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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