Blood Supply of the Le Fort I Maxillary Segment: An Anatomic Study John W. ‘and Michael T. Longaker, M.D. Ny New ¥ The vascular supply of the Le Fort osteotomy seg was studied by utilizing standard latex injection te niques. Anatomie dissections in 10 fresh cad onstrated interruption of the descending palat ‘with preservation of the ascending palatine branch of the facial artery and the anterior branch of the ascending al artery within the attached posterior palatal pedicle in all specimens following Le Fort I maxillary osteotomy, These ascending arterial branches entered the soft palate ata position approximately 1 cm posterior to the pterygomaxillary junction, which was dis Fupted during the Le Fort I maxillary osteotomy. Separate ink injections of total maxillary osteotomy segments con firmed vascular perfusion of the ipsilateral hemimaxillary segment by the ascending palatine artery. Thus vascular supply of the mobilized Le Fort I maxillary segment is by ‘means of the ascending palatine branch ofthe facial artery and the anterior branch of the ascending pharyngeal ar tery in addition to the rich mucosal alveolar anastomotic network overlying the maxilla, (Plast. Reconstr. Surg: 100: 843, 1997.) vers de Since its introduction by Cheever! in 1867, the Le Fort I maxillary osteotomy has been used reliably to correct congenital and ac- quired deformities of the jaws. Blood supply of the osteotomized maxillary segment initially was felt to be dependent on the integrity of the descending palatine artery.” Yet maxillofacial surgeons have observed survival of mobilized Le Fort I segments despite obvious surgical disruption of these vessels. Subsequent investi- gations by Bell and others demonstrated viabil- of the maxillary segment and teeth follow- ing disruption of the descending palatine ries."' Therefore, it has been believed that the viability of the osteotomized segment is dependent on a rich alveolar anastomotic net. work, The purpose of this study was to define From the Institute of Reconstructive Plastic Surgery at the New York University Medical Center. Received for publica revised December 18, 199 jebert, M-D., Claudio Angrigiani, M.D., Joseph G. McCarthy, M.D., vascular pedicle to the mobilized maxillary segment following Le Fort I osteot omy MATERIALS AND METHODS Utilizing standard latex injection techniques with vascular filling of vessels to less than 0.1 mm in diameter, 10 fresh cadaver dissections were undertaken. This was accomplished by first flushing the vascular system with lactated Ringer's solution or saline. Tota-body arterial perfusion was performed by means of aortic cannulation and pulsatile infusion of 3 liters of colored liquid latex. Stripping of the entire arterial wall Jeaves a latex cast of the arterial lumen (Fig. 1). The maxillary segment was then approached anteriorly, posteriorly, medi- ally, and laterally. Classic Le Fort I osteotomies were performed on 10 cadavers with wide mo- bilization of the osteotomized segment. The osteotomy lines extended through the yomer- ine groove, medial and anterolateral walls of the maxillary sinus, and pterygomaxillary junc- tion. In an additional 5 fresh cadavers, separate ink injections were performed into the ascend- ing palatine artery by means of a cannula in- troduced following complete mobilization of the Le Fort I osteotomy segment. RESULTS Dissection of the Le Fort I segment in all cadavers demonstrated interruption of the de- scending palatine arteries and continuity of the ascending palatine branch of the facial artery as well as the anterior branch of the ascending pharyngeal artery within the attached posterior September 5, 1996; 83Fic. 1. Fresh cadaver specimen with facial skin removed tripping demonstrating latex cast of facial arteries followin fof arterial walls, This injection technique allows accurate anatomic dissections of vessels greater than 0.1 mam in dian palatal-pharyngeal softtissue pedicle (Figs. 2 through 8) It was observed that the pterygopalatine ca nal, containing the descending palatine artery and lying within the posterior wall of the max- illary sinus, was divided during the pterygopal: atine disruption (see Fig. 4). The ascending palatine branch of the facial artery was I to 1.5 mm in diameter and entered the soft palate by crossing over the levator veli palatini: muscle (see Figs. 7 and 8). The anterior branch of the ascending pharyngeal artery was 0.8 to 1.2 mm in diameter and entered the soft palate slightly more cephalad compared with the palatine artery by coursing over the tensor veli palatini and levator palatini muscles (see Fig 7). Both arterial branches entered the soft pal ate posterior to the pterygoid muscles. A rich anastomotic network existed within the maxilla