CPT® Code 21146

1. Indications

The LeFort I osteotomy procedure, as described by CPT® Code 21146, is indicated for patients presenting with specific conditions that necessitate midface reconstruction. These indications include:

• Facial Bone Deformities Patients with congenital or acquired deformities of the facial skeleton that affect the midface region.
• Cosmetic Enhancements Individuals seeking aesthetic improvements in the midface area for better facial symmetry and appearance.
• Ungrafted Unilateral Alveolar Cleft Cases where there is a need to reconstruct the alveolar ridge in patients with a history of cleft lip and palate.

2. Procedure

The procedure for a LeFort I osteotomy involves several detailed steps to ensure successful midface reconstruction. The following outlines the procedural steps:

• Step 1: Preparation and Anesthesia The patient is prepared for surgery, and anesthesia is administered to ensure comfort throughout the procedure.
• Step 2: Incision and Access An incision is made in the buccal sulcus, extending from the first molar on one side to the first molar on the opposite side, allowing access to the maxilla.
• Step 3: Tunneling of Palatal Mucosa The palatal mucosa is carefully tunneled to prevent tearing during the maxillary osteotomy, preserving the integrity of the surrounding tissues.
• Step 4: Exposure of the Nasal Cavity The lateral aspect of the nasal cavity is exposed, and the nasal mucosa is elevated to facilitate the surgical procedure.
• Step 5: Marking Bone Cuts Using preoperative measurements, the physician marks the planned bone cuts in the maxilla to guide the osteotomy.
• Step 6: Cutting the Maxilla A bur is used to cut the lateral wall of the maxilla, followed by the placement of a thin osteotome to apply gentle pressure and fracture the medial and posterior walls.
• Step 7: Separation of the Pterygoid Plate The pterygoid plate is separated from the maxilla using a pterygoid osteotome, ensuring careful handling to avoid damage.
• Step 8: Fracturing the Anterior Nasal Spine The anterior nasal spine is fractured, and the gouge or osteotome is angled towards the floor of the nose to facilitate further separation.
• Step 9: Downfracturing the Maxilla The maxilla is downfractured using thumb pressure and mobilized with the pterygoid osteotome, allowing for repositioning.
• Step 10: Bilateral Anterior Osteotomy An anterior osteotomy is performed at the premolar region bilaterally, followed by trimming of the nasal septal cartilage, posterior wall, and palatal bone.
• Step 11: Repositioning and Stabilization The maxilla is repositioned and stabilized with wires, ensuring that the desired alignment is achieved.
• Step 12: Bone Graft Harvesting Bone grafts are harvested from the iliac crest or another site, with a skin incision made over the iliac crest to access the bone surface.
• Step 13: Configuration of Bone Grafts The harvested bone is configured to the desired size and shape, or morcellized and placed in the defect as needed.
• Step 14: Application of Intermaxillary Fixation An intermaxillary fixation device is applied to maintain the position of the maxilla during healing.
• Step 15: Closure of Incisions The buccal incision is closed, completing the surgical procedure.

3. Post-Procedure

After the completion of the LeFort I osteotomy, patients are typically monitored for any immediate complications. Post-procedure care may include pain management, instructions for oral hygiene, and dietary modifications to accommodate healing. Patients are advised to avoid strenuous activities and follow-up appointments are scheduled to assess healing and the positioning of the maxilla. The expected recovery period may vary, and patients should be informed about signs of potential complications that require immediate medical attention.