Abstract
Le Fort I osteotomy is commonly used to rectify craniofacial deformity in orthognathic surgery and it can be used in approaching a cranial base lesion. This technique has not been well documented in craniofacial penetrating trauma. This article describes a case of midface penetrating injury caused by a grinding wheel. A modified Le Fort I osteotomy was used to remove the foreign object. This surgical approach can be safe and effective when removing foreign bodies in the midface. Good access and adequate exposure can be achieved, which facilitate precise foreign body extraction and achieve reasonable cosmetic results.
Case report
A 24-year-old male was referred to the emergency department for management of severe midface trauma. On presentation, a large laceration and fracture of the nasomaxillary complex was noted. The laceration was bleeding profusely and heavily contaminated. The patient remained conscious and was able to obey commands during examination. History revealed that a broken grinding wheel was the cause of the injury and was embedded in the patient’s midface. The grinding wheel caused a 10 cm longitudinal wound, from 1 cm above the supra-orbital rim to the floor of the nose superficially. It penetrated into the left orbit, left maxillary sinus, nasal cavity and the skull base ( Fig. 1 A ). Computer tomography (CT) showed the grinding wheel and confirmed fractures in the nasal bones, left orbital rim, left anterior wall of maxilla and left temporal bone ( Fig. 1 B). The patient was intubated orally as part of emergency airway management and a surgical tracheostomy was performed. During wound exploration and an initial attempt at foreign body mobilization, the grinding wheel was fractured, leaving one segment firmly embedded in the peteryogomaxillary fossa. The remaining fragment was difficult to remove due to poor visibility and access ( Fig. 2 A ).
In order to avoid unnecessary trauma to surrounding vascular structures and for haemorrhage control, Le Fort I osteotomy was chosen to improve surgical access. An intraoral incision, approximately 5 mm above the mucogingival junction, was made from the upper right second premolar to the upper left second premolar. A mucoperiosteal flap was raised to expose the anterior piriform aperture, anterior maxillary wall and the posterior zygomatic crest. A conventional Le Fort I osteotomy was performed on the right side from the piriform aperture to the pterygomaxillary suture. The left Le Fort I osteotomy was modified by placing the piriform plate cut 1 cm above the conventional position ( Fig. 2 B). The nasal mucosa was carefully elevated followed by separation of the anterior nasal spine, nasal septa and vomer. A curved osteotome was used to separate the maxilla from the pterygoid process. Following down-fracture of the maxilla, the foreign body was clearly seen in the left maxillary sinus ( Fig. 2 C and D). The fragment was removed atraumatically. The maxilla was internally fixated with three L-shaped miniplates. The deep fragment of the grinding wheel was 5 cm long and 3 cm wide. A cranial base fracture was ruled out clinically because the posterior and superior wall of the maxillary sinus and middle cranial fossa were intact. The intraoral and facial wounds were closed.
Postoperatively, the patient received prophylactic antibiotics and routine pain control. The patient showed satisfactory aesthetic and functional results after 3.5 months. No further abnormalities of the craniofacial region were noted during follow up ( Fig. 3 ).
