 to OMFS lecture series. Continuing with surgical management of jaw tumors, we shall be discussing maxillectomy in this lecture. Maxillectomy is a general term for procedure carried out to reset any extensive neoplasm affecting the upper jaw. So, what exactly is maxillectomy? Total maxillectomy refers to surgical resection of the entire unilateral maxilla. As you know, maxilla is a paired bone. So, resection of unilateral maxilla is termed as total maxillectomy and resection of entire maxilla or entire bilateral maxilla is termed complete maxillectomy. This includes the resection of the floor and medial wall of the orbit and also the etymol sinuses. The osteotomies or the resection may be extended to include orbital excentration. It means removal of complete orbital contents that is orbital excentration, spinaudectomy and resection of the pterygoid blades. So, this is the procedure carried out for maxillectomy. Now, we shall have a look at certain significant structures and landmarks relevant to total maxillectomy. The figure on the left is the lateral view of maxilla. Here a window cut is made to access the interior of the maxillary sinus. So, from this view, you can make out the fronto-echmoidal suture line. Here is the fronto-echmoidal suture line which is above the lamina paparizia. What you see in red color is the lamina paparizia and this is the fronto-echmoidal suture line. It is here along the fronto-echmoidal suture line that anterior and posterior etymodule foramen are located. These are the anterior and posterior etymodule foramen. This line is in correspondence with the level of the flow of anterior cranial fossa. Therefore, it is very important to limit your osteotomy cut just below this suture line. If not there are chances that you will enter the cranium. The image on the right shows the bony anatomy of lateral wall of nose. The inferior turbinate here which is red in color is restricted with the total maxillectomy. But the middle turbinate is generally preserved unless it is involved in pathology. This figure here demonstrates the anatomy of medial wall of eye. So, note here that this is the lamina paparizia. Here is the fronto-echmoidal suture line again as you saw in the previous diagram with anterior and posterior etymodule foramen. Here is the latrimel fossa. Here is the latrimel fossa and this is optic foramen. It is within the optic foramen that optic nerve is present. So, an important thing to remember here is that the posterior etymodule foramen is only 5 to 11 millimeters away from the optic nerve within the optic foramen. So, while carrying out the osteotomy cut, keep in mind the location of optic nerve so that you do not damage it. So, understanding the anatomy pertaining to the skull in this region is of utmost importance in order to plan the extent of maxillectomy and to avoid the inadvertent complications to vital structures. The relevant bony anatomy of heart palate includes incisive foramen which transmits incisive nerve and vessels, the greater palatine foramen and lesser palatine foramen which transmits greater palatine and lesser palatine vessels and nerves and teragoid plates. In total maxillectomy, resection includes that of teragoid plates as well. Moving on to the vasculature. An understanding of the blood supply of the maxilla is very important because it permits the surgeon to anticipate when and where to encounter bleeding and also to plan the sequence of surgery. Surgeon tries to reserve the most vascular parts of the surgery until last in order to minimize blood loss and also to avoid blood covering the surgical field. The only significant vein which is encountered during maxillectomy is the angular vein at the medial canthus of eye. As you can see in this picture this is the medial canthus of the eye and you encounter angular vein over here. The arterial blood supply to the maxilla as you already know is from the external and internal carotid artery. Both are branches of common carotid artery. Artidial supply relevant to maxillectomy are the facial artery or the external maxillary artery and internal maxillary artery which is otherwise called just the maxillary artery. So here is the terago maxillary fissure through which the internal maxillary artery enters the terago palatin fossa. So the two important branches of external carotid artery which is relevant here are the facial artery and the maxillary artery. And few important branches of internal carotid artery relevant here are the anterior and posterior etymodal artery because you now know the importance of anterior and posterior etymodal ferramen. So through anterior and posterior etymodal ferramen emerges the anterior and posterior etymodal artery. So it is of importance here and also we have seen that the optic nerve lies within the optic ferramen. So associated to optic nerve lies the ophthalmic artery. So therefore three branches of internal carotid artery are relevant in maxillectomy those are anterior and posterior etymodal