all maxillectomy types in detail and maxillofacial resection ,indications ,contraindications ,preoperative asssessment and detail techniques and rehabilitations
3. 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 and
nasopharyngeal neoplasm
• May be needed in patients with extensive fungal /granulomatous infections
• Malignant tumors of oral cavity with extensive involvement of palate
• Not indicated in the management of tumors which are better managed by
chemoradiation (lymphoma and rhabdomyosarcoma )
4. Contraindication
• Distant metastases
• Gross brain invasion
• Central skull base invasion
• Bilateral optic nerve or chiasm infiltration.
• Extension through the sphenoid sinus walls
• Significant trismus
• Poor general condition of the patient
• Patient not consenting to undergo the procedure
11. Preoperative evaluation
Preoperative consent includes discussing,
• The facial incisions
• Loss of sensation in the infraor-bital nerve distribution,
• Diplopia, epiphora, enophthalmos,potential injury to the optic nerve,
• CSF leak.
• Consent for harvesting graft/flap if tissue reconstruction is intended
12. Medial Maxillectomy
Indicated for
• Low-grade malignant tumors, inverted papillomas, and other tumors of limited
extent on the lateral wall of the nasal cavity or the medial wall of the maxillary
antrum.
27. • Step 7: Exposure of the Anterior, Inferior, or
Lateral Maxillary Sinus (When Necessary)
• Use backbiting instruments to resect the
lacrimal bone (and nasolacrimal duct) up to
the nasal aperture.
• Perform proper EDCR if NLD is
transected
29. POSTOPERATIVE CONSIDERATIONS
• Irrigation with saline solution
• Serial in office debridement
• patient should be instructed to massage the nasolacrimal
duct externally during the postoperative period.
• Long term surveillance for recurrence
30. Total Maxillectomy
• Complete removal of the maxilla becomes necessary when :
• primary tumor arising from the surface lining of the maxillary sinus fills up the entire
antrum.
• Primary mesenchymal tumors arising in the maxilla such as soft tissue and bone
sarcomas also require total removal of the maxilla to encompass the entire lesion.
44. Total Maxillectomy with Orbital
Exenteration
• Indicated when a primary tumor of the nasal cavity or paranasal sinuses extends into
the orbit through the orbital periosteum.
• Orbital exenteration of a functioning eye with normal vision is considered only if the
possibility of a curative resection exists
• Removal of a functioning eye for a palliative operation is not recommended.
• facial moulage and clinical photographs should be obtained to facilitate subsequent
fabrication of a facial prosthesis.
45. Peroral Partial Maxillectomy
• Indicated for small tumours of the hard palate and superior alveolus
• CT scans in axial and coronal planes is mandatory for accurate delineation of the
extent of the tumor before embarking on a peroral partial maxillectomy
48. Complications:
• Intraoperative hemorrhage
• Troublesome Epiphora
• Damage to orbital structures
• . Damage to cornea
• Loss of vision
• Velopharyngeal incompetence (Nasal leak of ingested fluids)
• Cosmetic defects / scars
• Trismus due to scarring of muscles of mastication
49. Anterior Craniofacial Resection
• Indicated for tumors involving the anterior skull base
• It allows wide exposure of the complex anatomical structures at the base of skull
permitting monobloc tumor resection
• Classical CFR consists of transfacial/transnasal and transcranial approaches
• Recently, endoscopic assisted CFR has been used as substitutive for the open
transfacial approach.
• Pure endoscopic approach, without a transcranial approach, has been attempted for
tumor removal in the anterior skull base
50. OPEN CFR
• Preoperative broad-spectrum antibiotics should be given because of the connection
between the sinonasal cavity and the cranial cavity.
• A lumbar puncture is performed to decompress the brain and minimize retraction
70. Reconstruction
Goals of Maxillary Reconstruction
1. Obtain a healed wound.
2. Restore palatal competence and function.
3. Restore normal mastication and deglutition.
4. Support the eye.
5. Maintain a patent nasal airway.
6. Support and suspend facial soft tissues.
7. Restore the midfacial contour.
72. Obturators
Advantages
• Shortens operative time
• Shortens post op hospital stay
• Better visualization for surveillance
• Helps in speech and swallowing
• Restores aesthetics
Disadvantages
• Hypernasal speech
• Regurgitation of food and fluids into nasal
cavity
• Difficulty maintaining hygiene
• Need for repeated adjustments
73. Microvascular Free Flaps
• Indicated for large defects
• Matching to three-dimensional shape of defect
– Provide bone, palatal and nasal lining, skin, soft tissue
• Requires vascular pedicle 10-15 cm long
• Multiple different options
– Myocutaneous
– Osteomyocutaneous
– Combination with free bone grafts
74. Free Flaps
• 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
Extension through the sphenoid sinus walls often suggests involvement of the carotid arteries or penetration into the cavernous sinus,
Significant trismus is suggestive of gross invasion into the pterygoid musculature
Gingivobuccal incision
Bilateral septocolumellar and intercartilaginous incisions., Transfixion incision.
Lateral rhinotomy incision (mours incision )
Weber furgusson incisions and its modification
CT clearly demonstrates bone abnormality; however, it may overestimate the extent of tumor
MRI distinguishes tumor from surrounding soft tissue and is especially valuable in differentiating tumor from
secretions resulting from sinus obstruction . MRI also demonstrates perineural spread better than CT
does.
Multidicplinary team approach
CT scan of patient with inverted papilloma
done under general anesthesia with orotracheal intubation
INCISION is marked and infiltrated with local antiesthetic with adrenaline 1:100000
tarsorraphy or ceramic corneal shield
The skin incision is deepened through the soft tissues and
the musculature of the upper lip and cheek up to the anterior bony wall
of the maxilla.
