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575

CLINICS IN
PLASTIC
SURGERY
Clin Plastic Surg 34 (2007) 575583

The LeFort I Transmaxillary Approach


to Skull Base Tumors
Saswata Roy, MD, MSa,*, Pravin K. Patel, MDb, Tadanori Tomita, MDc,d
-

History
Indications
Surgical approach
Preparation
The exposure
The osteotomy

This article discusses the surgical approach using


the LeFort I and its variations to the extracranial
skull base for removal of craniocervical lesions
from the sphenoid to the fourth cervical vertebra
between the carotids. Clival lesions with superior
and inferior extension and nasopharyngeal lesions
can be accessed by this transmaxillary approach
(Fig. 1). This exposure provides a good angle of
view for clival lesions that extend superiorly behind
the sella turcica.

History
In 1859, von Langenbeck [1] described the horizontal maxillary osteotomy, and in a case report in 1861
he described the removal of fibroids of the pterygopalatine fossa [2]. In 1867, Cheever [3] used the von
Langenbeck approach for removal of a tumor of the
nasopharynx in two patients. In one patient who
had an angiofibroma, he performed a unilateral horizontal maxillary osteotomy, and in the other patient, who had a histologically undiagnosed
tumor, he used a bilateral horizontal osteotomy to

Skull base exposure


Reconstruction
Postoperative management
Complications
Summary
References

approach the mass [3,4]. In 1893, Lanz [5] described


an approach developed earlier by Kocher in which
the upper lip is divided and the maxillary palate is
sectioned along the midline, thus further extending
the von Langenbeck exposure (Fig. 2). In 1898
Partsch [6] described mobilization of the maxilla
for access without the need to divide the lip. In
1901, LeFort [7] described the classic lines of fractures from which the controlled surgical procedures
eventually derived their nomenclature. The key difference from present practice was the pterygoid horizontal fracture in LeForts original description
versus the surgical vertical separation of the pterygoid plate that was developed years later. In 1907,
Pincus described inferior displacement of the
maxilla for removal of a nasopharyngeal polyp. A
succession of surgeons (Wassmund, Axhausen,
Steinkamm, Gillies, Rowe, Dingman, Harding, Cupar, Obwegeser, Hogeman, Willmar, and Pfeiffer)
contributed to the development of osteotomy for access to tumors and for mobilization to correct
malocclusion. This history ahs been described
elegantly by Drommer [8]. By the end of the

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

0094-1298/07/$ see front matter 2007 Elsevier Inc. All rights reserved.

plasticsurgery.theclinics.com

doi:10.1016/j.cps.2007.05.013

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Roy et al

Box 1: Transfacially accessible skull base


tumors and lesions
Benign
Angiofibroma
Chondroma
Chordoma
Craniopharyngioma
Fibrous dysplasia
Meningioma
Neurofibroma
Osteoblastoma,
Osteochondroma
Meningocele
Aneurysm
Rheumatoid arthritis

Fig. 1. Dotted red line outlines the region of the nasopharyngeal and skull base accessible by LeFort I
type transmaxillary approach.

twentieth century, the LeFort I type osteotomy and its


variations became the procedure of choice for access
to tumors of the skull base [921]. Today, certain lesions that are intrasellar (pituitary tumors, craniopharyngiomas, Rathkes cysts) and involve the
upper third of the clivus (chordomas) are best approached endoscopically. When more extensive exposure is needed, however, the transmaxillary

Malignant
Acinic cell adenocarcinoma
Adenocarcinoma
Adenoid cystic carcinoma
Chondrosarcoma
Chordoma
Fibrous histiocytoma
Olfactory neuroblastoma
Rhabdomyosarcoma
Sarcoma

approach gives best access to the clival lesions


with superior and inferior extension and to moderately sized nasopharyngeal lesions. This exposure
provides a good angle of view for clival lesions
that extend superiorly behind the sella turcica.

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

The Lefort I Transmaxillary Approach

Fig. 3. Red arrows indicate skull base tumors. (A) Chordoma. (B) Juvenile nasopharyngeal angiofibroma expanding the pterygopalatine fossa. (C) Fibrous dysplasia lesion of the cranial base. (D) Esthesioneuroblastoma invading 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 decision to operate is complex and varies with the lesion
and the individual patients situation. It requires an
understanding of the natural history of the lesion.
The results, as would be expected, are better with
benign lesions than with malignancy. Complete resection is possible when the lesion is well encapsulated, slowly growing, and extradural. When the
clival dura is involved, it can be removed without
significant injury to the brain stem. In general the
prognosis is good and is related to the extent of removal at the initial procedure. Recurrence requiring
re-exposure creates a difficult situation. When the tumors are malignant, without capsule, and aggressive, complete resection is rarely possible. When
the lesion is malignant, the decision to intervene is

difficult and frequently is made as a measure of


last resort after failure of radiation. The outcome
of surgical, radiation, and chemotherapeutic treatment is beyond the scope of this brief article
[1821]. This article focuses only on the technical aspects of exposure should that be deemed part of the
patients management.