artery and ophthalmic artery. The sensory nerve supply to the maxilla is through maxillary division of trigeminal nerve and the only branch of surgical significance here is the infrarbital nerve as it exit through the infrarbital ferramen. The only other major nerve to be considered here is the optic nerve as it emerges through the optic ferramen. Prior to the surgery a computer tomography of the maxillofacial region is done and it is an important means of determining the superior posterior lateral and medial extent of the tumor and the restriction required. Once a tumor involves the orbital fat or muscle then orbital extentuation is recommended. So as I told the superior extent of the lesion or the surgery is the orbit and the roof of the etymoid. The posterior extent is the pterigoid plates and the lateral extent is the zygoma and intratemporal fossa. Moving on to how the surgery is performed. The surgery is done under general anesthesia with orecchial incubation. If the eye is to be preserved then eyelids are sutured which is also called tarsorephi. A tracheostomy is then done to secure airway for post-operative period. Local anesthesia with vasoconstrictor is injected along the plant skin incisions. The surgery is considered in three stages soft tissue dissection and bone exposure, bone resection and closure or reconstruction. The first step is the incision and soft tissue dissection. Access to the maxilla is generally obtained by designing the classic Weber-Hergosen incision. The typical incision splits the midline of the upper lip but for better cosmetic results incision can be placed along the ridge of the philtrum that extends till the vermilion border. The incision is turned laterally at the base of the columnilla that is from here the incision is turned laterally and then around the alabase. It then extends along the side of the nose to within 2 mm of the medial canthus of the eye and is again turned along the lower eyelid till the lateral canthus of the eye. So this is the basic design of Weber-Hergosen incision. The same incision is extended intraorally through the labile mucosa through the labile mucosa of the upper lip the external incision is extended intraorally. So intraorally the incision is continued through the gingival margin. It is then connected with a horizontal incision which is placed in the depth of the labial buccal vestibule extending behind to the maxillary tuberosity. From the tuberosity region the incision is turned medially across the posterior edge of the heart palate. Here is the posterior edge of the heart palate and from here the incision is turned medially. So this limits at several millimeters proximal to the midline of the heart palate. The incision should not include the mid palate in suture. It ends a few millimeters proximal to it. So from here the incision is turned again anteriorly at an angle of 90 degree. So you have an external incision which is continued intraorally. It connects with a horizontal vestibular incision till the posterior aspect of maxillary tuberosity which is then turned medially and then again it is turned anteriorly at 90 degree. So basically the incision ends at the place where it actually originated or started. The next step after incision is the soft tissue reflection or bone exposure. The cheek flap is reflected till posterior to the maxillary tuberosity. The soft tissues of the face are elevated from the facial aspect of the maxilla using an elevator and the facial aspect of the anterior aspect of the maxilla is exposed. Here is the infarbital foramen where you encounter the infarbital nerve and vessels and they are transited. At the medial canthus of the eye angular vessels are quarterized or ligated adjacent to the canthus. Here you strip off the tissues all the way around the maxilla up till the tergomaxillary fissure which is located at the posterior maxilla but it should not go beyond the fissure to avoid an injury to the maxillary artery. So what is the limit of bone exposure? Supposedly the exposure should include medial wall of the orbit and the orbital flow. Medially the extent is the lateral wall of the ipsilateral nasal cavity and in the ovary the palatal mucosa is elevated to visualize the heart palate and soft palate. You identify the maxillary tuberosity and pterygoid plates which are located just posterior to the maxillary tuberosity. So once you have achieved sufficient exposure at this point soft tissue dissection is complete and the bony part of the maxillectomy can be performed. Coming to bone resection. The sequence of the osteotomies is usually planned to reserve the heavy bleeding towards the end of procedure but it may need to be adjusted depending on the location and extent of the tumor. The first osteotomy is through the inferior orbital rim and along the orbital flow. A sharp osteotome is used to cut through the malaria buttress here is the malaria buttress and the inferior orbital rim. This osteotomy should be placed lateral