splint (not shown).

Fig. 12. Access to the clival region through the trans-maxillary approach.

References

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