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Fig. 41.11 Preoperative
image of post-nasal space
with a tumour involving
lateral wall (top), Medial and
lateral pterygoids have been
exposed, posterior wall off
maxillary sinus overlying
contents of PPF was removed
(middle), Lateral and medial
pterygoids together with
Eustachian tube cartilage
were removed leaving
exposed lateral and medial
pterygoid muscle and
parapharyngeal space
P. Surda et al.
Posterior maxillary sinus wall is removed drilled down
completely. Once this is achieved, the next step is to mobilise
the contents of PPF by dividing the greater palatine artery,
vidian bundle and SPA. PPF is pushed laterally in order to
drill away medial and lateral pterygoid plates. This gives us
access to paraharyngeal space and infratemporal fossa.
Tumours extending into this area often invade Eustachian
tube and cartilage. In such cases, this must be transected and
removed together with peritubaric muscles and partially with
both pterygoid muscles.
Prior to further dissection, it is mandatory to identify
ICA.Dissection of the vidian canal tracks posteriorly towards
the second genu of the ICA.As we drill the oor of the sphenoid
sinus, Vidian canal is identied at the junction of the medial
pterygoid plate and the lateral sphenoid oor. Using diamond
burr, Vidian canal then is gently drilled away with until we
establish the exact position of ICA, which can be followed to
further identify the horizontal portion entering petrous apex.
Subsequently, Eustachian tube and surrounding muscles
can be removed. Area is reconstructed with nasoseptal ap.
We recommend placing multiple pieces of nasopore over the
nasoseptal ap. Reconstructed area is supported with silastic
sheet, which is attached to the nasal septum and removed
5weeks after the surgery.
SPA a. &
41 Endoscopic Resection ofNasal andParanasal Sinus Neoplasms
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MT
foramen
429
Middle cranial
R
LRS
V
fossa
Petrous ICA
Fig. 41.12 Illustration of anatomical areas that can be accessed via
posterior maxillary wall using the approach described by Kesimsiri
et al. [29]. MT middle turbinate; PNS postnasal space; LRS lateral
41.7 Treatment oftheNeck
Management of the neck in primary sinonasal neoplasms is a
topic that continues to provoke signicant debate. There is a
ne balance to be struck between optimising oncologic outcomes and limiting the morbidity associated with treatment
of the neck.
One key principle is that all patients with conrmed sinonasal neoplasm must have clinical assessment of the neck
through careful palpation of all cervical nodal levels.
Detection of a nodal mass should prompt further evaluation,
most often by ultrasound guided ne needle cytology. In
addition, the vast majority of patients with sinonasal neoplasms will have imaging scans that stage the neck and chest.
The workhorse of neck staging scans is the CT, as it offers
excellent sift tissue resolution of nodal groups including the
retropharyngeal lymphatics, which are the rst echelon for
the maxillary sinus and nasal oor. Pathological nodes
detected at imaging will be reected in staging, with consequences for both curability and treatment intensity.
A patient with no pathological nodes found at clinical
and radiological evaluation is said to have a ‘N0’ neck. The
most contentious debate is centred around these patients and
PPF
Maxillary
sinus
PNS
recess of sphenoid sinus; PPF pterygopalatine fossa; ITF infratemporal
fossa; ICA internal carotid artery; SPA sphenopalatine artery
ITF
the need for elective treatment of the N0 neck. One broad
principle of management of neck metastases comes from
the British Association of Head and Neck Oncologists, who
would advocate elective neck treatment if the risk of metastases is greater than 10–15%. The overall risk of neck
metastases in sinonasal malignancies is 25%; however, there
is wide variation according to histological subtype.
Therefore, the rationale for elective treatment of the neck is
strongest in esthesioneuroblastoma and weakest in adenocarcinoma [28].
In addition, as tumour stage progresses there is an
increased rate of nodal metastases. Patients with T3 and 4
squamous cell carcinomas and SNUC are therefore likely to
have a risk of nodal involvement of 15% or greater and thus
are considered for elective neck treatment [23, 28].
Individual MDTs will have individual preferences for the
strategy to treat both N0 and N+ neck disease, whether surgical or with radiotherapy. Both have proponents and detractors, and neither is without morbidity; a case can be made for
either surgical or oncological treatment on an individual
basis. However, as far as possible, a single strategy should be
used to treat the neck to minimise morbidity and preserve a
treatment option for future in the case of recurrence.
