MAXILLECTOMY

PROF.S.SUBBIAH et.al
Maxillectomy
Department of Surgical Oncology
Centre for Oncology
GRH,Royapettah

Maxilla
• Facial appearance
• Mastication, speech and deglutition
• Irregular paired pneumatic bones
• Maxillary sinus (Antrum of Highmore)
• 6 walls/ surfaces

Maxillectomy - History
• Lazars in 1827 – concept of maxillectomy
Procedure aborted – due to excess blood loss
• Joseph Gonsol – first successful maxillectomy in 1827
• Syme – first maxillectomy with orbital exenteration
• High mortality, morbidity and disfigurement
• Advancement in anaesthesia  reduced blood loss
• Portmann and Rotrouvey – transoral approach in 1927
• Weber Ferguson in 1950

Infraorbital foramen

Ohngren's classification
• Imaginary line between medial canthus to angle of mandible
• Infrastructure - anterior inferior part
- good prognosis
• Suprastructure - postero superior part
- related to vital structures --> poor prognosis
- often needs radiotherapy

Spread of maxillary tumour

Indications for maxillectomy

Most common indications for malignancy
1. Squamous cell carcinoma
2. Adenocarcinoma
3. Minor salivary gland tumours
4. Esthesioneuroblastoma
5. Undifferentiated (small cell neuroendocrine) carcinoma
6. Melanoma
7. Sarcoma

TNM staging

Types of maxillectomy
1. Medial maxillectomy
2. Partial maxillectomy
3. Subtotal maxillectomy
4. Total maxillectomy with preservation of orbit
5. Total maxillectomy with orbital exenteration
1. Suprastructural maxillectomy
2. Infrastructural maxillectomy

Approach for maxillectomy
1. Endoscopic
2. Transoral - transpalatal
3. Transfacial
a. Lateral rhinotomy incision
b. Weber Ferguson incision
4. Facial degloving
5. Craniofacial

Lateral rhinotomy & Weber Ferguson
Incisions

• Lateral rhinotomy approach
- for medial maxillectomy
- for tumours of medial wall of maxilla
- also for tumours of lateral wall of nasal cavity

Weber Ferguson incision and it's modifications

Weber Ferguson incision
• For subtotal or total maxillectomy
• Modifications:
1. Dieffenbach - direct visualization of posterior maxilla
2. Lynch - avoids ectropion, better cosmesis, better flap vitality
3. Borle extension (question mark)- for temporalis flap

Transoral-transpalatal approach
• Combination of sublabial gingivobuccal sulcus incision and palatal
incision
• For inferior (infrastructure) maxillectomy
• Also for tumors of upper alveolar ridge and hard palate

Midfacial Degloving & Sublabial Approach

Midfacial Degloving & Sublabial Approach
• For large benign tumours - juvenile nasopharyngeal angiofibroma
• Advantages - 1. simultaneous exposure to inferior and medial
maxilla bilaterally
2. no external scar on face
• Disadvantage - 1. limited superior and posterior exposure
2. Retraction

Brown's Classification of maxillectomy and
midface defect

midface defect
• Vertical classification:
I — maxillectomy not causing an oronasal fistula
II — not involving the orbit
III — involving the orbital adnexae with orbital retention
lV — with orbital enucleation or exenteration
V — orbitomaxillary defect
VI — nasomaxillary defect

midface defect
• Horizontal classification:
a — palatal defect only; not involving dental alveolus
b — less than or equal to 1/2 ; unilateral
c — less than or equal to 1/2 ; bilateral or transverse anterior
d — greater than 1/2 maxillectomy
 Letters refer to increasing complexity of dentoalveolar and palatal
defect, and qualify the vertical dimension

Santamaria and Cordeiro or MSKCC
classification

Santamaria and Cordeiro classification
• Type I defect - limited maxillectomy
Resection of one or two walls of maxilla excluding palate
• Type II defect - subtotal maxillectomy
Resection of maxillary arch, palate, anterior and lateral
walls (lower five walls)
Preservation of orbital floor

Santamaria and Cordeiro classification
• Type III defects - total maxillectomy
Resection of all six walls of maxilla
IIIa - orbital contents preserved
IIIb - orbital contents exenterated
• Type IV defects - orbitomaxillectomy
Resection of the orbital contents and upper five walls of maxilla
Preservation of the palate

Santamaria and Cordeiro type I and II

Santamaria and Cordeiro IIIa

Santamaria and Cordeiro IIIb and IV

Prosthesis
• Dental prosthesis
• Maxillofacial prosthesis
• Titanium prosthesis - CAD/ CAM ( computer aided design or
Computer assisted manufactured

CAD/CAM Titanium prosthesis

• Orbit support - Temporal fascia/flap
- vascularised or avascular bone graft
- Titanium mesh

Take home message
• Medial maxillectomy - lateral rhinotomy approach
• Inferior maxillectomy – transoral/transpalatal approach
• Subtotal and total maxillectomy - Weber Ferguson incision
• Large benign nasopharyngeal tumour - Midfacial Degloving &
Sublabial Approach

Take home message
• Algorithm for reconstruction - based on type of defect
• Large surface area with small to medium volume defects - Radial
forearm fasciocutaneous or osteocutaneous flap
• Large volume with medium to large surface area defects - rectus
abdominis free flap
• Orbital floor reconstruction - bone graft combined with soft tissue
flaps

Thank you

MAXILLECTOMY

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