between the ascending palatine branch of the facial artery, the anterior branch of the ascend. alveolar ing pharyngeal artery, and the PLASTIC AND RECONSTRUCTIVE SURGERY, September 1997 branches of the internal maxillary artery (see Fig. 5) Separate ink injections into the ascending palatine artery of five cadavers demonstrated that at least the entire half of the ipsilateral palate was stained (Fig. 9). Discussion The loss of smalll or large bone segments due to ischemia following Le Fort I maxillary os teotomies is a disastrous complication for max- illofacial surgeons. A detailed knowledge of the vascular supply to the maxilla is essential to avoid possible untoward sequelae. Proper soft tissue flap design with preservation of the pal atal vascular pedicle is essential. In addition, inappropriate stretching of the palatal mucosal pedicle must be avoided. Early investigations by Bell and colleagues Jed us to believe that the viability of the Le Fort palatal splints or excessive Fic, 2 The face has heen disrupted from the eranial base inal plane and is viewed from behind, Note the palate with intact teeth and posterior nasal septum, On the let side Of the palate, the posterior soft tissues have been preserved, The ascending palatine branch of the facial artery coursing, cross the masseter muscle is demonstrated on the left side as iLenters the posterior soft palate (arra,Vol. 100, No. 4 / BLOOD SUPPLY OF Le For I MAXILLARY SEGMENT 845 Posterior Descending. Palatine Artery Maxillary Artery Superior Posterior ‘Alveolar Artery Maxillary Sinus FIG, 3. (Above) Close-up view of same specimen as in Figure 2, An ostcotome is seen 1 cm anterior to the ascending palatine artery (small arm) in the position of a pterygomanillaty disruption. On the ri and the ptery side of the specimen, the posterior soft palate ly with removal of the posterior wall of the maxillary sinus and the posterior palatine bone. Branches of the descending palatine artery have been preserved by removing shave been removed. Dissection has continued anteri the pterygopalatine canal and are seen entering the hard palate (lange arvow). (Below) Corresponding line drawing of cadaver osteotomy segment primarily was dependent importance of “palatal contributions” to the on an extensive alveolar anastomotic network integrity of the mobilized maxillary segment with disruption of the descending palatine ar- More recently, You et al.°? have elegantly teries.* Their subsequent studies" raised the demonstrated angiographically that the palatalHG. 4 (Ze) An oblique ponterior view of the miace ‘manillary disruption; the descending ps specimen, abundant and rs than the vessels vascular supply is has greater vessel d supplying the buccal n aveolar gingival vascular network. Conve tional labiobuccal degloving incisions with sub- periosteal dissection of the maxilla interrupt the majority of this alveolar anastomotic art rial network. In addition, an in vivo viability study in primates by You et al.’ demonstrated that blood flow to mobilized maxillary se} ments following Le Fort I osteotomy is the same in monkeys with the descending palatine arteries ligated as in monkeys with intact di scending pala 's, thus quantitatively confirming the safety of dividing the descend- ing palatine arteries with Le Fort I osteotomies. We initiated our antomic dissections in an effort to confirm the experimental data seen in primates. The anatomic findings correlated well with the preceding experimental studies. Our cadaver anatomic study demonstrated preservation of the ascending palatine branch of the facial artery and the anterior branch of PLASTIC AND RECONSTRUCTIVE SURGERY, September 1997 The left medial and lateral pterygoid plates are seen above the osteotome. The left pterygoid muscles have been removed. The edge of the osteotome is positioned to perform the pteryyo- atine artery (arrow) is obviously risk, (Right) Corresponding line drawing of cadaver the ascending pharyngeal artery within the in- tact posterior palatal soft tissues in all cadaw specimens studied. In addition, interruption of the descending palatine arteries, as is ofte seen during Le Fort I osteotomy, was con- firmed in all specimens. The pterygopalatine canal containing the descending palatine a tery lies within the posterior wall of the maxil- Jary sinus and is vulnerable to injury. Moreover with complete mobilization or downfracture of the maxillary fragment, the descending pala- tine artery is avulsed or interrupted. A rich anastomotic network exists within the maxilla between the ascending palatine branch of the facial artery, the anterior branch of the ascen ing pharyngeal artery, and alveolar branches of the internal maxillary artery. These anatomic dissections confirmed the angiographic find. ings of You etal.” with the ascending palatine terial branch of the facial artery and the terior branch of the ascending pharyngeal tery giving off vessels with greater diameters and in greater numbers than the alveolarVol. 