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17. Antognoni P, Turri-Zanoni M, Gottardo S, etal. Endoscopic resection followed by adjuvant radiotherapy for sinonasal intestinal-type
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I. Endonasal endoscopic resection and radiotherapy in olfactory
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DM, Otto BA, et al. Endoscopic endonasal transpterygoid
approaches: anatomical landmarks for planning the surgical corridor. Laryngoscope. 2013;123(4):811–5. https://doi.org/10.1002/
lary.23697.
Maxillectomy
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KarlPayne, OmarBreik, PravPraveen, andSatParmar
42
42.1 Introduction
A maxillectomy is dened as an operation that involves
removal of all or part of the maxillary bone. The broad indication for a maxillectomy is to resect pathology originating
from, or invading the maxilla. It may not be surprising to
know that the surgical principles discussed in this chapter
have not changed a great deal over the past few decades—the
main advancement being the advent of endoscopic surgery
and improved three-dimensional planning to facilitate more
accurate reconstruction.
It is outside the scope of this atlas to provide a full anatomical review, but readers should be aware of the key structures that can cause potential complications, both intra- and
post-operatively. The maxilla houses the maxillary antrum
with its role in sinus drainage, as well as supporting the orbit,
attaching laterally to the zygoma, dening the nasal cavity
medially and forming the roof of the mouth inferiorly containing the upper dental arch. The maxillary antrum is one of
four bilateral sets of paranasal sinuses, in close relationship
to the frontal, sphenoid and ethmoid sinuses. Despite its role
in middle third anterior facial prominence, the maxilla
extends both superiorly and posteriorly into areas of high
anatomical risk. Posterosuperiorly lies the base of skull, with
K. Payne
Institute of Cancer and Genomic Sciences, University of
Birmingham, Birmingham, UK
O. Breik (*)
Department of Oral and Maxillofacial Surgery, Royal Brisbane and
Women’s Hospital, University of Queensland,
Brisbane, QLD, Australia
P. Praveen
Department of Oral and Maxillofacial Surgery, University
Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
e-mail: prav.praveen@uhb.nhs.uk
S. Parmar
Department of Oral and Maxillofacial/Head and Neck Surgery,
Queen Elizabeth Hospital, Birmingham, UK
the anterior two thirds of the orbital oor being thin maxillary bone. The arterial supply of the maxilla originates from
the maxillary artery, a branch of the external carotid artery.
Branches of the third part of the maxillary artery (in relation
to the lateral pterygoid muscles) supply the midface, including the—posterior superior alveolar artery, infraorbital
artery, descending palatine artery and sphenopalatine artery.
On the whole, venous draining mirrors the arterial supply;
however, of clinical relevance is the pterygoid venous plexus
located in the infratemporal fossa posterior to the maxilla.
The pterygoid venous plexus is a potential source of considerable intra-operative bleeding when dissecting and osteotomising the posterior maxilla. This chapter will discuss the
preoperative assessment and surgical planning of a maxillectomy patient, further detailing the classication, surgical
approaches and maxillectomy procedure itself with the aid
of intra-operative clinical photographs.
42.2 Preoperative Checklist,
Considerations andAnaesthesia
42.2.1 Preoperative Investigations
Routine investigations should be as per the preoperative
work-up for any major head and neck surgical procedure.
These include blood tests (full blood count, renal function,
clotting screen, cross-match/group and save), electrocardiogram, CXR and exercise tolerance testing if indicated.
Special investigations will have been performed to stage
the tumour. Our protocol is for a CT head, neck and thorax,
to include an MRI head if marrow signal from bony inltration, but other institutional imaging protocols may vary and
should be followed accordingly. Cross-sectional imaging
will demonstrate the extent of the tumour and guide the plan
for resection. Depending on the extent of the tumour, the surgeon can begin to plan the ideal approach to resecting the
maxilla. Patients planned for larger resections including the
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_42
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orbital oor should have preoperative ophthalmic assessment, to include visual acuity and a HESS chart.
Hints and Tips
3D surgical planning will require a ‘ne-cut’ CT scan
of the facial skeleton and the planned graft site. The
data from this scan will enable software to render and
manipulate the defect and an accurate stereolithographic 3D model to be printed and/or virtual planning. If these facilities are available in your institution,
always be sure to arrange for this scan early to give
adequate time for reconstructive planning.
