Dr T Balasubramanian

Otolaryngology online 1

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
History
Otolaryngology online 2

Bleeding was the most common danger
Complications due to anesthesia
Post op sepsis
Secondary deformity due to poor prosthesis support
Dangers - Historic
Otolaryngology online 3

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
Indications
Otolaryngology online 4

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
Tips
Otolaryngology online 5

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
Contraindications
Otolaryngology online 6

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
Bilateral tumors
Otolaryngology online 7

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
Imaging
Otolaryngology online 8

CT
Otolaryngology online 9

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
Ocular evaluation
Otolaryngology online 10

Bleeding
Infection
Epiphora
Break down of skin graft
Numbness of cheek area
Atrophic rhinitis
Complications
Otolaryngology online 11

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
Bleeding
Otolaryngology online 12

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
Infection
Otolaryngology online 13

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
Epiphora
Otolaryngology online 14

Caused due to transection of infraorbial nerve
Infraorbital nerve can be conserved if not involved
by the tumor
Numbness of cheek area
Otolaryngology online 15
Otolaryngology online 16

Consent issues
Dental extraction
Tracheostomy
Prosthesis issues
Cosmetic defects
Otolaryngology online 17

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
Surgical steps
Otolaryngology online 18

Incision
Weber Fergusons
incision is used
Lateral rhinotomy
incision with horizontal
infraorbital component
and midline lip split
Otolaryngology online 19

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
Otolaryngology online 20

Infraorbital component
This is the horizontal
component of weber
Fergusons incision
Made about 1 mm
below the infraorbital
rim
Otolaryngology online 21

Flap
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Bone cuts
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Palatal cut
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Zygoma cut
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Maxilla removal
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Prosthesis
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Specimen
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Closure
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Temporary tarsorraphy
Corneal shield
Significant laceration of periorbita should be
sutured
Eye protection
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