100, No. 4 / BLOOD SUPPLY OF LE FORT I MAXILLARY SEGMENT a, Posterior Descendi Palatine Artery Fic. 5. (Above) zygoma removed. Wit 847S48. ‘Anterior Descendi Palatine Artery Bucco-gingival Sulcus ) Left hemi-Le Fort Lmanillary the anterior palate. Two posterior descendin PLASTIC AND RECONSTRUCTIVE SURGERY, September 1997 Facial Artery Labial Artery sgment viewed from above, The anterior descending palatine artery (large arrow) palatine arteries are also seen (red arvow). Branches of the facial mall arrow). (Below) Corres ling line drawing of cadaver specimen,Vol. 100, No. 4 / wLOOb SUPPLY OF Le FORT I MAXILLARY SEGMENT 849 Anterior Branch ae of Ascending miaynmctatey (YS, ‘Ascending Palatine Artery Facial Artery External Carotid Artery rer specimen that has been divided in the midsagittal plane, The ral cavity, an fe edentulous ) and the lett b dial aspect. The tongue (larg hemimanilla are demonstrated anteriorly and the cervical spine posteriorly. The ascending palatine artery are demonstrated ente the posterior aspect ) Corresponding with ts anterior branch arteties are preserved in the mi ascending pharyngeal arte oft palate (triangles). The the lized Le Fort I maxillary segment. perfusion of over half the branches of the internal maxillary artery within tery demonstrati the labiobuccal gingiva palate with selective ipsilateral ascending pala- Our findings were confirmed with separate tine arterial injection. Thus the “palatal contri- ink injections into the ascending palatine ar- butions” to blood supply of the mobilized Le850 Anterior Branch of Ascending Pharyngeal Artery ‘Tensor Veli Palatini Muscle Levator Veli Palatini Muscle Soft Palate Facial Artery / an soni, Fic, 8. Line drawing of posterior veh tion, Note the relationship of the ascending palatine artery ‘and the anterior branch of the ascending pharygeal artery in relation to the vel paatini muscles Fort I maxillary segment previously reported by Bell et al.*® are the ascending palatine branch of the facial artery and the anterior branch of the ascending pharyngeal art John W. Siebert, M.D. 799 Park Avenue New York, N.Y. 10021 REFERENCES 1. Cheever, D.W. Displacement of the upper jaw. Med. Sg. Rep. Boston City Hosp. Ls 156, 1870. 2 McCarthy, J.G., Kawamoto, H. K., Grayson, B. H.,¢ Surgery of the Jaws. In J.G. McCarthy (Ed,), Plastic Surgery, Philadelphia: Saunders, 1990 PLASTIC AND RECONSTRUCTIVE SURGERY, September 1997 3, Bell, W.H. Revascularization and bone healing after anterior maxillary osteotomy: A study using adult che suis monkeys, J. Oral. Surg. 27: 249, 1969. 4, Bell, W. H.,and Lewy, B. M. -Revascularization and bone healing after posterior maxillary osteotomy. J. Oral Surg. 28: 313, 1971. Bell, W. H., Fonseca, R.J., Kennedy, J. W.. II and Lexy B.M. Bone healing and revascularization aft maxillary osteotomy. f. Oral Surg. 33: 253, 1975, 6, You, Z, H., Zhang, Z. K./and Xia,J-L. A study of max: illary and mandibular vasculature in relation to oF thognathic surgery. Chin, J. Stomatol. 26: 263, 1991. You, Z: H., Zhang, Z. K., Wang, ¥. etal. Distibution of Minor Nutrient Foramina on the Bone Surfaces ofthe Maxilla, Presented at the Third Conference of Chi nese Oral and Masillofacial Surgeons, Xi'an, China, November, 1990. 8, You, Z.H., Zhang, Z.K., and Zhang, X.E. Le Fort 1 ‘osteotomy with descending palatal artery intact and ligated: A study of blood flow and quantitave histology Contemp, Stomatol 5: 71, 1991 9, Bell, W.1L, Mannai, C., and Luhr, H.G. Arcand sei- ‘ence of the Le Fort I dawnfracture, Int. Adal! Orthod. Onthegnath, Surg. 3: 23, 1988, 10, Lanigan, D. T., Hey, J. Hy and West, R.A. Aseptic ne- ‘oss following maxillary osteotomies: Report of 36 ‘eases. J. Oral Maxillofac. Surg. 48: 142, 1990. i Zl, Zhang, Z.K., and Xia, J.L. The swdy of scular commtinication between jaw bones and their surrounding tissues by SEM off resin casts. West Chin J. Stomatol. 8: 285, 1990, 12, You, 7. H., Ahang, Z. K,, and Xia, J.L jaw bone mucoperiosteum and itsrole in orthognathie surgery. Chin, J. Stomatol. 26:81, 1991 13, Bell, W.H., You, Z.HL, Finn, RA., and Fields, R.T Wound healing after multisegmental Le Fort Losteot- omy and transection of the descending palatine ves- sels. J. Oral Maxillofac. Surg, 58: 1425, 199% 14, Lanigan, D.T, Wound healing after multisegmental Le Fort I osteotomy and transection of the descending, palatine vessels (Discussion). J. Oral Maxillofac. Surg 4: 1433, 1905, Blood supply ofVol. 100, No. 4 / L0Ob suPPLY OF Lk FORT I MAXILLARY SEGMENT 851