42.2.2 Reconstructive Considerations
Whilst the primary goal of all surgical oncology is resection
of the tumour mass with adequate margins, it is prudent for
the head and neck surgeon to consider reconstruction and
functional rehabilitation from the outset when considering
resection of the facial skeleton. This is particularly important
when the tumour affects the maxilla/midface, as any reconstruction will have a potential impact upon mastication,
speech, swallow, vision and appearance. Options include
early or immediate reconstruct on with local or microvascular free aps, with or without osseointegrated dental implants
or an obturator- based prosthesis. Obturators may be the ideal
option for small maxillectomy defects and where retention is
possible from residual teeth. Reconstruction has advantages
over obturation—providing better outcomes for swallowing
and speech, especially in larger defects and when a signicant amount of soft palate has also been removed. However,
patient and surgical factors may impact this decision, and the
best practice is to consider these preoperatively and to have
open discussions of risk and morbidity with the patient.
Negating the additional operating time and surgical morbidity associated with free-tissue reconstruction may be favourable to reduce general anaesthetic time in high-risk patients.
Small alveolar defects can be closed with a buccal fat pad
or mucosal advancement ap and palatal defects with a mucosal island ap. Larger defects can be closed with a temporalis
ap but more often will require a soft tissue free-ap, most
commonly a radial forearm ap. When signicant bone has
been removed, in a Brown class II, III or IV defect, osseous or
composite osseo-cutaneous or myo-osseous free-aps should
be considered, options include the bula, DCIA or scapular
free-ap, among others [1]. This would provide bony support
for dental implants in large horizontal defects, or providing
support for orbital oor reconstruction in large vertical defects
and in turn preserve facial symmetry and contour. For posterior defects only, an alternative option is to consider a soft tissue ap with immediate implants. A ‘zygomatic implant
perforator’ (ZIP) ap involves placing immediate zygomatic
implants perforating through a soft tissue ap (usually a radial
forearm) to support early dental rehabilitation without the
need for a bony free ap reconstruction [2].
Where possible, virtual planning can be utilised to plan
the resection and reconstruction. With the development of
3D printing technology, cutting guides can be designed and
printed for an accurate resection and accurate reconstruction.
Figure42.1 demonstrates a case where resection is planned,
with preparation of cutting guides, as well as cutting guides
for harvest of a deep circumex iliac artery (DCIA) free-ap
reconstruction of the left maxilla (Fig.42.1).
42.2.3 Anaesthesia andAirway
The patient will be under a general anaesthesia, and the main
point to highlight here is the method of securing the airway.
Preference will depend on the surgeon and anaesthetist. For
smaller resection with a limited approach, a nasal or oral tube is
reasonable. As will be discussed, more often than not the maxillectomy will be part of a larger procedure involving regional
lymph node clearance in the form of a neck dissection with/
without reconstruction. In this instance, a tracheostomy provides a secure airway with adequate intra-oral and neck access.
42.2.4 Consent
Consenting for a maxillectomy will undoubtedly be one
stage of a larger procedure. Whilst there may be overlap of
risks between these stages, the specic risks of the maxillectomy resection need to be considered. Obviously, these
will change depending on the approach and extent of the
maxillectomy procedure undertaken.
General risks include bleeding, swelling, bruising, infection and scarring.
Specic Risks
• Scarring/tethering of upper lip
• Nasal deviation/deformity
• Skin breakdown
• Numbness of cheek
• Epiphora
• Scarring of lower eyelid and ectropion
• Trismus
• Tracheostomy (if not planned and consented for
separately)
• Dental extraction required as necessary
• Vessel/nerve damage (specic to approach and type of
maxillectomy)
• Complications involving eye if resecting orbital oor or
close to orbit—diplopia, ocular dysmotility, change in
vision, retrobulbar bleed resulting in permanent visual loss
• Trismus and altered mastication/dental function
• Tumour unresectable
ab
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c
d
e
Fig. 42.1 Virtual surgical planning. (a) Planned resection of left max-
illa. (b) Cutting guides prepared to allow accurate resection. (c) Planned
area of iliac crest for harvest where the curve of the iliac crest best
represents the shape and curvature of the left maxilla. (d, e) Iliac crest
superimposed on the defect, showing excellent curvature and contour of
the iliac crest for left maxillary reconstruction
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42.3 Indications
42.3.1 Pathology
As discussed, a maxillectomy is a procedure to resect abnormal pathology of the maxilla or invading the maxilla.
