18

MAXILLECTOMY
HARRY C. SCHWARTZ, D.M.D., M.D., F.A.C.S.

Cancers of the paranasal sinuses are rare, comprising
only about 3 per cent of all head and neck
malignancies. The maxillary sinus is by far the most
common primary site. Squamous cell carcinomas
predominate, followed by adenocarcinomas. Adenoid
cystic carcinomas, sarcomas, and other tumors occur
much less frequently.
Maxillary sinus carcinomas are rarely encountered
while still confined within the thin bony walls of the
antral cavity. Widespread extension of tumor beyond
the antrum led to discouraging results early in this
century when radiotherapy and/or cautery was the
common mode of treatment. With the advent of safe
endotracheal anesthesia, blood and fluid replacement,
antibiotics, and maxillofacial prosthetics, the current
methods of treatment have evolved. These combine
en bloc tumor resection, including maxillec-tomy and,
where necessary, removal of the involved orbit, cheek,
pterygoids, soft palate, nasopharynx, ethmoid or
sphenoid sinuses, and skull base, with radiotherapy.
The radiotherapy may be administered routinely, or it
may be reserved for those cases with inadequate
resection margins.
INDICATIONS FOR SURGERY
The decision to perform a maxillectomy is based
upon the pathology of the tumor, the degree of local
extension, the presence of nodal or distant metas-
tases, the general physical condition and age of the
patient, and numerous other factors. These factors
should be completely evaluated at a multispecialty
head and neck tumor conference. A detailed discus-
sion is beyond the scope of this chapter.
PREOPERATIVE ASSESSMENT AND
DECISION MAKING
A complete history and physical examination are
necessary prior to surgery. This subject is discussed
in Chapter 17.
MAXILLECTOMY 251
Examination of the head and neck helps to delin-
eate the degree of tumor involvement. Bulging of the
alveolus or palate, with malocclusion, mobile teeth, or
a poorly fitting upper denture, may indicate downward
extension. Infraorbital edema or anesthesia and
diplopia may indicate upward extension. Bulging of
the cheek and fixation of the skin to underlying bone
are indicative of anterior extension. Polypoid tissue in
the nose, epistaxis, or nasal discharge can result from
medial extension.
A preoperative computed tomography (CT) scan is
essential for all patients. It is far more sensitive than
standard radiographs or tomograms for delineating
bony expansion or destruction and the extent of the
soft tissue mass. It is of enormous help in planning
the resection.
Every patient should be evaluated by a maxillofacial
prosthodontist prior to surgery. Impressions are taken
for construction of a surgical obturator. If there are
teeth in the contralateral maxillary arch, all acute or
impending dental problems must be dealt with. As
many teeth as possible are salvaged for retention of
the obturator. In edentulous patients the obturator is
fixed by internal skeletal suspension. The surgeon
outlines the proposed resection on the dental model
so that the prosthodontist can fabricate an appropriate
appliance.
Upon completion of the preoperative assessment,
decisions must be made regarding the surgical ap-
proach; the extent of the tumor resection (including
the need for orbital exenteration, ethmoidectomy,
resection of facial skin, soft palate, or pterygoids, and
combined craniofacial resection); the necessity for
neck dissection; the requirements for flaps, grafts, or
other reconstructive procedures; and the design of the
surgical obturator. The surgeon must be sufficiently
flexible to allow for modification of the surgical
treatment plan and the obturator based on
intraoperative findings. Consent for removal of the
eye should be obtained from all patients, regardless of
the anticipated extent of resection.
252 MAXILLECTOMY
SURGICAL APPROACH AND
INTRAOPERATIVE PROBLEMS
Access to the maxilla is generally attained utilizing
the classic Weber-Fergusson incision. The eyelids are
approximated with a temporary tarsorrhaphy suture. It
is helpful to tattoo the vermilion border and other
points on both sides of the incision with methylene
blue. These points are then matched during closure.
The usual incision splits the midline of the upper lip
(Fig. 18-1A). An improved cosmetic result can be
obtained by incising along one of the philtral ridges
and then offsetting the incision at the vermilion
border (Fig. 18-IB and C). The incision turns laterally
at the base of the columella, then around the alar base
and along the side of the nose to within 2 mm of the
medial canthus. It then turns laterally once again, 2
mm below the lower lid margin, to the lateral canthus.
