maxillectomy a review

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Maxillectomy a review

Dr T Balasubramanian

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Concept described by Lazars in 1826 Syme first performed it in 1829 Portman described sublabial transoral approach

in 1927 Smith described extended maxillectomy in 1954 Fairbanks & Barbosa described infratemporal

fossa approach for advanced maxillary sinus tumors in 1961

Midfacial degloving approach was popularized in 1970

History

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Bleeding was the most common danger Complications due to anesthesia Post op sepsis Secondary deformity due to poor prosthesis

support

Dangers - Historic

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Malignant tumors involving maxilla Benign tumors of maxilla causing extensive

bone destruction (fibrous dysplasia) May be performed as a part of combined

resection of skull base neoplasm May be needed in patients with extensive

fungal / granulomatous infections (rare) Malignant tumors of oral cavity with extensive

involvement of palate

Indications

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Not indicated in the management of

lymphoreticular tumors which are better managed medically

Tumors involving inferior aspect of maxillary sinus can be managed by performing partial maxillectomy

Rehabilitation and prosthesis issues should be planned well in advance in consultation with dental surgeons

Tips

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Poor general condition of the patient Bilateral tumors with bilateral orbital

involvement Malignant tumors with skull base extension. Patient not consenting to undergo the

procedure Systemic disorders like uncontrolled

diabetes / poor cardio respiratory reserve

Contraindications

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Involvement of orbits on both sides – This

could compromise the vision because orbital exenteration will have to be performed

Removing bilateral tumors is not only a surgical challenge but also a challenge to design appropriate prosthesis. Since it is rather difficult to design prosthesis for patients who undergo bilateral total maxillectomy it is a relative contraindication

Bilateral tumors

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Both axial and coronal CT scans will have to

be performed in order to ascertain the extent of lesion

MRI will have to be performed in patients with erosion of skull base to rule out intracranial extension

Imaging helps in deciding osteotomy location. Superior osteotomy above the level of frontoethmoidal suture line will result in intracranial injury and CSF leak

Imaging

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CT

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Vision should always be tested before taking

the patient up for surgery Tumor involvement of orbit is an indication of

orbital exenteration If orbital exenteration is planned appropriate

prosthesis should be designed to fill up the defect

Ocular evaluation

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Bleeding Infection Epiphora Break down of skin graft Numbness of cheek area Atrophic rhinitis

Complications

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Can be minimized by coagulating bleeders Angular vessels should be secured properly Breaking maxilla from pterygoid process will

cause bleeding from internal maxillary artery. Simple hot packs will help in reducing bleeding during this stage

When lip splitting incision is used bleeding from labial vessels is common and should be secured at the earliest

Bleeding

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Can be minimized by following strict asepsis Avoiding undue use of cautery will minimize

tissue necrosis / infection Post op antibiotics By conserving skin as much as possible

without compromising tumor margins

Infection

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Nasolacrimal duct is transected during

maxillectomy thus causing epiphora Simple transection of nasolacrimal duct rarely

causes epiphora unless followed by stricture which usually occurs following radiotherapy

Insertion of silicone tube after transection of nasolacrimal duct

Marsupialization of nasolacrimal duct

Epiphora

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Caused due to transection of infraorbial nerve Infraorbital nerve can be conserved if not

involved by the tumor

Numbness of cheek area

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Consent

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Consent issues

Dental extraction Tracheostomy Prosthesis issues Cosmetic defects

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General anaesthesia Infiltration with 1% xylocaine with 1 in

100,000 adrenaline Marking incision site Reflection of skin flap over maxilla Bone cuts Disarticulation of maxilla

Surgical steps

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Incision

Weber Ferguson’s incision is used

Lateral rhinotomy incision with horizontal infraorbital component and midline lip split

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Sublabial component

Sublabial incision is performed after splitting upper lip in midline

This facilitates elevation of flap from anterior wall of maxilla

Extends through entire bucco gingival sulcus up to maxillary tuberosity

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Infraorbital component

This is the horizontal component of weber Ferguson’s incision

Made about 1 mm below the infraorbital rim

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Flap

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Bone cuts

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Palatal cut

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Zygoma cut

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Maxilla removal

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Prosthesis

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Specimen

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Closure

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Temporary tarsorraphy Corneal shield Significant laceration of periorbita should be

sutured

Eye protection

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Thank you