Malignancy will be the indication in the majority of cases,
most commonly, an epithelial cancer of the oral cavity (upper
alveolus) that has invaded the maxillary bone or requires
bone resection to obtain a clear margin. Of this group, a
squamous cell carcinoma (SCC) is by far the most prevalent,
and primary SCC of the maxillary sinus is much less common (<3% of head and neck cancers). Other rarer histological subtypes include salivary cancer—adenoid cystic or
mucoepidermoid carcinoma and sarcoma or lymphoma. On
occasion, it may be necessary to perform a maxillectomy for
benign pathology, for example, brous dysplasia, an inltrating bro-inammatory lesion, or extensive osteonecrosis.
42.3.2 Contraindications
Contraindications for a maxillectomy can be divided into
patient-specic and disease-specic factors. Patient factors
will be identied in preoperative assessment, including
(among others) systemic disorders such as severely uncontrolled diabetes, untreated coagulopathy, poor cardiorespiratory reserve with high mortality risk from general anaesthesia
or a prolonged procedure. Disease contraindications will be
identied when staging the pathology and will indicate an
inoperable malignancy due to extend of invasion, for example, signicant skull base extension. These factors will often
be case/patient specic and should always be discussed at
the head and neck cancer multidisciplinary team meeting.
42.3.3 Maxillectomy Classication
There is a plethora of published classications for maxillary
defects in the literature, and confusion arises when literature
uses terminology from different classications interchangeably. The classication system proposed by Cordeiro (2000)
[3] uses the terms ‘limited’, ‘sub-total maxillectomy’ and
‘total maxillectomy’, somewhat analogous to a Brown class
I-III. In general, a sub-total maxillectomy preserves the
orbital oor and contents, a total maxillectomy resects the
orbital oor and an orbito-maxillectomy resects the orbital
contents (Brown class IV). A ‘partial maxillectomy’ (Davison
classication, 1998 [4]) is analogous to a sub-total maxillectomy; however, the terms ‘infrastructure’ and ‘suprastructure’ maxillectomy can be confusing. An infrastructure
maxillectomy corresponds to a Brown class I/II, whilst a
suprastructure maxillectomy is nearer to a Brown class V
defect. A ‘medial’ maxillectomy describes resection of the
medial and supero-medial walls of the maxilla, often
accessed via endoscopic means or a lateral rhinotomy
incision.
In this chapter we refer to the Brown classication of
maxillary defects. Originally published in 2000, the Brown
classication described maxillectomy defects as a combination of four vertical components (I–IV) and three horizontal
components (a–c). In general, the vertical component
describes the likely aesthetic effect of surgery and the horizontal component the difculty of oral rehabilitation. In
2010, Brown (Fig.42.2) revised the classication to include
vertical midface components—orbitomaxillary (V) and
nasomaxillary (VI) [5].
III
Fig. 42.2 Brown classication of maxillectomy defects, with Class I–IV representing vertical resection components, and a–d representing horizontal components [5]
III IV
I
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42.4 Surgical Technique
As highlighted, a maxillectomy is not one single procedure,
but a collection of variants based upon a core procedure to deal
with the complex anatomy and difcult surgical access in this
area. As such, no one approach can be applied to all resections.
One should be aware of the different approaches and types of
maxillectomy and the common combinations of these. Such
knowledge is paramount, in addition to the exibility to
change approach on table should the resection or potential
complications require it. Surgical approaches to the maxilla
include: transoral, transnasal, lateral rhinotomy, transfacial
(Weber-Fergusson), midfacial degloving, transmandibular
and bicoronal/cranial (for retromaxillary access). All of these
approaches are done under a general anaesthetic and local
anaesthetic injection of lignocaine with adrenaline at planned
incision sites. Corneal shields or temporary tarsorrhaphy incisions should be used to protect the cornea. This section will
discuss the techniques for various surgical approaches available to access the maxilla and highlight different types of maxillectomy procedures for different classications of defect.
42.4.1 Transoral Approach
Most small tumours of the maxillary alveolus or palate are
easily accessible via a simple transoral approach. This technique is commonly employed and is the technique of choice
for most small anterior maxillary/palatal lesions, or Class I
and low-level Class II resections in patients with adequate
mouth opening. The main advantage of the transoral approach
is that it leaves no facial scars. The approach involves marking out the planned margins around the tumour/lesion. This is
followed by a dissection down to bone. Once adequate bony
exposure is achieved, a reciprocating saw is used to perform
the osteotomies. The rst osteotomies should be the vertical
osteotomies either through tooth sockets, or between teeth.
Linking palatal and horizontal osteotomies can then be performed, and these are linked to the vertical osteotomies. Once
completed, the lesion can be mobilised by using straight
osteotomes. Often, with transoral resections, the main bleeding is encountered from the greater palatine artery. This can
often be controlled with bipolar diathermy (Fig.42.3).