As the cheek flap is elevated, the infraorbital nerve near the orbital rim is carefully preserved.
Nasal cavity is entered
Anterior antrostomy is done
A silk suture is placed through the detached medial canthal ligament and left long for identification, for subsequent reapproximation to the nasal bone.
Malleable retractor
Frontoethmoidal suture
Anterior and posterior ethmoid foramena
Anterior antrostomy
Osteotomies are made along the floor of the nose through the bone between the antrum and the nasal cavity (A), through the
frontal-ethmoid suture below the level of the anterior ethmoid artery (B), and along the medial floor of the orbit to the posterior wall of the antrum
The soft tissue attachment removed with scissors
Nasolacrimal duct
Endoscopic
images showing reflection
of the middle turbinate
medially to reveal the
contents of the middle
meatus. Polyps and tumor
can be debulked with
instruments or a tissue
shaver.
Perform a subtotal inferior turbinectomy using endoscopic
scissors by incising between the anterior one
third and the posterior two thirds of the turbinate,
just behind the Hasner valve
Angled Beaver blade
Use downbiting instruments and a high-speed irrigating
drill to resect the medial maxillary wall down
to the nasal floor
Endoscopic image showing the mucosal flap
redraped along the floor (asterisk) and into the maxillary
sinus defect when the procedure is complete.
The pedicle is resected
and the surrounding
bone drilled away to
remove nests of tumor
within the bone. B, The
area of attachment
(circle) has been drilled
down.
*
Introral picture
Odontogenic myxoma
Skin of eye lid raised crefully
Orbicularis oculi muscle
The upper cheek flap is elevated approximately 1 cm
lateral to the lateral canthus of the eye to provide sufficient exposure of
the entire anterior and anterolateral wall of the maxilla
Subperiosteal dissection of the orbital contents in the lower part of the orbit permits excision of the orbital plate of the
maxilla, which will be the superior margin of the surgical specimen.
Division of the attachment of the masseter muscle on the
inferior border of the zygoma
The palatal incision is extended posteriorly in the midline
up to the junction of the hard and soft palate, at which point it turns
laterally behind the maxillary tubercle up to the gingivobuccal sulcus.
2-Entry is made into the nasal cavity by opening the
vestibule of the nasal cavity through the piriform recess to expose the
nasal process of the maxilla.
When Soft tissue dissection is completed
Mark the osteotomy site with cautery
The proposed bone cuts for total maxillectomy are marked
on the patient with the use of electrocautery.
Superomedially, the nasal process of the maxilla is divided
Superolaterally, the maxilla is separated from the zygomatic arch,
inferiorly the maxilla is divided through its alveolar
process between the lateral incisor and canine tooth up to the
midline and from there onward through the midline up to its posterior margin
Inferolaterally, the maxilla is separated from the pterygoid plates through its hamulus to provide a monobloc
resection.
high-speed power saw is used
Oscillating saw
Curved osteotome
A split-thickness skin graft is used to line the facial flap and cover the exposed soft tissue in the infratemporal fossa.
An intraoral view 3 months after surgery.
Final prosthesis
Gingivobuccal incision with a periosteal elevator used to elevate the periosteum up to the level of the inferior orbital nerve.
Antrostomy with visualization of the maxillary sinus floor and infraorbital rim.
The hard palate is transected to the midline and into the maxillary sinus while trying to avoid the lateral nasal wall and nasal cavity
Posterior osteotomy created by aiming superomedially
A split-thickness skin graft is used to line the raw surfaces
due to over packing the maxillectomy cavity compromising vascularity of optic nerve
In 1997, Yuen et al. cranionasal resection
Due to the development of the endoscope technique and instruments,
Olfactory neurblastoma (esthisoneuroblastoma
After the scalp hair is shaved
, a bicoronal incision is made from ear tragus to ear
tragus down through the subcutaneous tissue and down to the
plane superficial to the galea aponeurotica
The scalp flap is elevated in a plane superficial to the galea aponeurotica and the pericranium.
The posterior scalp flap is retracted significantly to obtain a generous portion of the galea and pericranium for the pedicled flap.
Raney clips.
The proposed line of incision (U-shaped) in the pericranium for the elevation of a galeal-pericranial flap for subsequent use
during repair of the skull base
Complete elevation of the flap over the calvarium exposes the underlying frontal bone
A retractor placed in the center of the field shows the exposed upper part of the nasal bones and the supraorbital ridges bilaterally.
The proposed line of the bone cut is marked on the anterior wall of the frontal sinus and the frontal bone.
A single burr hole is made in the midline and dural elevators are used to elevate the dura adjacent to the burr hole on both
sides to permit introduction of the side-cutting Midas Rex saw
The mucosa of the frontal sinus is completely curetted out,and its posterior wall is removed to cranialize the sinus.
The dural sleeves have been divided and ligated.
A retractor placed along the midline over the sagittal sinus exposes the posterior part of the cribriform plate and the planum sphenoidale.
Before this anesthetist is asked to withdrow 15-20 ml csf from lumber drain
A high-speed drill with a fine burr is used to make the bone cuts through the floor of the anterior cranial fossa.
the bone cut goes through the roof of the left orbit, remaining lateral to the lamina papyracea on the left side, through the
sphenoid sinus posteriorly, and through the cribriform plate, remaining medial to the lamina papyracea on the right-hand
Bone cuts are now made through the nasal process of maxilla and through the lacrimal fossa and the anterior aspect of the
lamina papyracea within the orbit on the left-hand side.
The medial wall of the maxilla in its lower part is divided with an osteotome through the floor of the nasal cavity as far as back
posteriorly as possible.
The incision in the nasal septum
galeal pericranial pedicled flap is swung down to cover the bony defect in the skull base
The craniotomy is closed with appropriate miniplates
Suction drain placed extradural space