Background: The LeFort I osteotomy is a well known midface procedure that repositions the upper jaw bone. To perform the procedure a complete subperiosteal undermining is needed across the entire maxilla including around the pyriform aperture. A well known adverse aesthetic sequelae of this procedure is widening of the nostrils due to the lateral pull of the subperiosteal released musculoligamentous tissues.
To prevent this nostril effect it has long been advised that during closure two specific maneuvers be done. The first is an internal alar cinch suture to pull the lateral nostrils back together. The second is a V-Y musculomucosal closure to pull back in the released muscular attachments toward the midline. Together these techniques typically keep the nostril widths unaffected. But if they are not performed, or even sometimes when they are, they may still be an increased nasal width as a result.
When nostril width reduction is desired after a LeFort osteotomy there are several techniques available to do so. These include external nostril narrowing through either internal wedge removal or transalar suture placement which can be performed either through external sill excisions or done intraorally.
Case Study: This female was bothered by her increased nostril width after having undergone a bimaxillary orthognathic procedure one year previously.
Under general anesthesia (as she was having other procedures being done as well) 4mm nasal sill wedges were marked out. (5mms on the left due to asymmetry) The skin wedges were excised and closed primarily.
Internal transoral nostril narrowing sutures work best during the Left procedure where wide tissue releases permit better inward tissue movements. Externally the only decision is whether to use transalar sutures or not. If the amount of alar width reduction is 4mms or less than I feel they are needed. Any larger width reduction would benefit by a long lasting resorbable suture passed underneath the columella between the alar side walls.
1) The width of the nostrils can become exaggerated after a Left I osteotomy due to the wide tissue releases along the sides and underside of the nose.
2) The most reliable form of nostril narrowing from tissue degloving is an internal wedge technique.
3) Post LeFort nostril narrowing usually does not need to be more than around 4mms.
Dr. Barry Eppley