Hints and Tips
The limits of the transoral approach will often be
reached when trying to achieve the posterior resection
margin. A resection should never be compromised in
efforts to preserve cosmesis. If there is concern about
achieving an adequate resection margin, the authors
have a low threshold for performing a lip split and limited Weber Fergusson approach to improve access.
This will be discussed further below.
42.4.2 Transnasal
The transnasal approach is an almost exclusive endoscopically assisted approach to small tumours only of the maxillary sinus or maxillary septum. In experienced hands, it
provides excellent access to the nasal cavity and also the
associated paranasal sinuses and skull base. Small sinus and
septal tumours extending into the oral cavity can also be
resected via combined endoscopic and transoral approach. A
nasal septal lesion involving the palate can be approached
endoscopically to separate the septum above the lesion, followed by intraoral resection around the lesion allowing the
lesion to be delivered through the oral cavity. With the development of improved endoscopic skills, total maxillectomies
can potentially be performed using these combined techniques [6].
42.4.3 Lateral Rhinotomy
Arguably, this approach has been superseded by recent
advances in endoscopic surgery. However, for large or difcult
to access sinonasal masses of the lateral nasal wall, this is still
the approach of choice. It also provides access to the ethmoid
and frontal sinuses, anterior skull base and the nasopharynx.
This approach has found its widest application in medial maxillectomies for inverted papilloma [7]. The main advantage of
this access procedure is its versatility. If required, the incision
can be extended superiorly with the addition of a lynch extension or glabellar extension or inferiorly within the nasolabial
fold, or a lip split. With a lip split and a lynch style incision for
superior extension, orbital access can be improved, and even
posterior maxillary access can be adequate for a total maxillectomy [8]. The traditional lateral rhinotomy approach begins
with a skin incision below the columella in the midline,
extending around the alar and into the supra-alar crease and
superiorly into the facial nasal groove. The incision is carried
through the muscular layer to the piriform aperture. Once in
the subperiosteal plane, the piriform fossa is identied and followed superiorly to identify the nasal bones. Depending on the
access required, the nasal lining is then incised through the
lateral nasal vestibule to access the nasal cavity, being mindful
to avoid hitting the inferior turbinate. For a complete medial
maxillectomy, the medial canthal ligament is detached to
access the medial wall of the orbit, and the nasolacrimal duct
is transected at the junction with the nasolacrimal sac. The sac
needs to be then divided and marsupialised to prevent development of epiphora. Using small osteotomes, osteotomies performed of the nasal process of the maxilla and nasofrontal
junction then allows mobilisation of the nasal complex with
the overlying soft tissue giving access to the ipsilateral nasal
cavity. For access to entire nasal cavity, the septum is released
from the mobilised segment. Lateral elevation of the cheek
ap up to the level of the infraorbital nerves exposes the entire
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ba
c
Fig. 42.3 Photo showing intraoral access for maxillectomy.
(a) Yellow arrow demonstrating a low grade mucoepidermoid carcinoma with bone involvement. (b) transoral excision - class II resection performed without access procedure.
Immediate implants placed into residual edentulous maxilla.
medial maxilla and nasal cavity. Subsequent osteotomies
depend on the resection required. Closure involves rotating the
nasal skeleton back in place. Often, no xation is required.
Soft tissue closure is similar to a Weber-Fergusson approach
and will be discussed below (Fig.42.4).
42.4.4 Transfacial: Weber-Fergusson Approach
The Weber-Fergusson approach (and its various described
modications) has been widely used since it was rst
described for access. The rst to describe this approach
remains unclear, but a clear early mention is to be found in
the textbook by Sir William Fergusson from the nineteenth
century, System of Practical Surgery [9]. This approach is
ideal for class II, III, IV and V maxillectomies. It provides
very good access to the anterior maxilla, orbital oor and
orbit. Tumours extending posterior to the maxillary tuberos-
d
(c) radial forearm free ap reconstruction after healing with
prosthetic bar to retain a full upper denture. (d) facial appearance after rehabilitation with adequate tumour clearance and
no scarring or residual facial deformity
ity and involving the pterygoid plates may not be as readily
accessible with this approach alone. Especially when the
tumour extends superiorly towards the skull base, or into the
infratemporal fossa, access posteriorly can be improved by a
concurrent lip split mandibulotomy, or an additional temporal approach [10, 11]. The step-by-step technique for the
Weber-Fergusson approach is described below with hints
and tips for each section.
