Maxillectomy - Total

Considerations

• • Plan the appropriate maxillectomy 

    • Medial, inferior, subtotal, total, extended total with possible transcranial skull base approach 

  • Ohngren’s line, an imaginary line drawn from the medial canthus to the angle of the mandible, separates the maxillary sinus into anteroinferior and posterosuperior aspects

    • Tumors anterior to Ohngren’s line are associated with a better prognosis

    • Tumors posterior to Ohngren’s line are more likely to have involvement of the orbit and infratemporal fossa and, because of the proximity of these structures, are less curable

  • Plan for the defect

    • Loss of oral-nasal separation

    • Obturator fabrication by the maxillofacial prosthodontist

    • NLD sacrifice 

      • Immediate DCR

    • Periorbital involvement

      • Orbital exenteration and recon

  • SCC of the hard palate

  • eMedicine: Malignant Tumors of the Palate

  • 2006: Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate

  • 2008: Treatment outcomes in squamous cell carcinoma of the maxillary alveolus and palate: a population-based study

  • Reconstruction and rehabilitation

  • 2007: A protocol for maxillary reconstruction following oncology resection using zygomatic implants

  • 2016: Rehabilitation of a complex midfacial defect by means of a zygoma-implant-supported prosthesis and nasal epithesis: a novel technique

Preparation

• • Osteotomes

  • Powered saws

  • Obturator

  • Blood products 

Procedure

• • Total maxillectomy 

  • Tarsorrhaphy suture

    • Lateral rhinotomy incision

      • possible Weber-Ferguson extension

      • possible Diefenbach extension (2012: Versatility of Dieffenbach’s Modification of Weber Fergusson’s Approach for Treatment of Maxillary Pathologies

    • Gingival-buccal incision laterally to the maxillary tuberosity

    • Cheek flap elevation in the subperiosteal plane

    • Divide the infraorbital nerve 

    • Expose the periorbital, assess involvement 

    • Divide the NLD

    • Divide the inferior orbital rim through the trimalar buttress into the ethmoid at the level of the frontoethmoid suture

    • Remove ethmoid partitions 

    • Divide the palate 2-3 mm ipsilateral to the nasal septum

      • Preserve the incisors

  • Divide the soft tissue at the junction of the soft and hard palates laterally to the buccogingival sulcus incision at the posterior maxillary buttress

  • Divide the lateral orbital wall

  • Fracture the maxilla from the pterygoid plates 

    • *Expect brisk bleeding from the IMA and venous plexus

    • Blindly divide the soft tissue attachments at the posterior maxilla 

    • Control the bleeding with packing and then suture ligation of the IMA and bipolar of veins 

    • DCR 

    • STSG to the facial flap facing the maxillary cavity 

    • Insert the prosthesis and fix with lag screw

    • Pack the maxillary cavity with Xeroform

    • Close the skin

      • Approximate the medial canthal tendon to nasal bone periosteum 

    • Remove the tarsorrhaphy suture

    • Pressure dressing to the face 

Post-op

• • Soft diet

  • Chlorhexidine swish and spit 

  • Peri-operative antibiotics while packing in place

  • POD 5 remove prosthesis and packing 

  • Immediate placement of interim prosthesis

    • Prosthodontist to modify as needed 

    • Final adjustments depend on post-op XRT

  • Myringotomy with tube for persistent ETD

High-Yield

Links

• YouTube (7:52) - Maxilla anatomy and bone cut planning

• YouTube (8:32) - Total maxillectomy

• eMedicine - Maxillectomy

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - INFERIOR MAXILLECTOMY

• OPEN ACCESS ATLAS OF OTOLARYNGOLOGY, HEAD & NECK OPERATIVE SURGERY - TOTAL MAXILLECTOMY, ORBITAL EXENTERATION

• Iowa Protocols - Maxillectomy

• Total Maxillectomy: A Review