Surgical approach
Preparation
Appropriate studies are obtained to establish the extent of the lesion and surgical approach (Fig. 4).
Patients who have angiofibroma should undergo
angiography and embolization within 48 hours of
surgery (Fig. 5).
Before the surgical procedure, the authors establish 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 surgical planning.

indexing acrylic splint. The splint should be fabricated so that it includes a posterior transpalatal
bar to prevent collapse, and it should be elevated
off of the palatal mucosa to allow for postoperative
edema. The possibility of malocclusion is discussed
specifically with the patient. In children, parents are

counseled about dental injury and subsequent dental development and the potential for adverse midfacial development.
The patient is intubated transorally, and the orotracheal tube is wired circumferentially to the mandible. The operative field is infiltrated generously

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

The Lefort I Transmaxillary Approach

with lidocaine solution containing epinephrine,


specifically in the areas of the incision, the pterygomaxillary recess, the hard and soft palate, the posterior-lateral nasopharyngeal wall, and the nasal
lining. Obtaining vasoconstriction of the nasal lining is critical. The nasal cavity is packed with cottonoid soaked in 4% cocaine and 1% phenylephrine.
In the preparation, it is important to include the
scalp for the possible need of a temporalis flap to reconstruct the skull base. Additionally, the nasolacrimal ducts are cannulated if the transverse maxillary
osteotomy is planned above the inferior turbinate.
Pressure-equalizing tubes are placed to counter eustachian tube dysfunction, which often occurs with
lesions involving the posterior choanae and nasopharynx. The anesthesiologists are asked to plan
for hypotensive anesthesia, and agents such as
aprotonin can be used when appropriate to help
minimize bleeding.

The exposure
The exposure required depends on the location and
size of the lesion as well as on the involvement of
surrounding structures. The anterior cranial base
can be exposed through multiple approaches: transmaxillary, facial degloving, and transoral. The
choice of approach or approaches depends on the
lesion and the operative field of view necessary for
the resection. Additionally segmentation of the
midface can be done in a variety of ways, depending
on the need for exposure and on the blood supply
of the elements. The exposure must be planned
carefully by a multispecialty team (neurosurgery,
otolaryngology, plastic surgery, and oral and maxillofacial surgery) to minimize complications from
technical miscalculations.
Transoral approach
The transoral approach is best for small midline
chordomas of the lower third of the clivus extending to C3-4 region. After the palate is injected
with a vasoconstricting agent, the uvula is split in
the midline; this splitting adequately exposes the
lower clivus and the floor of the sphenoid sinus.
The incision can be extended laterally to 4 to 5
mm of the teeth and followed anteriorly past the
mucoperiosteum of the hard palate. The palatine
neurovascular bundle is ligated on the side of greatest exposure. Once the bony palate is exposed, a drill
can be used to remove enough bone to achieve adequate exposure of the upper clivus.
Facial degloving (transmaxillary approach)
Facial degloving exposes the midfacial skeleton
without any visible scars. An upper gingivolabial
sulcus incision is made well above the attached gingiva. The maxilla, zygoma, orbital rim,

pterygomaxillary recess, and nasal piriform are exposed fully. When needed, intercartilaginous and
transfixion rhinoplasty incisions are combined
with bilateral sublabial incisions. Soft tissues of
the nose are elevated from the bony-cartilaginous
junction (Fig. 6).
Planning of the osteotomy
The osteotomy then can be planned depending on
the exposure needed (Fig. 7). The LeFort I can be extended to include the zygoma and orbital rims, to
varying degrees, to access the tumor fully. Additionally it can be combined with a midline split of the
soft palate to translocate each side laterally to allow
central access. A median labiomandibulotomy and
a mandibular swing, detaching the pharynx from
the base of the skull and incising the eustachian
tube, can be added for further exposure. Thus this
approach provides access to large anterior cranial
base tumors with lateral infratemporal fossa extensions and to tumors of the lower clivus and anterior
cervical spine.
Plate registration
When the exposure is complete, the planned LeFort
I type and its extended osteotomy is marked with
a pencil. Miniplates then are adapted to the medial
nasomaxillary and lateral zygomatic-maxillary buttresses (Fig. 8). The authors prefer to use 2.0-mm
miniplates that are easily adaptable to the surface
contours. The adaptation must be perfect. These
four plates then are fixed with a single screw hole
on either side of the planned osteotomy. Additionally a plate is adapted across the midline at the
base of the anterior nasal spine in preparation for
a palatal split. The plates then are removed and
labeled appropriately. In children, the osteotomy
should be placed as superior as possible to minimize
injury to the developing permanent dentition.

