Operative Techniques in Otolaryngology (2010) 21, 166-170

Total maxillectomy
Amy L. Pittman, MD,a Chad A. Zender, MDb

From the aDepartment of Otolaryngology, Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois;
and the
b
Department of Otolaryngology-Head and Neck Surgery, University Hospitals-Case Western Reserve Medical Center,
Cleveland, Ohio.

KEYWORDS Tumors of the nasal cavity and paranasal sinuses are uncommon and represent both malignant and
Maxillectomy; benign pathology. These neoplasms often present as locally advanced lesions. Depending on the extent
Maxillary sinus of the disease, a total maxillectomy has been traditionally used for eradication of disease successfully.
tumors; Although radiation therapy may be an option, patients treated with surgical excision benefit from
Paranasal sinus preservation of adjacent vital structures. Free tissue transfer provides many reconstructive options for
tumors; the head and neck surgeon and is reliable for restoring near-normal functional recovery.
Orbital exenteration 2010 Elsevier Inc. All rights reserved.

Introduction and indications
Tumors of the nasal cavity and paranasal sinuses are infre-
quent in incidence, making up less than 10% of lesions in
the head and neck region. Most of these tumors are epithe-
lial in origin, with squamous cell carcinoma being the most
common pathologic diagnosis. Tumors may also originate
in the bone, salivary glands, or odontogenic apparatus. Un-
fortunately, malignant lesions of the region tend to mimic
benign disease, thus delaying diagnosis until the tumor
becomes problematic and evident at an advanced stage.
Surgical excision is often a component of, if not the primary
modality in, treatment. This is related to the close proximity
of the nasal cavity and paranasal sinuses to important struc-
tures such as the orbit and brain. Exceptions to this rule
would include lymphoma or other lesions that are respon-
sive to chemotherapy or radiotherapy. Benign lesions usu-
ally require excision alone, whereas malignant neoplasms
are often treated with adjuvant therapy.
When dealing with both benign and malignant lesions,
the operation can be tailored to the tumor type and location.
Inverted papillomas are an example of a benign tumor with
the potential for malignant transformation. They can be
Address reprint requests and correspondence: Chad A. Zender,
MD, Department of Otolaryngology-Head and Neck Surgery, UH Case
Medical Center, 11100 Euclid Ave, Cleveland, OH 44106.
E-mail address: Chad.Zender@UHhospitals.org.
1043-1810/$ -see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2010.07.005
treated with a medial maxillectomy removing the lateral
nasal wall, medial orbital wall, and medial wall of the
maxilla, preserving the hard palate. Another example is
when treating tumors of the alveolus (eg, squamous cell
carcinoma). An inferior maxillectomy removing the inferior
portion of the maxilla and floor of the nose can be per-
formed, preserving the orbital floor and medial components
of the maxilla and nose. When tumors involve the orbital
contents (orbital fat or ocular muscle involvement), an or-
bital exoneration can be performed in conjunction with the
maxillectomy. This article will describe a traditional max-
illectomy with orbital preservation.
Patient selection
Advanced tumors may be unresectable when they begin to
involve the lateral sphenoid sinus (cavernous sinus), intra-
cranial contents, or carotid artery. Ohngrens line is an
imaginary line drawn from the angle of the mandible to the
medial canthus on the ipsilateral side (Figure 1). The line
divides the midface into an anteroinferior and posterosupe-
rior quadrant, with the latter being typically more challeng-
ing to treat and carrying a poorer prognosis.
The extent of the tumor dictates the extent of the max-
illectomy necessary for adequate resection. For example, an
inferior or partial maxillectomy may be sufficient for neo-
Pittman and Zender Total Maxillectomy
Figure 1 Ohngrens line.
plasms confined to the inferior sinus or palate. Conversely,
if there is extension into the skull base, pterygomaxillary
fossa, or infratemporal fossa, then a combination of surgical
approaches may be necessary. A total or complete maxil-
lectomy is indicated for tumors that involve the floor of the
orbit, inferior rim, or posterior maxillary wall.
The extent of therapeutic surgical intervention is dictated
by the general well being of the patient, with careful con-
sideration of comorbid conditions, prognosis, and patients
preference.
Preoperative preparation
History and physical examination, with emphasis placed on
intraoral and intranasal anatomy, are essential. This in-
volves assessment of the nasal cavity and nasopharynx with
an endoscope. The integrity of the infraorbital nerve and
malar soft tissue can reveal extension outside of the max-
illary sinus. Preoperative biopsies of the tumor should be
obtained for histologic confirmation of disease. All patients
should be evaluated with a CT, MRI, or possibly both. CT
will show bony anatomy, but may overestimate the margins
of the tumor. MRI is superior in distinguishing tumor from
surrounding soft tissue.
A dental evaluation should be completed preoperatively
to extract grossly infected teeth but also to take necessary
impressions so that a surgical obturator can be made if soft
tissue reconstruction is not planned. The device is inserted
following excision with the intent of retaining operative
167
packing and to facilitate postoperative swallowing and
speech.
Alternatively, soft tissue reconstruction of the midface
defect can be planned with a reconstructive surgeon. A
microvascular free flap or localregional flap can be used,
depending on anticipated needs postoperatively. This may
include fasciocutaneous, myocutaneous (if bulk is required),
or osseocutaneous flaps. Consultation by an ophthalmolo-
gist may be helpful when determining the potential for
involvement of the orbit.
Surgical technique
The procedure is completed under general anesthetic. A
preoperative dose of a broad spectrum antibiotic is admin-
istered to cover normal flora of the oral and nasal cavities.
In addition, the author typically administers a 10-mg dose of
Decadron, unless otherwise contraindicated. Tarsorrhaphy
is used to protect the globe during the procedure and is
removed immediately post procedure. Traditionally, the sur-
gical approach used for a complete maxillectomy includes a
lateral rhinotomy or a modified WeberFerguson incision.
When not designed appropriately, these incisions can lead to
unsightly scars; however, maintaining the incision within
the borders of the facial subunits can minimize both distor-
tion and functional impact. Although the initial incision for
a complete maxillectomy is similar to that used for a partial
maxillectomy or medial maxillectomy, a much wider expo-
sure is essential. Supraciliary or subciliary incisions may be
made if orbital exenteration is planned. Please illustrate (Dis-
cuss why and when supraciliary and when subciliary). The lip
splitting incision runs along the ipsilateral philtrum to respect
the subunits of the upper lip. The incision is carried through the
skin, subcutaneous tissue, and musculature of the upper lip and
cheek (Figure 2).
A cheek flap is then elevated at the level of the perios-
teum of the anterior maxilla. An upper gingivolabial sulcus
incision is also made intraorally to facilitate in flap elevation
(Figure 3). The infraorbital nerve is encountered just infe-
rior to the infraorbital rim and is divided. Elevation of the
cheek flap extends to approximately 1 cm lateral to the
lateral canthus. The orbicularis oris muscle is retracted ce-
phalic to expose the orbital rim. A freer elevator is used to
lift the periosteum posteriorly along the floor of the orbit.
After the periorbita has been lifted inferiorly and medially,
the lacrimal fossa, lamina papyracea, and lacrimal sac are
identified. The sac and duct are transected, and the sac is
marsupialized. Medial elevation must be carried above the
frontoethmoid suture line, which can be identified by the
anterior and posterior ethmoid arteries. These arteries can be
clipped or bipolared, but care must be used when manipu-
lating the posterior ethmoid artery because of it close prox-
imity to the optic nerve (35 mm). The orbital plate of the
maxilla should be exposed. The orbit is inspected for ex-
tension of tumor, and, if involved, an exenteration is per-
formed. Attention is then turned to the zygoma, where the
attachments of the masseter are transected using electrocau-
168 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010

