Total maxillectomy is a surgical procedure to remove the entire maxilla bone. It was first described in the 1820s and approaches have been refined over time. It is indicated for malignant tumors involving the maxilla, extensive benign tumors, or fungal/granulomatous infections. Contraindications include poor general health, bilateral orbital involvement, or skull base extension. Potential complications include bleeding, infection, epiphora, skin graft breakdown, numbness, and atrophic rhinitis. Careful surgical planning and follow up are required due to significant reconstruction and rehabilitation needs.

1. Dr T Balasubramanian
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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
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3. Dangers - Historic

 Bleeding was the most common danger
 Complications due to anesthesia
 Post op sepsis
 Secondary deformity due to poor prosthesis support
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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
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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
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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
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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
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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
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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
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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
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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

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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

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29. Closure

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30. Eye protection

 Temporary tarsorraphy
 Corneal shield
 Significant laceration of periorbita should be
sutured
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