CPT® Code 21155

1. Indications

The Le Fort III osteotomy, as described by CPT® Code 21155, is indicated for patients presenting with significant midfacial deformities that may affect both function and aesthetics. The following conditions may warrant this surgical intervention:

• Midfacial Deformities: Patients with congenital or acquired deformities in the midface region that require surgical correction.
• Facial Trauma: Individuals who have sustained injuries resulting in malalignment or deformity of the facial bones.
• Orthognathic Surgery: Cases where correction of occlusal discrepancies necessitates repositioning of the midface in conjunction with lower maxillary adjustments.
• Facial Asymmetry: Patients exhibiting significant asymmetry in facial structure that impacts both appearance and function.

2. Procedure

The procedure for CPT® Code 21155 involves several detailed steps to ensure effective reconstruction of the midface and lower maxilla:

• Step 1: Incision and Exposure An incision is made from one ear, extending along the hairline across the forehead and down to the opposite ear. This approach allows for the creation of a coronal flap, facilitating access to the supraorbital region, nasal bones, and malar complex. A supplemental orbital floor approach may be utilized for enhanced exposure.
• Step 2: Bone Marking and Cutting Prior to making any cuts, the physician marks the planned bone cuts based on preoperative measurements. Bone cuts are executed on one side of the face and mirrored on the opposite side, ensuring symmetry in the reconstruction.
• Step 3: Bone Separation and Repositioning The facial bones are completely separated from the cranial base. The physician then repositions the bones as necessary to correct the identified deformity, checking measurements to confirm the desired repositioning has been achieved.
• Step 4: Bone Graft Harvesting Bone is harvested from the iliac crest through a separate incision. The muscle is stripped to expose the bone surface, and cortical and/or cancellous bone is harvested, configured to the required size and shape, or morcellized for placement.
• Step 5: Fixation The repositioned bones and any bone grafts are secured in place using wires, miniplates, or screws, ensuring stability during the healing process.
• Step 6: Le Fort I Procedure Concurrently, an incision is made in the buccal sulcus from the first molar on one side to the first molar on the opposite side. The lateral aspect of the nasal cavity is exposed, and the nasal mucosa is elevated. Bone cuts are made on the lateral wall of the maxilla, and the pterygoid plate is separated from the maxilla.
• Step 7: Maxillary Downfracture The maxilla is downfractured using thumb pressure and mobilized with a pterygoid osteotome. Anterior osteotomy is performed at the premolar region bilaterally, and the maxilla is repositioned and stabilized with wires.
• Step 8: Final Checks and Closure Measurements are rechecked to ensure proper repositioning of the maxilla, and lip position and occlusion are assessed. Finally, all incisions are closed to complete the procedure.

3. Post-Procedure

Post-procedure care following the Le Fort III and Le Fort I osteotomies includes monitoring for complications such as infection, bleeding, or issues with bone healing. Patients are typically advised to follow a soft diet to minimize stress on the surgical sites. Pain management is also an essential component of post-operative care, and follow-up appointments are necessary to assess healing and the stability of the bone repositioning. Patients may require physical therapy to aid in recovery and to restore normal function and movement in the facial region.