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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4372_Библиотеки_им_академика_М_И_Перельмана
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K. Payne et al.
Fig. 42.5 Markings for Weber-Fergusson incision. (a) Shows mark-
ings with dotted lower eyelid extension within a lower lid crease if
needed. A common mistake performed during these approaches is to
make the lateral rhinotomy incision too laterally. This incision needs to
be made within the margin of the lateral nasal facial subunit to hide the
to the zygomatic body (Fig.42.12). This incision has most
commonly been described to lie within a subciliary or subtarsal crease extending into a crow’s foot crease or along the
lateral canthus. The incision is performed by incising through
orbicularis oculi to bone in a preseptal plane. The skin ap is
raised laterally in a subperiosteal plane, or in a plane that preserves a surgical margin when resecting expansive tumours.
This provides clear access to the orbital oor for resection
(Fig.42.13). The sequence of osteotomies for class III resections follows the same principles as a class II resection.
Anterior, superior and palatal osteotomies are performed rst,
and then the posterior osteotomies are performed where signicant bleeding is likely to be encountered. When closing
the infra-orbital extension of the incision, always pay close
scar as shown in the photo. (b) Demonstrates the chevron incision
within the lip which improves adaptation on closure. Also note the
extension of the incision into the nasal sill. This further breaks the scar
improving aesthetic outcomes
attention to the lower lid and in particular the corner at the
medial canthus. In our experience, this is the site most common to fail and breakdown, especially if the patient receives
post-operative radiotherapy. Judicious intra- operative wound
closure can prevent a myriad of further post-operative complications. The other important potential complication of this
approach is lower lid ectropion, which is very common especially due to the loss of the infraorbital rim, and post-operative radiotherapy with most of these resections [14]. To avoid
this complication, some authors have described substituting
the subciliary incision for a transconjunctival incision [15,
16]. Although we have no experience with this technique, it
stands to reason that it would reduce the risk of ectropion and
other lid complications.
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a
b
c
Fig. 42.6 Completion of the lip incision and lateral rhinotomy with
exposure of the piriform aperture. (a) Demonstrates the incision of lip
and lateral rhinotomy. (b) Extension of lip incision into labial mucosa
to the point of planned maxillary osteotomy. (c) Exposure of piriform
aperture, with Howarth’s elevator between maxilla and lateral nasal
mucosa
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a
b
c
Fig. 42.7 Raising cheek ap. (a, b) Mucosal incisions made while
raising cheek ap, leaving enough mucosal margin for a complete
resection. (c) Forceps pointing to the infraorbital nerve which was pre-
served in this case. If better access is necessary, the infraorbital nerve
can be sacriced here
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a b
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Fig. 42.8 (a) This photo demonstrates the access to the posterior
aspect of the maxilla, and complete soft tissue dissection performed
prior to osteotomies. (b) The lateral extent of the resection extends to
For Class IV resections, where orbital exenteration is
required, the approach is modied. The lateral extension of
the approach goes around the upper and lower eyelid margins, rather than only a subciliary incision alone. This incision is closed primarily at the time of closure.
42.4.5 Midfacial Degloving
Midfacial degloving is a technique for accessing the anterior
maxilla, nasal cavities and paranasal sinuses without external incisions. This technique was originally described for the
recontouring of maxillary brous dysplasia [17] but has
since been described and used for the resection of maxillary,
nasal cavity and paranasal sinus lesions and tumours [18,
19]. The main advantage of this technique is avoiding facial
scars. For maxillary tumours, it provides very good access
the coronoid process of the mandible, which is demonstrated lateral to
the retractor in this photo. A coronoidectomy was performed and sent
for histopathologic analysis as an additional margin
for Class II resections, especially bilateral anterior resections
(e.g. Class IIc). Combining the midfacial degloving technique with a transconjunctival extension has been described
for a total maxillectomy as well [20].
The technique commences with the nasal dissection. The
incisions made include bilateral median hemitransxion
incisions and an intercartilaginous incision (between the alar
or lower lateral cartilage and the upper lateral cartilage).
Once the hemitransxion incisions are made, they are joined
across the midline anterior to the septal cartilage and together
with the intercartilaginous incisions create circumferential
incisions within the nasal vestibule. Through the intercartilaginous incision, the dorsum of the nose is undermined with
joseph scissors subperiosteally. Once the nasal dissection is
complete, intraoral vestibular incisions are made, and dissection can be performed in the subperiosteal or supraperiosteal
plane depending on the type of lesion and planned resection
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Fig. 42.9 (a) Reciprocating saw used for anterior osteotomy through
upper right central incisor tooth socket. (b) Reciprocating saw used for
horizontal le fort 1 level osteotomy. This osteotomy is completed as far
margins. The nasal incisions are then connected to the ves-
posterior to the zygomatic buttress as possible. A subsequent horizontal
osteotomy needs to be made from posterior to anterior through the pterygoid plates to connect with the other osteotomy
42.4.6 Techniques forRetromaxillary Access
tibular incision allowing for the midface to be degloved
superiorly. The ap being raised contains the alar cartilages
and nasal skin. As the ap is raised, the upper lateral cartilages are exposed eventually exposing up to the medial canthus and glabella region. Bilaterally, the lateral extent is
limited by the infraorbital nerves. Periosteal releasing incisions may enable improved retraction and access. The osteotomies and remainder of the resection proceeds as normal.
