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Le Fort 3 Midface Distraction Advancement at North Austin Campus

Conditions

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Le Fort 3 advancement is a surgery that brings the entire upper jaw forward below the eyebrow level. This includes the cheekbones, nose, and upper jaw and teeth. It is also known as “midface advancement” and is a type of Le Fort osteotomy In North Austin we use this powerful surgery in the treatment of syndromic craniosynostosis such as Apert syndrome, Crouzon syndrome, and Pfeiffer syndrome. The surgery not only changes the profile of a patient whose upper jaw has not grown as much as the lower jaw, it also improves breathing, bite and protection of the eyes.

Our surgeons have performed one of the largest series of successful Le Fort 3 surgeries in the country and are recognized internationally for this technique. For certain conditions we will recommend a segmental Le Fort 3 surgery known as a LF2ZR. One of our surgeons first described this specific technique for the treatment of Apert syndrome, and centers around the world now perform LF2ZR.

  • We use a technique known as “distraction osteogenesis” to move the Le Fort 3 bone forward.
  • Using distraction osteogenesis allows us to move the Le Fort 3 bone forward greater distances and avoids the need for bone grafts or plates and screws.
  • This is a full-day operation
  • Your surgeon will perform the Le Fort 3 osteotomy through a coronal incision to prepare the face for movement after surgery.
  • At the end of the surgery, your surgeon attaches a “halo” distractor to your child’s skull and it attaches to a custom splint made by our orthodontist. In some cases we will apply the distractor a day or two after the Le Fort 3 surgery during a brief operation. 
  • Your child will remain in the ICU under sedation for the first 2-3 days after surgery. If they do not have a tracheostomy, we will usually keep their breathing tube in place until their swelling starts to go down
  • While your child is recovering at home, a parent or other caregiver turns little screw posts attached to the splint twice a day for 2 to 3 weeks. This brings the upper jaw and cheekbones forward at a rate of 1-2 mm a day. 
  • After turning is complete and once everything is in the right place, the distractor stays on for 6 to 8 more weeks. This helps the bone heal in its new position. New bone will grow and fill in the gaps and stabilize the face in its new position.
  • After healing, the distractor is removed in a short operation. Your child does not need to stay the night and goes home after the surgery. Pain medicine is usually not needed after removal of the distractor. 
  • The average age of patients who our surgeons have treated with Le Fort 3 surgery are 8 years old. If your child has severe airway obstruction and needs the surgery to remove or avoid placement of a tracheostomy, we have done the surgery as young as 3 years of age. 
  • If your child does not have any significant airway obstruction or can be managed with a positive pressure breathing device (CPAP), we usually recommend waiting until at least 7 years of age before having the surgery, but the surgery can be done at any time after that with the same results.
  • The younger a child is at the time of the Le Fort 3 advancement, the more we will need to advance their face. 
  • Before surgery, all children undergoing midface surgery will have their front teeth far behind their bottom teeth. After Le Fort 3 advancement we will intentionally over-correct this difference so that the front teeth are ¼ to ½ inches in front of the lower teeth. We do this to plan for continued growth of the lower jaw to catch up.
  • Almost all patients who have a Le Fort 3 advancement when they are younger will still require corrective orthognathic (jaw) surgery to finalize their bite after orthodontic treatment.
  • Is a blood transfusion needed during the surgery?
    • Yes, a blood transfusion is required to keep your child’s blood levels safe during the surgery. Blood work will be drawn before surgery to prepare and you will sign a separate consent form.
  • What should I expect during the time in hospital?
    • After surgery your child will be taken to the CT scanner for a post-surgery image, and then taken to the Pediatric Intensive Care Unit (PICU). We will reunite you with your child as soon as possible after the PICU team has assumed care. It can be emotional to see your child for the first time in the PICU since they will have the distraction device in place and a number of tubes to help with giving fluids and nutrition. They will be kept very sedated for 24 hours to keep them comfortable. Swelling of the face will be the most 24 hours after surgery and will last 2-3 days before the swelling quickly goes down. Your child will be transferred to the hospital inpatient ward after 2-3 days in the PICU. Total length of time in the hospital is 5 to 7 days. You will be able to stay with your child throughout the hospital say. We recommend you take time to rest outside of the hospital while your child is in the PICU, or alternate with another caregiver. It is important you are not sleep-deprived when they go to the ward since you will be more involved in their care after that and will start to learn to turn the distraction devices. 
  • How do you control my child’s pain after the procedure?
    • During the time in the PICU, your child will receive pain medicine through their intravenous lines and will be kept sedated for their comfort. After 24 hours they will be allowed to be more awake and we will start to transition their pain medications to acetaminophen (Tylenol), ibuprofen, and a prescription pain medicine called oxycodone. These are the three medications your child will continue after they are discharged from hospital, but the oxycodone is only needed for a few days. Acetaminophen and ibuprofen is given as needed during the turning phase of distraction, but is rarely needed during the healing phase.
  • How difficult is it to turn the devices?
    • Parents have reported that they found turning the devices a lot easier than they had anticipated. The small screwdrivers used to turn the device have arrows to show the director of turning and are easy use after a few tries. We will provide you with a small calendar to record each turn that is done in the morning and again in the evening.
  • Does turning the device hurt my child?
    • Your child should not feel pain when you turn the devices. The devices move the face very slowly at a rate of 1 to 2 mm per day. Early in the turning phase the screwdrivers are easy to turn, and your child usually does not feel any movement. Towards the end of the 2-3 week turning phase the muscles can start to stretch, and your child may feel an ache after turning that is like the feeling after having orthodontic braces adjusted. This is usually managed with over-the-counter acetaminophen (Tylenol) and ibuprofen.
  • What will my child feel like during the turning phase?
    • Although families usually mentally prepare themselves for the surgery and hospital stay, we will also help you prepare for the turning phase. Even though the turning of the devices does not cause pain, your child’s face is slowly and steadily moving forward over weeks, and therefore it does not have time to fully heal until the turning phase is complete. Families who have undergone Le Fort 3 procedure describe the turning phase as tiring. Your child will need your emotional support during this phase and encouragement that what they are feeling is temporary and that they will feel better after the turning is over. We have child life and child psychology teams available to you during this time if needed. Turning of the devices often causes drooling and extra saliva production. This stops quickly after the healing phase begins.
  • If we don’t live within easy driving distance from the hospital, how long will we need to stay in Austin?
    • After your child is discharged from the hospital, we will need to see them in our clinic once a week during the entire turning phase. During these visits we will take an x-ray to track the movement of your child’s face and the change in their airway shadow. Your surgeon may need to make some minor adjustments to the device during this period. These are done in clinic and do not cause any pain. We do not need to see your child in clinic during the healing phase after turning is complete, but will keep in touch through messaging and video visits. Families who live out-of-state will usually arrange to have temporary lodging in Austin for 3 to 4 weeks to complete the surgery and turning phase. At that point your child can return home either on the plane or by car.
  • What will my child feel like during the 6 to 8 week healing phase?
    • During the healing phase at home, your child will want return to many of their pre-surgery activities. Since the halo device is no longer being turned, their bones start to heal quickly, and their face quickly starts to feel more normal to them. They just need to avoid activities that would put their halo device at risk, such as ball games, energetic play, or running. If your child was experiencing drooling during the turning phase, it usually quickly stops during the healing phase.