Simultaneous Modified Kufner Le Fort III Osteotomy and Le Fort I Distraction: A Novel Approach to Complex Midface Hypoplasia

Background: Maxillary hypoplasia and class III malocclusion are common in patients with cleft lip and palate. Typically, Le Fort I advancement is sufficient to correct this condition. In more severe phenotypes, hypoplasia extends cephalically to the orbital rim, resulting in poor eyelid support, negative vector, and exorbitism. Strategies to address this deformity have included Le Fort III advancement, high-wing Le Fort I osteotomies, malar implants, and the Kufner Le Fort III osteotomy. However, if the patient presents with adequate nasal radix projection and greater maxillary deficiency than malar hypoplasia, the above strategies do not allow for differential movement to successfully balance facial proportions. Methods: A 17-year-old female with bilateral cleft lip and palate presented with malar hypoplasia, mild/moderate exorbitism, and class III malocclusion with 21 mm of negative overjet. A modified Kufner Le Fort III osteotomy was performed through a bicoronal incision to advance the zygomas 6 mm while preserving nasal radix projection. Custom titanium plate fixation was used at the zygomatic arches and orbital rims. A high-wing Le Fort I osteotomy was completed and bone-borne distraction hooks and a Rigid External Distraction device provided an additional 15 mm of distraction. Mandibular ramus bone grafts were used for the zygomatic arch defects. Results: The combined osteotomy enabled differential movement of the zygomas and maxilla, preserving nasal radix projection and improving facial balance. Zygoma repositioning enhanced midface support and exorbitism, while maxillary advancement improved projection and occlusion. Postoperative CT confirmed healing at the facial buttresses, with positive overjet maintained after hardware removal. Conclusion: This case demonstrates the successful use of the Kufner Le Fort III osteotomy combined with Le Fort I distraction osteogenesis to address complex cleft-related midface hypoplasia. The technique enables controlled, differential movement of midface structures, correcting functional and esthetic deficiencies without causing nasal elongation, providing an effective solution for severe deformities.