For tumours extending into the posterior maxilla, the pterygoid plates and the infratemporal fossa may require other
techniques for assess. These techniques designed predominantly for access to the infratemporal fossa provide excellent
access to the posterior maxilla. These techniques can also be
combined with a Weber-Fergusson approach for improved
anterior access as well.
After resection, the soft tissues are allowed to return to their
normal position. Care needs to be taken to close the nasal
and oral incisions. The nose is packed for 24h ideally with a
resorbable or non-resorbable nasal pack. An external nasal
splint can also be applied for 10 days during healing
(Fig.42.14).
42.4.6.1 Lip Split Mandibulotomy
This technique is described in detail in the mandibular
access procedures (see Chapter 32), but it deserves mention
here. A lip split mandibulotomy with complete release of
the ipsilateral mylohyoid muscle allows swinging of the
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a
b
c
Fig. 42.10 (a, b) Mobilizing the maxillectomy specimen. (c) Defect after control of haemorrhage
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Fig. 42.11 Photograph immediately after closure. With an obturator in
situ as it was decided this patient would be for secondary reconstruction
after conrmation of complete resection
K. Payne et al.
mandible for almost direct access to the posterior maxilla
[21]. This technique is especially indicated in patients with
posterior maxillary tumours and limited mouth opening and
tumours with extension into the infratemporal fossa, as it
eliminates intact mandible from obstructing adequate
access. The additional risks of this technique include lower
lip and chin paresthesia, non-union of the mandible and
osteoradionecrosis (Fig.42.15).
42.4.6.2 Temporal Approaches
totheRetromaxillary Region
Obwegeser in 1985 described a temporal approach to the
TMJ, retromaxillary region and infratemporal fossa with
various iterations described since then depending on the
exact location of the pathology [10]. This extensive approach
involves a hemicoronal incision with a preauricular extension, zygomatic arch osteotomy leaving the zygoma pedicled
on the masseter muscle, coronoid osteotomy with mobilisation of the coronoid superiorly still attached to the temporalis
muscle, giving direct access to the retromaxillary region and
infratemporal fossa. Often, for large posterior maxillary
tumours, this approach is performed in combination with a
transfacial approach, allowing osteotomies of the pterygoid
plates at the level of the base of the skull. Alternative osteotomies can be considered depending on the location of the
tumour [11]. These approaches add new complications such
as temporal hollowing, maxillary and mandibular branches
of trigeminal nerve injury and CSF leak.
ab
cd
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Fig. 42.12 Photographs of a patient planned for a high Class IIB
Maxillectomy. (a) Markings for the Weber-Fergusson approach and
neck dissection markings are also visible. (b) Demonstrates defect after
resection. (c) Demonstrates deep circumex iliac artery (DCIA) ap in
situ with pre-fabricated reconstruction plate secured to the zygomatic
body on the left. The WF approach provided adequate access for resection and xation for reconstruction. (d) Closure
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Fig. 42.13 Photograph of a patient with a large
Right maxillary benign extending through into
the orbital oor planned for a class III resection.
This demonstrates the orbital oor access from a
Weber-Fergusson approach
K. Payne et al.
bc
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a
Intercartilaginous
incision
Transfixion
incision
Lower lateral
cartilage
Upper lateral
cartilage
d
Fig. 42.14 Schematic drawing demonstrating the key steps in the midfacial degloving technique. (a) Demonstrates the nasal incisions made
and highlights the communication bilaterally between the incisions. (b)
Subcutaneous dissection within subcutaneous plane between lower lateral and upper lateral cartilages. (c) Diagrammatic representation demonstrating the access once the transcartilaginous nasal incisions have
been made for resection of a tumour invading involving the anterior
maxilla and lateral nasal wall. (d) Linking of the nasal incisions with
e
maxilla up to the medial canthus. (e) Exposure of the medial and anterior maxilla and nasal cavity with midfacial degloving technique. (f)
Intra-operative photograph of midfacial degloving in a child with a
maxillary tumour, demonstrating the access once the transcartilaginous
and intercartilaginous incisions are made with easy access superiorly to
the medial canthus. (g) Access with marking for tumour resection.
(Intraoperative photographs courtesy of Professor Andrew Heggie,
Royal Children’s Hospital, Melbourne, Australia)
the vestibular incision allows great access to the anterior and medial
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