CPT® Code 21150

1. Indications

The Le Fort II osteotomy procedure, represented by CPT® Code 21150, is indicated for patients presenting with specific facial bone deformities. The following conditions may warrant this surgical intervention:

• Treacher-Collins Syndrome A genetic disorder leading to underdevelopment of facial bones, particularly affecting the midface region.
• Severe midfacial hypoplasia A condition characterized by inadequate development of the midface, which can result in functional and aesthetic issues.
• Facial trauma Injuries that result in significant displacement or fracture of midfacial structures may necessitate reconstruction.
• Congenital facial deformities Other congenital conditions that affect the structure and function of the midface may also be indications for this procedure.

2. Procedure

The Le Fort II osteotomy procedure involves several critical steps to ensure successful reconstruction of the midface. The process begins with the extraction of premolars and last molars as needed to facilitate access to the surgical site.

• Step 1: An incision is made in the buccal sulcus, extending from the first molar on one side to the first molar on the opposite side. This incision allows for access to the underlying facial structures.
• Step 2: The lateral aspect of the nasal cavity is exposed, and the nasal mucosa is elevated to provide a clear view of the surgical area. The exposure is extensive, reaching from the piriform aperture anteriorly to the pterygomaxillary-palatine fissure posteriorly, and from the infraorbital osseous rim superiorly to the nasolacrimal duct medially and the lateral orbital rim laterally.
• Step 3: Using preoperative measurements, the surgeon marks the planned bone cuts on the facial bones. This step is crucial for ensuring accurate repositioning during the procedure.
• Step 4: The periorbita is detached from the anterior orbital rim, allowing for further access to the orbital structures.
• Step 5: Medial and lateral orbital osteotomies are performed on one side of the face. The lateral vertical osteotomy extends through the maxillary buttress, followed by a horizontal cut made to the pterygomaxillary-palatine fissure.
• Step 6: The anterior orbital floor osteotomy is completed, extending to the infraorbital nerve, utilizing the previously created medial and lateral orbital rim cuts.
• Step 7: The procedure is then mirrored on the opposite side of the face, ensuring symmetry in the reconstruction.
• Step 8: The bones are downfractured, ensuring that all segments are completely mobilized for repositioning.
• Step 9: The repositioned bones are checked for proper alignment, and measurements are verified to confirm that the desired repositioning has been achieved. The lip position and occlusion are also assessed to ensure functional outcomes.
• Step 10: If bone allograft is required, it is harvested from the iliac crest. A skin incision is made over the iliac crest, and the muscle is stripped to expose the bone surface. Cortical and/or cancellous bone is harvested, configured to the desired size and shape, and placed in the defect as needed.
• Step 11: The bones and any bone grafts are secured in place using wires, miniplates, or screws. An intermaxillary fixation device is then applied to maintain the position of the bones during the healing process.
• Step 12: Finally, the buccal incision is closed, completing the surgical procedure.

3. Post-Procedure

Post-procedure care following a Le Fort II osteotomy is critical for optimal recovery. Patients are typically monitored for any complications, and pain management strategies are implemented. Swelling and bruising are common, and patients may be advised to apply ice packs to the affected areas. A soft diet is recommended to minimize discomfort while eating, and patients should avoid strenuous activities during the initial recovery phase. Follow-up appointments are essential to assess healing, check the alignment of the facial structures, and remove any sutures if necessary. The overall recovery time may vary depending on the individual’s health status and adherence to post-operative care instructions.