This presentation discusses total maxillectomy

1. Dr T Balasubramanian
Otolaryngology online 1

2. History

 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
Otolaryngology online 2

3. Dangers - Historic

 Bleeding was the most common danger
 Complications due to anesthesia
 Post op sepsis
 Secondary deformity due to poor prosthesis support
Otolaryngology online 3

4. Indications

 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
Otolaryngology online 4

5. Tips

 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
Otolaryngology online 5

6. Contraindications

 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
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7. Bilateral tumors

 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
Otolaryngology online 7

8. Imaging

 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
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9. CT

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10. Ocular evaluation

 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
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11. Complications

 Bleeding
 Infection
 Epiphora
 Break down of skin graft
 Numbness of cheek area
 Atrophic rhinitis
Otolaryngology online 11

12. Bleeding

 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
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13. Infection

 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
Otolaryngology online 13

14. Epiphora

 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
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15. Numbness of cheek area

 Caused due to transection of infraorbial nerve
 Infraorbital nerve can be conserved if not involved
by the tumor
Otolaryngology online 15

16. Otolaryngology online 16

17. Consent issues

 Dental extraction
 Tracheostomy
 Prosthesis issues
 Cosmetic defects
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18. Surgical steps

 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
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19. Incision

 Weber Ferguson’s
incision is used
 Lateral rhinotomy
incision with horizontal
infraorbital component
and midline lip split
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20. 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
Otolaryngology online 20

21. Infraorbital component

 This is the horizontal
component of weber
Ferguson’s incision
 Made about 1 mm
below the infraorbital
rim
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22. Flap

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23. Bone cuts

Otolaryngology online 23

24. Palatal cut

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25. Zygoma cut

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26. Maxilla removal

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27. Prosthesis

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28. Specimen

Otolaryngology online 28

29. Closure

Otolaryngology online 29

30. Eye protection

 Temporary tarsorraphy
 Corneal shield
 Significant laceration of periorbita should be
sutured
Otolaryngology online 30

31. Otolaryngology online 31