to the maxillary sinus. This can be confirmed using a CT scan. The osteotome should not enter into the maxillary sinus. Once you cut through the buttress and the inferior orbital rim the osteotomy is then placed into the floor of the orbit aiming for the intra orbital fissure. Second osteotomy is at the frontal process of maxilla and the lacrimal bone. An oscillating saw is used for osteotomy and not an osteotome because the bone over this region is hard. The osteotomy is directed towards butt kept a few millimeters below the level of the frontal ethmoidal suture line. As you can see in the diagram here. The third osteotomy is basically connecting the first two osteotomies. It is done by gently tapping an osteotome to enter the ethmoid air cells at the medial wall of the orbit. So while performing this osteotomy you retract the contents of the orbit laterally. The osteotome is directed posteriorly till the posterior ethmoidal foramen. Remember to keep the osteotomy line few millimeters below the frontal ethmoidal suture line. From here that is from near the posterior ethmoidal foramen the osteotomy is directed inferiorly to join the first osteotomy. So here is the optic optic foramen through which optic nerve exits. So it is important to safeguard the optic nerve as well as the posterior ethmoidal artery. Hence the third osteotomy is also complete. The fourth osteotomy is the palatal osteotomy. A sharp osteotome is used to cut vertically through the superior agriolus and the heart palate as you can see in the diagram here. The placement of the osteotomy is dependent on the palatal extent of the tumor. It is preferable to extract a tooth and to place the osteotomy through the dental socket rather than to place it between two teeth as this might devitalize the adjacent tooth and make the soft tissue closure difficult. The palatal osteotomy is extended to the posterior margin of the heart palate. The next is the osteotomy of nasal septum and it is required only if the palatal osteotomy is placed across the midline. If the osteotomy at the palate is through the mid palatine fossa only then osteotomy of nasal septum is necessitated. This is done using an osteotome or heavy scissors. The final osteotomy is to separate the maxillary tuberosity from the tergoid plates. This is done by tapping with a curved osteotome in the groove between the maxillary tuberosity and the tergoid bone. That is over here. You place a curved osteotome at this area between the tuberosity and the tergoid plate. So the superior extent of this osteotomy is the tergomaxillary fissure. Here is the tergomaxillary fissure which is the superior extent of the final osteotomy. All the osteotomy cuts are complete. The maxillectomy specimen can now be gently down fractured and the entire specimen is removed from its remaining attachments using a large curved scissors. After the removal of the specimen some amount of brisk bleeding is expected which is controlled with local measures and electrocortory. Branches of the maxillary artery in the tergomaxillary fissure area may require ligation. The specimen should be inspected to make sure that complete tumor has been excised. All the sharp bony projections should be smoothened and the palatal mucosa which was retained is used to cover up the medial bony margin. Here is how a maxillary defect will look like. This is the case photograph, the clinical photograph and this is a coronal CT demonstrating the resected lateral nasal wall including the inferior turbinate, the ankinate process, the orbital floor including the infarbital nerve, the lamina paparacea and the anterior apmoid. Here you can see the middle turbinate is preserved. In this case a free fibula flap is used to reconstruct the maxlectomy defect. The surgical obturator which is prefabricated is placed to seal the defect and the obturator is fixed to the remaining teeth by means of interdental wiring. The main cheek flap is then turned back and closed in layers. Orbital accentuation is indicated when the tumor has invaded the orbital fat or surrounding muscles. As you can see in the CT here the tumor has invaded the orbital contents. So whenever orbital accentuation is performed try to preserve the both the eyelids as much as possible. So here the eyelids have been preserved and they are sutured together. Coming to the post-operative management. Patients are kept in an intensive care unit for the first one or two days for cardiovascular monitoring and necessary maintenance of fluids and electrolytes. The patient is kept on liquid diet and instructions are given for maintenance of oral hygiene. Prophylactic antibiotic therapy is advocated for five to seven days. The surgical obturator is removed after 15 days and the wound is irrigated with warm saline and hydrogen peroxide. Any excess skin graft and other debris are removed. Long-term follow-up is necessary. So this is all about maxlectomy and we have thus completed surgical management of jaw tumors. Thank you.