Advantages of an Image-Guided Subcranial Technique for Le Fort III Osteotomies for Midface Advancement: A Case Series

Objective: Le Fort III osteotomies are used to advance the midface in children with midface hypoplasia and syndromic craniosynostosis. Complications can occur during the subcranial osteotomies, leading todural violations as well as vascular and neurologic injuries. In patients with cerebrospinal fluid (CSF) shunts, CSF leak places them at risk of shunt infection. To avoid these injuries, surgeons may utilize an intracranial approach to gain optimal visualization of the cranial base for the horizontal cut through the ethmoid bone, at the naso-frontal junction, below the cribiform plate. A formal craniotomy to simply assure a safe osteotomy, however, may well be an unnecessary morbidity. The aim of this study was to describe the indications for and technical advantages of image guidance for subcranial Le Fort III osteotomies without a craniotomy. Methods: We describe the use of the StealthStation 3-D intraoperative image guidance system for subcranial Le Fort III osteotomies and associated clinical outcomes. An electronic medical record search at a single academic institution identified 10 patients with Current Procedural Terminology codes 21154-21155 (reconstruction midface, Le Fort III). Results: Six patients underwent image-guided subcranial Le Fort III osteotomies between 2008 and 2023. There were no cases of vascular injury, cranial nerve injury, or cerebrospinal fluid leak. No patients with a CSF shunt experienced shunt infection during follow up. Conclusions: Image-guidance provides technical advantages as an alternative approach to subcranial Le Fort III osteotomies while allowing the surgeon to avoid the morbidity of a craniotomy.