Maxillectomy - Classification
Considerations
Anatomy
Two horizontal butresses
Three vertical butresses
Hexahedron with six walls
Roof = orbital support
Floor - anterior hard palate
Serves as the insertion of most muscles of facial expression and mastication
History
1820s - The first total maxillectomy by have been performed by Dupuytren and Gensoul
1841 - First recorded maxillectomy by Liston
1933 - Extensive review authored by Ohngren
Indications - Tumors or benign conditions involving or destroying the maxilla, specifically the
Orbit
Nasal cavity
Paranasal sinuses
Palate
Oral mucosa
Implications - Major functional impact on
Speech
Deglutition
Orbital function
Cosmesis
Reconstruction
Know your defect
Volume
Surface area
Bone - orbital floor, anterior arch of the maxilla
Soft tissue
Assess critical structures
Eyelids, nasal airway, palate, oral commissure
Time tested options
Skin graft
Cervicofacial flap
Pectoralis myocutaneous flap
Local and regional flaps
Palatal mucoperichondrial island flap
Up to 15 cm2 surface area
Strong enough for through-and-through defects
Can rotate 180 deg on its pedicle
Buccal fat pad
Rich vascular supply
Best for defects up to 4 cm in diameter
Can be used in combination with free bone grafts
Submental island
7-15 cm in size
Well hidden donor site scar
Temporalis
Good for orbital support
Free flaps
Needed for larger defects
Provide like-for-like tissue matching
Inner lining, bone, soft tissue bulk, skin
Require 10-15 cm long vascular pedicle
May be combined with free bone grafts
Advantages
Allows for dental restoration (osseointegrated implants)
Freedom to orient, shape and inset flap as needed
Disadvantages
Longer surgical and recovery times
Increased potential for complications
Delay in diagnosis of local recurrence
Options
Radial forearm - large surface area with minimal bulk, may include bone, excellent for lining
Fibula - excellent bone stalk
Rectus abdominus - large surface area and volume, may be divided into 2-3 flaps, ideal of type III and IV defects
Iliac crest - excellent bone stalk but short pedicle
Scapula - soft tissue rotatability around bone
Anterolateral thigh - large volume but short pedicle
Prosthesis - Obturation
Advantages
Shorter operative time
Shorter postop hospital stay
Better visualization of maxillectomy cavity for surveillance
Disadvantages
Hypernasal speech
Regurgitation of foods and liquids into nasal cavity
Constant patient care and difficulty maintaining hygiene
Need for repeated adjustments
Brown (2000)
2000: A modified classification for the maxillectomy defect aka "Liverpool classification"
Class 1 - maxillectomy without an oro-antral fistula
Class 2 - low maxillectomy (not including orbital floor or contents)
Class 3 - high maxillectomy (involving orbital contents)
Class 4 - radical maxillectomy (includes orbital exenteration)
Classes 2 to 4 are qualified by adding the letter a, b, or c
The horizontal or palatal component is classified as follows
a - unilateral alveolar maxillectomy
b - bilateral alveolar maxillectomy
c - total alveolar maxillary resection
Santamaria and Codeiro (2000)
2000: A classification system and algorithm for reconstruction of maxillectomy and midfacial defects
Type I (Limited maxillectomy)
One or two walls, preservation of palate
Type II (Subtotal maxillectomy)
Lower 5 walls, preservation of orbital floor
Type III (Total maxillectomy)
Resection of all six walls
Orbital preservation (IIIa) vs exoneration (IIIb)
Type IV (Orbito-maxillectomy)
Upper 5 walls, preservation of palate
Okay and Urken (2001)
Palatomaxillary defects were divided into 3 major classes and 2 subclasses
The aim of this defect-oriented classification system was to organize and define the complex nature of the restorative decision-making process for the maxillectomy patient