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

Fig. 6. Extensive exposure with degloving of the midface 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 the


pterygomaxillary fissure is separated with a curved
osteotome. The LeFort I fragment then is downfractured with finger pressure and mobilized with disimpaction forceps (Fig. 9). Further exposure can
be achieved by sectioning the single-piece maxilla
between the central incisors using a combination
of a fine burr, a thin interdental osteotome, and a
reciprocating saw. Each half of the maxilla then is
retracted laterally. The conventional LeFort I type
osteotomy can be varied to extend from above the
inferior turbinate to include the zygoma. The lacrimal duct should be cannulated at the time of

surgery to maintain its integrity with the upper level


osteotomy.
To segment the maxilla, a palatal incision is made
from the central incisors to the junction of the hard
and soft palate. The soft palate is divided at the midline and the hard palate with a reciprocating saw.
The interdental osteotomy is made with a fine osteotome. Once completed, each half is then translocated laterally (Fig. 10) and maintained with
a retractor to expose the nasopharyngeal space for
tumor resection (Fig. 11) and the skull base
(Fig. 12).

Skull base exposure


An incision then is made from the anterior sphenoid (basisphenoid) to the foramen magnum

Fig. 8. To restore the anatomy and occlusion, plates


are adapted at the medial and lateral buttresses prior
to sectioning the maxilla.

Fig. 9. The Segment downfractured, before splitting


into two halves.

The Lefort I Transmaxillary Approach

Fig. 10. Each half of the maxilla is laterally rotated to


allow access to the clival region.

(basiocciput). The pharyngeal mucosa and musculature are retracted laterally to the limits of the
hypoglossal foramina and the petrosphenoid fissure. Further exposure can be achieved by extending
the retromolar incision inferiorly. The surgeon then
has access from the sphenoid roof to the fourth or
fifth vertebra, the infratemporal fossa, the region
bounded by the carotid arteries, and the anterior
rim of the foramen magnum. Resection of the clivus
and removal of the tumor then can be accomplished. The dura is incised or excised, depending
on involvement and the tumor removed.

Reconstruction
Once the tumor is resected, the extent of the defect
is evaluated. For a sella turcica or sphenoidal or clival midline defects, the dura must be closed watertight with a fascial graft. The authors prefer to use

the temporalis fascia. Even if direct closure is possible, they still prefer reinforcing the closure with
a fascia as an overlay. Fibrin then is applied, followed by a bone graft. The bone graft can be taken
from the posterior maxillary wall. The posterior
pharyngeal mucosa is approximated; however,
when the defect is extensive, the temporalis muscle
is used. The maxilla then is reassembled. The two
halves are aligned based on the occlusion using
the prefabricated occlusal acrylic splint with a palatal crosspiece to prevent yaw. The preregistered
plates are brought back into the operative field
and are used to secure the maxilla back in its original position (Fig. 13). When the holes have been
predrilled, the authors typically use a larger diameter emergency screw to secure the plates. The occlusion should be checked to ensure that the
mandible comes passively into the splint.
Next the palate is reconstructed. If the soft palate
is divided, it is reapproximated along both the nasal
and oral layers with repair of the intervening levator
muscle. The mucosa along the edge of the hard
palatal edge is elevated minimally to allow
reapproximation.

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

Complications
Complications can be extensive. Complications
specifically related to the transmaxillary exposure
would include traction injury to the infraorbital
nerve, injury to the dental roots or developing tooth
buds, lacrimal duct disruption, avascular necrosis of
the soft-tissue lining, bone, and teeth, postoperative

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

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References

Fig. 12. Access to the clival region through the transmaxillary approach.

Fig. 13. Reassembly of the facial skeleton using pre-registered fixation and a palatal occlusal splint (not shown).

malocclusion, oronasal fistula, and velopharyngeal


dysfunction [21]. This morbidity must be balanced
against the natural history of the unresected lesion.

Summary
In its essence the approach to this region by segmenting and displacing the maxilla remains unchanged since its initial description. Today,
however, better instrumentation (along with endoscopic approaches) and fixation allow an efficient
exposure and eliminate the need for external skin
incisions (Weber-Fergusson) in a subset of patients.
When more extensive exposure is needed, the principles of disassembling the cranio-orbital region of
Tessier for congenital deformities is used.

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The Lefort I Transmaxillary Approach

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