What are the different types of maxillectomy?

Types of Maxillectomy

Maxillectomy procedures are classified into three main categories based on the extent of resection: limited maxillectomy, subtotal maxillectomy, and total maxillectomy, with further subclassifications based on orbital involvement and palatal resection. 1

Main Classification Systems

Cordeiro and Santamaria Classification

• Type I: Limited Maxillectomy - Removal of one wall of the maxillary antrum 2
• Type II: Subtotal Maxillectomy - Removal of at least two walls including the palate 2
• Type III: Total Maxillectomy - Complete resection of the maxilla, further subdivided into:
  • Type IIIa: Total maxillectomy with preservation of orbital contents 2
  • Type IIIb: Total maxillectomy with orbital exenteration 2
• Type IV: Orbitomaxillectomy - Resection of the orbital contents with varying portions of the maxilla 2

Brown and Shaw Modified Classification

This system classifies maxillectomy defects based on vertical and horizontal components:

Vertical Component:

• Class 1: Maxillectomy without an oro-antral fistula 3
• Class 2: Low maxillectomy (not including orbital floor or contents) 3
• Class 3: High maxillectomy (involving orbital contents) 3
• Class 4: Radical maxillectomy (includes orbital exenteration) 3

Horizontal Component:

• a: Unilateral alveolar maxillectomy 3
• b: Bilateral alveolar maxillectomy 3
• c: Total alveolar maxillary resection 3

Surgical Approaches for Different Maxillectomy Types

Limited Maxillectomy Approaches

• Peroral approach - Used for smaller, more accessible lesions 1
• Medial maxillectomy - For lesions of the medial wall 1
• Upper cheek flap - Provides access to the anterior and lateral walls 1
• Transfacial approach - For more extensive limited resections 1
• Anterior craniofacial approach - When superior extension is present 1

Subtotal and Total Maxillectomy

• Cheek flap approach - Used in approximately 90% of subtotal and total maxillectomy cases 1
• Extended approaches - May include orbital exenteration in cases of orbital invasion (71% of total maxillectomy cases) 1

Reconstruction Considerations

Reconstruction Based on Defect Type

• Limited maxillectomy: Often can be managed with local tissue rearrangement or prosthetic rehabilitation 2
• Subtotal maxillectomy: May require free tissue transfer, particularly rectus abdominis or radial forearm flaps 2, 4
• Total maxillectomy: Almost always requires free tissue transfer for optimal functional and aesthetic outcomes 2
• Orbital defects: Following orbital exenteration, covering is required to promote healing and protect underlying bone 5

Free Flap Selection

• Rectus abdominis flap - Preferred for larger volume defects in total maxillectomy 2, 4
• Radial forearm flap - Better for smaller defects requiring thin, pliable tissue 2
• Osteocutaneous flaps - When bony reconstruction is needed 2
• Temporalis muscle flap - Alternative in elderly patients who are not free-flap candidates 2

Functional and Aesthetic Outcomes

• Chewing function: Return to unrestricted diet is achieved in approximately 44% of patients after subtotal or total maxillectomy 2
• Speech function: Normal or near-normal speech is achieved in approximately 80% of patients 2
• Aesthetic results: Generally better when cheek skin and lip are preserved (58% good to excellent outcomes) versus when external skin or orbital contents are excised (42% poor to fair outcomes) 2

Clinical Considerations in Maxillectomy Planning

• Preoperative imaging: Essential for determining extent of resection and reconstruction planning 6
• Sinus septa: Present in approximately 30% of patients, may complicate the surgical approach 6
• Otorhinolaryngology consultation: Recommended when medical history is positive for sinusitis symptoms 6
• Schneiderian membrane perforation: Most common intraoperative complication during sinus procedures, occurring in approximately 19.5% of cases 6

Special Considerations for Full Thickness Defects

• Full thickness maxillectomy defects extending into the sinus (ClinRad stage III) can be reconstructed with myocutaneous flaps or osteomyocutaneous flaps, with the latter allowing for dental implantation 6
• Obturation with prosthetic appliance may be considered for patients who are poor candidates for microvascular surgery 6