Maxillectomy - Total
Considerations
Plan the appropriate maxillectomy
Medial, inferior, subtotal, total, extended total with possible transcranial skull base approach
Ohngren’s line, an imaginary line drawn from the medial canthus to the angle of the mandible, separates the maxillary sinus into anteroinferior and posterosuperior aspects
Tumors anterior to Ohngren’s line are associated with a better prognosis
Tumors posterior to Ohngren’s line are more likely to have involvement of the orbit and infratemporal fossa and, because of the proximity of these structures, are less curable
Plan for the defect
Loss of oral-nasal separation
Obturator fabrication by the maxillofacial prosthodontist
NLD sacrifice
Immediate DCR
Periorbital involvement
Orbital exenteration and recon
SCC of the hard palate
2006: Cervical metastasis from squamous cell carcinoma of the maxillary alveolus and hard palate
Reconstruction and rehabilitation
2007: A protocol for maxillary reconstruction following oncology resection using zygomatic implants
Preparation
Osteotomes
Powered saws
Obturator
Blood products
Procedure
Total maxillectomy
Lateral rhinotomy incision
possible Weber-Ferguson extension
possible Diefenbach extension (2012: Versatility of Dieffenbach’s Modification of Weber Fergusson’s Approach for Treatment of Maxillary Pathologies
Gingival-buccal incision laterally to the maxillary tuberosity
Cheek flap elevation in the subperiosteal plane
Divide the infraorbital nerve
Expose the periorbital, assess involvement
Divide the NLD
Divide the inferior orbital rim through the trimalar buttress into the ethmoid at the level of the frontoethmoid suture
Remove ethmoid partitions
Divide the palate 2-3 mm ipsilateral to the nasal septum
Preserve the incisors
Divide the soft tissue at the junction of the soft and hard palates laterally to the buccogingival sulcus incision at the posterior maxillary buttress
Divide the lateral orbital wall
Fracture the maxilla from the pterygoid plates
*Expect brisk bleeding from the IMA and venous plexus
Blindly divide the soft tissue attachments at the posterior maxilla
Control the bleeding with packing and then suture ligation of the IMA and bipolar of veins
DCR
STSG to the facial flap facing the maxillary cavity
Insert the prosthesis and fix with lag screw
Pack the maxillary cavity with Xeroform
Close the skin
Approximate the medial canthal tendon to nasal bone periosteum
Remove the tarsorrhaphy suture
Pressure dressing to the face
Post-op
Soft diet
Chlorhexidine swish and spit
Peri-operative antibiotics while packing in place
POD 5 remove prosthesis and packing
Immediate placement of interim prosthesis
Prosthodontist to modify as needed
Final adjustments depend on post-op XRT
Myringotomy with tube for persistent ETD