A tarsorrhaphy suture is performed rst to protect the cornea during the procedure. The skin markings are made rst,
with ink used to mark out particular points to facilitate accurate closure. Extension of the incision infraorbitally (within
a subciliary or a subtarsal crease) as far as the lateral canthus
is commonly known as Dieffenbach’s modication, although
it is included in the original gure in Fergusson’s text [9].
Where possible, our preference is to avoid the lateral lower
lid extension of the incision, as it increases the risk of lid
complications such as ectropion. Hence, especially when the
42 Maxillectomy
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Fig. 42.4 Diagram demonstrating markings for a lateral rhinotomy
incision
orbit or orbital oor can be spared, the lip split and lateral
rhinotomy alone may provide enough access. The skin incision is similar to the lateral rhinotomy approach described
above; however, from the alar, the incision runs inferiorly
along the philtrum to the vermillion to perform a ‘lip split’
procedure (Fig.42.5). Extending along the philtrum leads to
better cosmetic results than a midline lip split [12].
The incisions commence at the lip and extend up the lateral rhinotomy. Care should be taken to cauterise or tie-off
the labial vessels as you incise through the lip. When incising
around the alar base, it is preferable to either perform the
incision 1–2 mm from the alar margins and to direct the
blade vertically down toward the maxilla and not under the
ala itself. This preserves the attachment of the elastic bres
of the alar cartilage to the periosteum of the lateral aspect of
the anterior nasal spine. This is believed to reduce the risk of
subsequent alar retraction. The lateral rhinotomy incision is
carried through the muscular layer to the piriform aperture.
In this case, the tumour does not extend into the lateral nasal
wall, as described above in the lateral rhinotomy approach,
the nasal cavity can be entered here through an incision in
the nasal mucosa. In this case, the lateral nasal mucosa can
be raised, and a Howarth is inserted to protect the lateral
nasal mucosa (Fig.42.6).
437
The cheek ap is then raised ensuring that the planned
mucosal and soft tissue margin for complete resection is preserved (Fig.42.7). The infraorbital nerve is then encountered
and is often sacriced especially if it is within the planned
maxillectomy. In a Class II resection where it can be preserved, maintaining the infraorbital nerve can limit access. In
that situation, an infraorbital osteotomy has been described
to mobilize the nerve within its foramen to improve access to
the posterior maxilla [13]. In our experience, this is unlikely
to be required.
Once the cheek ap is raised, the lateral and posterior
access is enough, even for a lesion involving the maxillary
tuberosity (Fig.42.8). The remaining soft tissue incisions are
then made, including the palatal incision and the posterior
incision involving the soft palate. A good rule to apply for all
maxillectomies is: Complete as much soft tissue dissection
as possible prior to any bony osteotomies. This especially
includes the posterior extent/soft palate dissection where a
through and through dissection is necessary (Fig.42.8). This
will save a lot of time after the bony osteotomies when bleeding makes it much harder to see, and time is of the essence.
The osteotomies are then sequentially performed to
mobilize the maxilla. Prior to performing the osteotomies,
the anaesthetist should be informed to deliver a period of
hypotensive anaesthesia and to elevate the head slightly to
minimize bleeding. In this class IIB resection, the anterior
and palatal osteotomies are performed rst, followed by the
high le fort 1 level horizontal osteotomy and then the posterior osteotomies through the midpoint of the pterygoid
plates (in this case) (Fig.42.9). If the pterygoid plates are to
be preserved, then a curved osteotome is used to perform a
pterygomaxillary dysjunction. Posterior osteotomies
through the pterygoid plates can be performed with an
osteotome or a saw. Our preference is to complete these
with a reciprocating saw and complete the osteotomies with
a large straight osteotome. At this point of the operation,
there is often signicant bleeding likely from the main trunk
of the internal maxillary artery, or from branches of it.
Bleeding cannot be controlled until the resection is completed. Large wooden handle Obwegeser osteotomes can be
used to connect the osteotomies and mobilize the maxillectomy (Fig. 42.10). Posterior muscular attachments are
released with mayo scissors.
Closure of the Weber-Fergusson approach needs to be
performed in layers, closing mucosa, then muscle and nally
skin (Fig.42.11). Care needs to be taken to ensure the alar is
either secured to underlying bone or a plate to avoid excessive widening of the alar base.
For higher level Class II and class III resections, an infraorbital extension or a complete Weber-Fergusson incision
may be required. This may also be required for improved
access for concurrent reconstruction as it gives better access
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