Types of Maxillectomy and Incisions for Maxillary Surgeries
Maxillectomy procedures are classified based on the extent of resection, with the most common types being limited, subtotal, and total maxillectomy, each requiring specific surgical approaches and incisions based on tumor location and extent.
Classification of Maxillectomy
- Limited Maxillectomy (LM): Involves removal of one wall of the antrum, requiring specification of which portion is removed (palate, anterior wall, or medial wall) 1
- Subtotal Maxillectomy (SM): Involves removal of at least two walls of the maxilla, including the palate 1
- Total Maxillectomy (TM): Complete resection of the maxilla, often requiring complex reconstruction 1
- Extended Maxillectomy: Total maxillectomy with additional structures (e.g., orbital exenteration) 2
Anatomical Considerations
- For maxillary sinus tumors, "Ohngren's line" (running from the medial canthus of the eye to the angle of the mandible) helps define the plane through the maxillary sinus 3:
- Tumors "below" or "before" this line involve the maxillary infrastructure
- Tumors "above" or "behind" this line involve the suprastructure 3
Surgical Approaches and Incisions
Limited Maxillectomy Approaches
- Peroral approach: Direct access through the mouth, used for accessible anterior lesions 1
- Medial maxillectomy: Used for lesions of the lateral nasal wall, providing excellent exposure with minimal morbidity 4
- Upper cheek flap: Access through the cheek for specific lesions 1
- Transfacial approach: External approach through facial incisions 1
Subtotal and Total Maxillectomy Approaches
- Cheek flap approach: Used in approximately 90% of subtotal and total maxillectomies 1
- Weber-Ferguson incision: Classic approach for total maxillectomy, involving an incision from the medial canthus, along the lateral aspect of the nose, around the ala, and through the upper lip 2
- Combined endoscopic and transoral approach: Modern technique that avoids facial incisions and provides better visualization of surgical margins 5
Reconstruction Options
- For limited defects: Local flaps or prosthetic rehabilitation may be sufficient 2
- For subtotal and total maxillectomy:
- Free flaps are preferred (91.7% of cases), with rectus abdominis and radial forearm flaps being most common 2
- Temporalis muscle transposition may be used in elderly patients who are not free-flap candidates 2
- Vascularized bone flaps or non-vascularized bone grafts may be incorporated for structural support 2
- For bilateral maxillectomy defects:
Surgical Principles
- En bloc resection of the primary tumor should be attempted whenever feasible 3
- In-continuity neck dissection is necessary when there is direct extension of the primary tumor into the neck 3
- Surgical resection should be planned based on clinical examination and careful interpretation of appropriate radiographic images 3
- Frozen section margin assessment should be considered when it will facilitate complete tumor removal 3
- Adequate resection is defined as clear margins with at least 1.5-2 cm of visible and palpable normal mucosa 3
Complications and Management
- Schneiderian membrane perforation is the most common intraoperative complication during sinus procedures (19.5% of cases) 7
- Postoperative complications may include abnormal bleeding, infections, and subacute sinusitis 3
- Retained secretions in the maxillary sinus may require removal during follow-up endoscopy 3
- Synechiae (bridging scar formation) may occur postoperatively, potentially requiring revision surgery 3
Functional Outcomes
- After maxillectomy reconstruction, approximately 44.4% of patients return to an unrestricted diet, 47.2% to a soft diet, and 8.3% to a liquid diet 2
- Speech outcomes: 38.9% normal, 41.7% near normal, 16.7% intelligible, and 2.8% unintelligible 2
- Dental rehabilitation with prosthetic dentures is possible in approximately 41.7% of patients 2