Intraorally, the incision is continued down through the
gingival margin, several millime-
ters to the proximal side of the midline if possible. It
is connected with a horizontal incision, in the depth
of the labiobuccal vestibule, extending back to the
maxillary tuberosity. From here the incision turns
medially across the posterior edge of the hard palate. It
then turns 90 degrees anteriorly, several millimeters
to the proximal side of the midline if possible, to
cross the gingival margin once again (Fig. 18-ZA). The
incision is carried to bone, except beneath the lower
lid, where the orbicularis oculi muscle is preserved. If
a Caldwell-Luc procedure was done previously for
biopsy, the incision must be included in the resection.
The cheek flap is then reflected back to the tuberosity
(Fig. 18-3A). The thickness of the flap depends upon
whether the tumor has crossed the anterior wall of the
maxilla. If this area is involved, several millimeters
of subcutaneous tissue must be left attached to the
bone. If skin is also involved, it should be excised
with a 1-cm margin of normal tissue. It is
reconstructed later with a flap.
254 MAXILLECTOMY
 The central incisor on the involved side is ex-
tracted, and the gingiva and palatal mucosa that were
retained are elevated back to the midline. The
incision extending around the nose is deepened into
the nasal cavity. The palatal bone is then divided near
the midline with a micro bone saw or a Gigli saw.
The nasal bone is next separated from the frontal
process of the maxilla with an osteotome or saw. The
orbicularis oculi muscle is retracted superiorly, and
the bone cut is extended across the maxilla, just
below the infraorbital rim, into the zygoma. If the
posterior wall of the antrum has not been invaded by
tumor, it is separated from the pterygoid plates with a
curved osteotome. Large curved scissors are then
placed behind the maxilla, the remaining attachments
are divided, and the specimen is removed (Fig. 18-4A).
At this stage there is often brisk bleeding. Branches
of the maxillary artery in the pterygomaxillary fissure
may require ligation. Much of the bleeding can be
controlled with packing and electrocautery. While the
packing is in place, the specimen should be inspected
to be sure that all tumor has been resected. The
packing is then removed, and any areas of residual
tumor are assessed fur further excision.
When tumor extends up to (but does not invade)
the roof of the antrum, the orbital floor should be
included in the resection (Fig. 18-4C). The perios-
teum is incised at the infraorbital rim, and it is
elevated from the orbital floor. Care is taken to
preserve an intact periorbita, as this usually main-
tains the level of the eye and prevents diplopia. The
orbital contents are then retracted upward for the
bone cuts.
When tumor invades the roof of the antrum, the
orbit, or the ethmoid sinuses, orbital exenteration
becomes necessary. The skin incision is carried
around both lid margins (see Fig. 18-1). The upper
lid skin is then undermined (see Fig. 18-3B) to expose
the superior orbital rim, where periosteum is incised
and reflected back to the optic pedicle. The pedicle
MAXILLECTOMY 255
is divided and the orbital contents are removed en
bloc with the maxilla, the entire orbital floor, and the
medial orbit (including the ethmoid sinuses and
lacrimal bone) (Fig. 18-4D).
Early tumors confined to the posterior antrum may
be treated with a more conservative resection that
spares the premaxilla (Fig. 18-4B). This greatly en-
hances the stability of a prosthesis, but it should
never be done at the expense of sound oncologic
surgical principles. The bone is divided through the
socket of the first premolar. The cut is taken across
the palate to the midline and across the anterior wall
of the maxilla, above the roots of the retained incisors
and canine, to the nasal cavity (see Fig. 18-2B).
After hemostasis has been obtained, appropriate
management of the maxillectomy defect will greatly
assist the prosthodontist in rehabilitation of the pa-
tient. All sharp bony projections should be trimmed.
The coronoid process of the mandible should be
removed, since its close proximity to the lateral
margin of the defect often causes the seal of the
prosthesis to be broken when the mouth is opened.
