What is the step-by-step surgical procedure for a right maxillectomy?

Surgical Procedure for Right Maxillectomy

The right maxillectomy procedure involves careful preoperative planning, appropriate surgical approach selection, and meticulous execution of a step-by-step technique to ensure complete tumor removal while minimizing complications.

Preoperative Considerations

• Comprehensive radiographic evaluation with three-dimensional imaging is essential to identify specific anatomy, presence of sinus septa (found in approximately 30% of patients), and anatomical variations 1
• Consultation with an otorhinolaryngologist is recommended if there is a history of sinusitis or related symptoms 1
• Ensure adequate antibiotic prophylaxis has been administered 1
• Prepare all surgical materials, sterile instruments, and necessary equipment 1
• Consider "Ohngren's line" for tumor classification, with tumors "below" this line involving maxillary infrastructure and tumors "above" involving suprastructure 2

Surgical Technique

Step 1: Patient Preparation and Approach

• Disinfect the perioral region thoroughly 1
• Place sterile drapes appropriately 1
• Administer local anesthesia with vasoconstrictor in the surgical area 1
• Select the appropriate surgical approach based on tumor location and extent:
  • For limited maxillectomy: peroral, medial maxillectomy, anterior craniofacial, upper cheek flap, or transfacial 3
  • For subtotal or total maxillectomy: cheek flap approach is most common 3

Step 2: Incision and Exposure

• Make a supracrestal incision with vertical release to access the area 1
• Elevate a complete mucoperiosteal flap to visualize the lateral wall of the maxillary sinus 1
• For more extensive resections, consider a Weber-Ferguson incision with possible extensions based on tumor extent 2

Step 3: Bone Resection

• Create an access window using a diamond round bur with a high-speed handpiece, piezoelectric equipment, and/or manual bone rasp 1
• Position the window near the zygomatic process to optimize access 1
• For total maxillectomy, make osteotomies at the following locations:
  • Frontal process of the maxilla
  • Zygomaticomaxillary buttress
  • Pterygomaxillary junction
  • Hard palate (midline or paramedian) 2, 4

Step 4: Tumor Removal

• Carefully detach the sinus membrane from the bony walls using sinus membrane elevators and/or blunt piezoelectric tips 1
• Perform en bloc resection of the tumor whenever feasible 2
• Ensure adequate resection with clear margins of at least 1.5-2 cm of visible and palpable normal mucosa 2
• Consider frozen section margin assessment to facilitate complete tumor removal 2
• For tumors extending to the orbit, orbital exenteration may be necessary (required in 71% of total maxillectomy cases) 3

Step 5: Hemostasis and Reconstruction

• Achieve meticulous hemostasis, particularly around the posterior superior alveolar artery to prevent abnormal postoperative bleeding (occurs in 14.5% of cases) 1
• Select appropriate reconstruction method based on defect classification:
  • For limited maxillectomy: local flaps or skin grafts may be sufficient 3
  • For subtotal or total maxillectomy: consider myocutaneous flaps, osteomyocutaneous flaps (allowing for dental implantation), or obturation with prosthetic appliance 5, 6
  • Complex repair is required in approximately 16% of cases, most often in total maxillectomy (37%) 3

Step 6: Closure and Postoperative Care

• Close the surgical site in layers, ensuring proper tissue approximation 1
• Schedule follow-up appointment 10-14 days postoperatively for suture removal, cleaning, and reinforcement of instructions 1
• Prescribe broad-spectrum antibiotics (amoxicillin 500mg TID for 7 days or clindamycin 300mg TID for 10 days if penicillin-allergic) 7
• Prescribe appropriate pain management (NSAIDs such as ibuprofen 600mg TID or acetaminophen 500mg TID) 7
• Consider corticosteroids in decreasing doses (dexamethasone 8mg day of surgery, 6mg day after, 4mg two days after, 2mg three days after) to reduce edema and trismus 7

Potential Complications and Management

• Schneiderian membrane perforation (most common intraoperative complication, 19.5% of cases): seal with absorbable barrier membrane or fibrin construct 2, 1
• Abnormal postoperative bleeding (14.5%): typically associated with damage to posterior superior alveolar artery 2
• Postoperative infections and subacute sinusitis (1.0% and 0.2%): require surgical drainage, debridement, removal of graft material, broad-spectrum antibiotics, and close monitoring 2
• Subacute sinusitis (manifests 3-7 days postoperatively): associated with severe suborbital pain and may lead to complete graft failure or secondary infections that can spread beyond the antral cavity 7

Classification of Maxillectomy

• Limited maxillectomy: removal of one wall of the antrum 3
• Subtotal maxillectomy: removal of at least two walls, including the palate 3
• Total maxillectomy: complete resection of the maxilla 3