tery. At this point, the orbital rim is transected at the trima-

lar suture laterally. Medially, the maxilla is transected 2 mm
below the frontoethmoid suture line to avoid entering the
anterior cranial vault. A rongeur, osteotome, or high-speed
cutting drill can be used to make these osteotomies, with all
bony cuts first being marked out using electrocautery (Fig-
ure 4). A malleable retractor is used to protect the orbital
contents while the bones surrounding the globe are manip-
ulated.
Next, the oral cavity is exposed, and a vertical, gingival
incision is made between the lateral incisor and canine. This
is extended superiorly to meet the sulcus and lip incision
and represents the anterior border of a total maxillectomy.
The mucosal incision is then carried intraorally along the
midline hard palate to the junction of the hard and soft
palate. It is then turned laterally around the maxillary tu-
bercle and superiorly up to the gingivobuccal sulcus. The
lateral incisor is extracted to allow for the bony cuts of the
palate to be performed. The palate is then divided with an
osteotome or saw. If possible, the nasal septum should be
left intact (Figure 5).
At this point, the hemi-maxilla can be fractured anteri-
orlyinferiorly and removed from the pterygoid plates with
a curved osteotome. Bleeding can be problematic during
Figure 3 The WeberFerguson incision provides excellent ac-
cess to the hard palate, lower half of the nasal cavity, maxilla,
maxillary sinus, and infratemporal fossa, and allows adequate
exposure if orbital exenteration is indicated.

this process and cannot be controlled until the specimen is

removed entirely. Usually, this involves blindly cutting the
soft tissue attachments posteriorly with curved Mayo scis-
sors. Generally, the source of bleeding is the internal max-
illary artery, which must be packed off until the artery can
be identified and suture ligated or clipped. Good communi-
cation with anesthesia is essential during this part of the
procedure.

