CPT® Code 21151

1. Indications

The LeFort II osteotomy procedure, as described by CPT® Code 21151, is indicated for patients presenting with specific facial bone deformities. These indications may include:

• Facial Bone Deformities: Conditions that result in abnormal positioning or structure of the midface, which may be congenital or acquired.
• Trauma: Injuries to the facial bones that necessitate surgical intervention to restore normal anatomy and function.
• Malocclusion: Misalignment of the teeth and jaws that can be corrected through repositioning of the midface.
• Orthognathic Surgery: Surgical correction of jaw discrepancies that affect facial aesthetics and occlusion.

2. Procedure

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

• Step 1: The surgeon begins by making both intraoral and cutaneous incisions to access the facial bones. An incision is created in the buccal sulcus from the first molar on one side to the first molar on the opposite side, allowing for adequate exposure of the surgical site.
• Step 2: The palatal mucosa is carefully tunneled to prevent tearing during the maxillary osteotomy. This step is crucial for maintaining the integrity of the oral cavity during the procedure.
• Step 3: The lateral aspect of the nasal cavity is exposed, and the nasal mucosa is elevated. The exposure extends 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 4: Using preoperative measurements, the surgeon marks the planned bone cuts on the facial bones. This careful planning is essential for achieving the desired repositioning of the midface.
• Step 5: The periorbita is detached from the anterior orbital rim, allowing for further access to the orbital structures.
• Step 6: 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 7: The anterior orbital floor osteotomy is completed to the infraorbital nerve, utilizing the previously created medial and lateral orbital rim cuts for guidance.
• Step 8: The procedure is then mirrored on the opposite side of the face, ensuring symmetry and balance in the reconstruction.
• Step 9: The bones are downfractured, ensuring that all bones are completely mobilized for repositioning.
• Step 10: The repositioned bones are adjusted as necessary to correct the facial bone deformity, with careful checks of lip position and occlusion to ensure functional and aesthetic outcomes.
• Step 11: 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 and configured to the desired size and shape.
• Step 12: The harvested bone is morcellized and placed in the defect as needed. Fixation is achieved using wires, miniplates, or screws to secure the bones and any grafts in the desired position.
• Step 13: An intermaxillary fixation device is applied to stabilize the jaw during the healing process, and the buccal incision is subsequently closed.

3. Post-Procedure

Post-procedure care following a LeFort II osteotomy includes monitoring for complications, managing pain, and ensuring proper healing of the surgical sites. Patients may require follow-up visits to assess the positioning of the bones and the integration of any bone grafts used during the procedure. Instructions regarding diet, oral hygiene, and activity restrictions will be provided to facilitate recovery. It is essential to monitor for signs of infection or other complications during the healing process, and adjustments to the intermaxillary fixation may be necessary as the patient progresses through recovery.