1.
Dr Utkal Mishra
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2.

 Concept described by Lazars in 1826.
 Syme first performed it in 1828.
 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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3.
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Types
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4.
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 Malignant tumors involving maxilla – Sq Cell Carcinoma
 Benign tumors of maxilla causing extensive bone destruction
(fibrous dysplasia)
 Extensive fungal / Granulomatous infections (rare)
 Malignant tumors of oral cavity with extensive involvement of
palate
Indications
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5.

 Lymphoreticular malignancies – Lymphoma and Pediatric
Rhabdomyosarcoma
 Bilateral tumors with bilateral orbital involvement
 Malignant tumors with skull base extension.
 Systemic disorders like uncontrolled diabetes / poor cardio
respiratory reserve
 Poor general condition of the patient
 Patient not consenting to undergo the procedure
Contraindications
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6.

Pre-op Evaluation
 Nasal Endoscopy & Biopsy
 Examination of Cranial Nerve
Function.
 Examination of oral cavity
 CT Scan / MRI
 Opthalmological evaluation
 Dental evaluation
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7.
Surgery
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8.

 General anaesthesia
 Marking incision site
 Corneal shield / Temporary tarsoraphy
 Infiltration with 1% xylocaine with 1 in
100,000 adrenaline
Surgical Steps
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9.

 Hypotensive Anaesthesia.
 Transoral Intubation is preferable.
 E.T. Tube secured opposite the side of tumor in lower lip.
 If Trismus present – Tracheostomy / Trans-nasal fibreoptic
intubation.
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Anaesthetic Considerations

10.

Incision
 Weber Ferguson’s incision is used.
 Lateral rhinotomy incision with
horizontal infraorbital component and
midline lip split.
 Extends 1cm lateral to lateral canthus.
 3mm below lower Eyelash.
 Along nasomaxillary groove.
 Curves along alar margin.
 Dividing upper lip over ipsilateral
philtrum.
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11.

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Incision
 Extends round the upper gingivobucal
sulcus upto maxillary tuberosity.
 Medially a midline incision given between
canine & lateral incisor extending upto
juncn. of hard & soft palate.
 The palatal incision should lie 3mm lateral to
midline.
 Incision carried laterally to join
gingivobuccal incision around posterior
maxillary tuberosity.

12.

Flap
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 Cheek flap elevated in subperiosteal
plane.
 Infraorbital nerve divided.
 Flap elevated till zygomatic process.
 Inferior and medial periorbita is
elevated to expose the floor of the orbit,
lacrimal fossa, and lamina papyracea.
 Nasolacrimal Duct transected &
Lacrimal sac is marsupialized.

13.

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Nasolacrimal Duct
The medial canthal ligament The nasolacrimal duct

14.

Bone cuts
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 Frontal process of Maxilla & lacrimal
bone.
 Floor of orbit
 Zygomatic process
 Palatal osteotomy
 Osteotomy to separate maxillary
tuberosity from pterygoid plates.

15.

Maxilla removal
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16.

Hemostasis
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 Bleeding from maxillary artery is controlled by ligation
 Venous bleeding from pterygoid plexus is controlled with
packing.
 Use of powered osteotomes results in less bleeding.

17.

Obturator Prosthesis
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 It prevents oro-antral & oro-nasal communication.
 Designed preoperatively.
 Attached to preserved dentition with wires
 If obturator is used then the surgical defect is lined by
skin graft internally supported with cuticell@.
 Disadvantage –
• Deficient aesthetic and functional reconstruction
• Rhinolalia
• Midface retrusion
• Inadequate prosthetic rehabilitation
• Difficult insertion in patients with trismus

18.

Closure
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19.
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 In early postoperative period, frequent oral irrigation is
encouraged.
 Oronasal irrigations are encouraged after removal of Vaseline
gauze.
 Jaw stretching exercise is advised to prevent development of
trismus.
 Once the raw area has healed satisfactory (3–4 weeks),
patient may be referred to the prosthodontic department
for permanent prosthesis
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Post op Care

20.
Complication
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21.
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 Bleeding
 Mid face retrusion
 Epiphora
 Break down of skin graft
 Numbness of cheek area
Complications
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22.

 Commonest site – Maxillary Artery
 Breaking maxilla from pterygoid process will cause bleeding from
internal maxillary artery. Simple hot packs will help in reducing
bleeding during this stage.
 Can be minimized by coagulating bleeders.
 Angular vessels should be secured properly.
 When lip splitting incision is used bleeding from labial vessels is
common and should be secured at the earliest
Bleeding
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23.
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Mid Face Retrusion
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24.
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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
 Marsupialization of lacrimal sac.
 Insertion of silicone tube after transection of nasolacrimal duct.
Epiphora
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25.

 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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26.
Reconstruction
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27.

Objectives
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 Closure of the surgical wound
 Elimination of the maxillary defect
 Restoration of Midfacial contour
 Support Eyeball
 Reconstruction of the palate
 Restore normal mastication and deglutition.

28.

Classification of Maxillary Defect
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 Vertical
I. Maxillectomy not causing an oronasal fistula
II. Maxillectomy not involving the orbit
III. Maxillectomy involving the orbital adnexa with orbital
retention
IV. Maxillectomy with orbital enucleation or exenteration
V. Orbitomaxillary defect
VI. Nasomaxillary defect
Horizontal
(a) Palatal defect only, not involving the
dental alveolus
(b) Defect ≤ one half unilateral
(c) Defect ≤ one half bilateral or
transverse anterior
(d) Defect greater than one half
maxillectomy

29.

 Obturator
 Local Flap –
Bichat Fat pad
Palatal mucoperichondrial island flap
Submental island
Temporalis
 Regional Pedicle Flap –
Buccinator Flap
Temporalis Muscle Flap
Temperoparietal Fascia Flap
Cervicopectoral Flap
 Microvascular Free Flap –
Rectus Abdominis Flap
Radial Forearm Flap
Iliac crest Flap
Lattismus dorsi Flap
Osteofasciocutaneous Fibula Flap
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Techniques

30.

Class I – IIb Defect
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 Obturator
 Radial forearm free flap

31.
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Radial forearm free flap
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32.
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Class III Defect
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 Lattismus Dorsi Flap
 Temporalis Flap
 DCIA Flap
 Rectus Abdominis Flap

33.
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Lattismus Dorsi Flap
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34.

Lattismus Dorsi Flap
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35.

Class IV Defects
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 Lattismus Dorsi Flap
 DCIA Flap

36.

Class V Defects
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 Temperoparietal MyoFascial
Flap

37.

Temporalis Flap
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38.
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Temporalis Flap
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39.
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Class VI Defects
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 Osteocutaneous Radial
forearm free flap

40.
Thank You
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