Figure 2 The WeberFerguson incision. (A) The lateral rhino-

tomy incision is incorporated in this approach. (B) The incision is
extended inferiorly to include (if needed) a splitting of the upper
lip in midline with sublabial gingivobuccal and palatal extensions.
(C) Superiorly, the incision may be extended in a subciliary fash-
ion or may include a contralateral Lynch extension to provide
adequate access to the orbit.
Figure 4 The approach allows for the bony cuts to be made
across the zygoma laterally, the floor of the orbit (roof of the
maxilla), the medial orbital wall (2 mm below frontoethmoid
suture line) and into the nasal cavity.
Pittman and Zender Total Maxillectomy
Figure 5 Intraoral and palatal incisions are made last because of
the associated bleeding and difficulty in controlling the internal
maxillary artery before the entire specimen is removed. The lateral
incisor is removed to allow for the bony cut through the palate to
be made.
With the entire maxilla removed, the surgical defect can
be examined. The entire maxillary component of the orbital
floor should be absent, with the periosteum intact. The nasal
cavity, pterygoid fossa, and nasopharynx are widely visible.
The wound is then copiously irrigated. What about support
for orbit? Is support even needed? What do you use? At this
point, the defect may be either reconstructed surgically with
a local what kind of local flap or free tissue transfer, or
nonsurgically with an orthodontic prosthesis. The aim for
either of these techniques is to create separation between the
nasal and oral cavity. If an orthodontic prosthesis going to
be used, a previously harvested split thickness skin graft is
then used to line the raw edges of the defect. Xeroform
gauze packing is used to secure the graft and prevent fluid
collection beneath the graft. The orthodontic prosthesis is
then inserted and secured with a lag screw or wired to the
remaining teeth.
Free tissue reconstruction
Reconstruction of the maxillary suprastructure, the perior-
bital region, and the lateral pyriform aperture can be per-
formed at the time of oncological ablative surgery. There is
a relative paucity of local vascularized soft tissue flaps that
can support such a reconstruction. Because the local soft
tissues do not lend themselves to pedicled or rotational
transfer, the most commonly used vascularized tissue for
midface reconstruction has been free tissue transfer. As
previously stated, the purpose of this reconstruction in-
cludes reestablishing a functional separation of the oral and
nasal cavity, thus restoring speech and swallowing. The
surgeon should also aim to re-create both the oral and nasal
mucosa and to provide a watertight seal in doing so. By
reconstructing in this manner, the flap can often be har-
vested at the same time as the ablative procedure, and thus
169
the patient leaves the hospital with a permanent, functional
reconstruction.
One possibility is the rectus abdominis flap. This partic-
ular flap provides a large surface area of vascularized flap,
which can actually be turned on itself to provide dual skin
paddles. It has been used successfully in reconstructing
palatal defects by supplying both an inner and outer lining.
The stability of this flap allows the microvascular pedicle to
survive in any number of environments, making it an espe-
cially hardy flap. The anterolateral thigh also presents a po-
tential donor for this particular type of head and neck defect. Its
long vascular pedicle makes it useful in the reconstruction of
the midface, and the flap provides an ample skin paddle.
Defects that require bulk and the freedom to place epithelial
surfaces in a number of different three-dimensional planes can
be reconstructed using a free latissimus flap. This flap can also
be used to create dual skin paddles. Several reports in the
literature note the efficacy of the latissimus dorsi flap for
complex and extensive defects of the midface and skull base.
There are multiple osseous free tissue flaps that can be
harvested to reconstruct lesions of the midface, including the
fibula, iliac crest, and scapula. The vascular supply in each of
these flaps will usually allow for osteotomies to be made, as the
defect requires, with the ability to re-create a palate, nasal floor,
or orbital floor. Depending on the thickness of the bone har-
vested, dental implants can be used if necessary.
Postoperative care
Oral irrigations should be completed often throughout the day
and postprandially. The patient should be instructed on the use
of gentle saline irrigation of the nasal and exposed sinus cav-
ities. After the second week, more aggressive saline irrigation
is recommended and is often necessary until the mucosa heals.
Adherence to oral exercises of the jaw is essential in preventing
trismus and pain due to inflammation. The patient should also
follow up with the primary surgeon for packing removal and
also with the prosthodontist if a temporary obturator was used.
Follow-up with radiation oncologist may be necessary, de-
pending on the final pathology.
Complications
The close proximity of many vital anatomical structures to
the nasal cavity and paranasal sinuses is responsible for
possible complications due to local extension of the primary
tumor or treatment (surgical resection and radiation ther-
apy). Surgical complications include bleeding, cerebrospi-
nal fluid leak, infection (skin and soft tissue infections,
meningitis, intracranial abscess, osteomyelitis), pneumo-
cephalus, blindness, and facial disfiguration due to exten-
sive resection. Failure to restore the oral and nasal separa-
tion adequately can lead to velopharyngeal insufficiency
and nasal regurgitation during swallowing. Inadequate
dacrocystorhinostomy during the excision can lead to per-
sistent epiphora. Enophthalmos or hypophthalmos due to
170 Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010

loss of orbital support can be prevented or minimized with
appropriate reconstructive techniques.
Discussion
Surgery for tumors of the nasal cavity and paranasal
sinuses can be technically challenging. However, ade-
quate ablation via total maxillectomy can achieve cure in
even locally advanced tumors. The difficulty lies in giv-
ing the patient an oncologically sound resection while
preserving important adjacent structures, without causing
cosmetic deformity. Multiple free tissue transfer possi-
bilities exist for reconstructing midface defects left by a
complete maxillectomy and have been used successfully
in the experience of this author as well as in the literature.