The flap of retained palatal mucosa is turned up to
cover the medial bony margin. This places thick,
keratinized mucosa at the point where the prosthesis
will fulcrum. A split thickness skin graft is then
sutured to the wound margins, preferably in a single
sheet (Fig. 18-5A). The undersurfaces of the cheek
flap, bone, muscle, periorbita, and even dura are all
covered. The graft is maintained in the defect with
iodoform gauze packing impregnated with tincture of
benzoin (Fig. 18-5B). Sufficient packing is used to fill
out the cheek contour. The surgical obturator,
previously fabricated by the prosthodontist (Fig. 18-
6A), is then relined with a soft denture reliner so that
it supports the packing and seals the defect (Fig. 18-
6B). The obturator is either fixed to the teeth or
suspended, depending upon the individual situation.
The cheek flap is then turned back and closed in
layers (Fig. 18-6C).
256 MAXILLECTOMY
POSTOPERATIVE MANAGEMENT
Patients are best kept in an intensive care unit for
the first 1 or 2 days for cardiovascular monitoring
and necessary replacement of blood, fluids, and
electrolytes. Most patients can ambulate on the first
postoperative day. Unnecessary lines and catheters
should be removed as soon as possible.
The use of the surgical obturator greatly simplifies
postoperative care. It enables the patient to take a
liquid diet by mouth immediately and prevents the
build up of debris in the mouth. Tooth brushing and
saline rinses are all that is needed for oral hygiene.
More importantly, the obturator promotes psycho-
logical well-being by virtually eliminating any visible
deformity.
Prophylactic antibiotic therapy is advisable. A drug
that covers oral and nasal/sinus flora, such as a
cephalosporin, should be chosen. Antibiotics are best
started on the day before surgery and continued for 5
days postoperatively. Additional antibiotic therapy is
based upon objective evidence of infection and the
results of wound cultures. Since the therapy leaves a
large open cavity that is drained by gravity, infection
is rare.
There is no need to remove the surgical obturator
for 2 to 3 weeks if the proper packing has been used.
Vaseline gauze or gauze impregnated with antibiotic
ointment becomes quite foul after 5 to 7 days and is
best avoided. When the packing is removed, the
cavity is irrigated with warm saline and hydrogen
peroxide. Excess skin graft and other debris are
removed. The obturator is then modified as needed
for contour and retention and to prevent reflux of
fluids. It is important to remember that the skin graft
will contract rapidly if permitted to. The obturator
should only be removed for cleaning. The contour of
the cheek must be maintained by the appliance.
Many patients will undergo postoperative radio-
therapy. This may be started at 3 to 4 weeks. Al-
though new impressions for a definitive obturator
may be taken at any time, it is usually best to wait
until radiotherapy has been completed. Patients who
do not have postoperative radiotherapy may have
impressions taken as soon as 3 to 4 weeks after
surgery.
LONG-TERM PROGNOSIS
Prognosis depends upon the specific pathology, the
degree to which tumor has spread beyond the
confines of the antrum, and the presence of metas-
tases. Unfortunately, many tumors are well advanced
before they become symptomatic, and these have a
poor prognosis.
KEY REFERENCES
Gullane, P.J., Conley, ].: Carcinoma of the maxillary sinus. J
Otolaryngol 12 141, 1983 Lang, B.R., Bruce, R.A.: Presurgical
maxillectomy prosthesis. J
Prosthetic Dent 17:613, 1967. Larson, D.L., Christ, J.E , Jesse,
R.H.. Preservation of the orbital
contents in cancer of the maxillary sinus Arch Otolaryngol
108:370, 1982. Lederman, M.: Tumors of the upper jaw, natural
history and
treatment. J Laryngol 84:369, 1970
Mmami, R.T., Hentz, V R : Application of maxillofacial instruments
and techniques to mandibulectomy and maxillectomy
Clm Plast Surg 9-541, 1982. Sisson, G.A., Johnson, N.E., Amiri,
C.S . Cancer of the maxillary
sinusclinical classification and management. Ann Otolaryngol
72:1050, 1963 Weber, A.L., Stanton, A.C.: Malignant tumors of the
paranasal
sinuses, radiologic, clinical and histopathologic evaluation of
200 cases. Head Neck Surg 6.761, 1984.