Extended lateral rhinotomy incision for total maxillectomy

Association of Virtual Surgical Planning With External Incisions in Complex Maxillectomy Reconstruction

Importance

Maxillectomy can commonly be performed through a transoral approach, but maxillectomy defect reconstruction can be difficult to precisely design, contour, and inset through this approach.

Objective

To evaluate whether the use of virtual surgical planning (VSP) and 3-dimensional (3-D) modeling is associated with a decrease in the requirement of lateral rhinotomy (LR) for patients undergoing total and partial maxillectomy reconstruction.

Design, Setting, and Participants

This retrospective cohort study was conducted among patients undergoing subtotal or total maxillectomy with microvascular free flap reconstruction with or without VSP and 3-D modeling at a single tertiary care academic medical center between January 1, 2008, and October 3, 2019.

Interventions

Maxillectomy and free flap reconstruction with or without VSP.

Main Outcomes and Measures

Necessity of LR or other external incision for contouring, placement, and fixation of reconstruction as well as surgical complications.

Results

Fifteen patients (12 men [80%]; mean age, 64 years) underwent maxillectomy with free flap reconstruction without VSP. Eight patients (53%) in this group underwent total maxillectomy, and 4 patients in this group (27%) underwent partial maxillectomy. Twenty-three patients (18 men [78%]; mean age, 58 years) underwent maxillectomy with free flap reconstruction and VSP and 3-D modeling. Twelve of these patients (52%) underwent total maxillectomy, and 11 (48%) underwent partial maxillectomy. Lateral rhinotomy was necessary for 1 patient (4%) in the VSP group vs 12 patients (80%; 95% CI, 54%-98%) in the pre-VSP group. There were no LR complications in the VSP group vs 6 in the pre-VSP group. Among both groups, 14 patients underwent fibula free flap, 22 patients underwent subscapular system free flap, and 2 patients underwent cutaneous or osteocutaneous radial forearm free flap. There were no flap failures in the LR group and 1 flap failure in the group without LR.

Conclusions and Relevance

This cohort study suggests that the use of VSP and 3-D modeling for maxillectomy reconstruction is associated the a decrease in the need for external incisions without compromising reconstructive flap utility.

Gain of exposure provided by extended incision in lateral rhinotomy approach: A cadaveric study

OBJECTIVE

To assess the gain of exposure provided by extensions of the lateral rhinotomy (LR) incision, including subciliary extension, lip-splitting extension, or both (Weber-Fergusson incision), by comparing the surgical field obtained with every incision. The final goal is to better delineate the indications of each approach.

MATERIALS AND METHODS

Prospective study on fresh frozen specimens. A LR incision was first performed, and then extended by subciliary and/or lip-splitting incisions. The exposure of the anterior facial skeleton and of the deep retromaxillar spaces (pterygopalatine fossa and infratemporal fossa) were assessed. The distance between the nasal bone and the most lateral part of the exposure was measured.

RESULTS

Dissection was performed on 4 specimens, with 7 LR. Three LR incisions were extended with subciliary incision, 3 with lip-splitting incision, and 4 with Weber-Fergusson incision. LR incision alone gave only limited access to the lateral orbital rim, the zygomatic arch and the maxillary tuberosity. Both subciliary and lip-splitting incisions gave access to the lateral orbital rim and to the zygomatic arch, but only upper lip incision provided a good access to the maxillary tuberosity. Weber-Fergusson did not significantly increase the surgical field obtained with lip-splitting extension alone. The exposure of the deep retromaxillar spaces was the same in all cases.

CONCLUSION

LR incision with lip-splitting extension provided an optimal access to the anterior facial skeleton and to the maxillary tuberosity. In terms of exposure, it was equivalent to Weber-Fergusson approach. The exposure of deep spaces was the same regardless of the incision.

Large orbital defect reconstruction in the setting of globe-sparing maxillectomy: The titanium hammock and layered fibula technique

INTRODUCTION

The purpose of our study was to describe a novel technique for reconstruction of orbital defects after maxillectomy using a non-anatomic titanium mesh suspension of orbital contents for both support and volume correction. This construct is then articulated with a layered fibula osteocutaneous free flap that restores orbital rim, zygoma, and maxillary alveolus. We herein present our application of this technique, including refinements over time and long-term outcomes.

METHODS

A retrospective review was performed on 12 patients who underwent reconstruction of Brown class III orbitopalatomaxillary defects with extensive orbital involvement (at minimum complete orbital floor and rim absent) with titanium mesh sling and a layered fibula free flap.

RESULTS

Primary reconstruction was accomplished in all 12 patients. The mean postoperative length of stay was 8 days (6-14 days). There were no free flap failures or perioperative re-explorations. Patients were routinely extubated on postoperative day #1 and began oral intake by postoperative day #3. At a mean follow-up length of 48 months, unrestricted eye function was accomplished in all patients. Midfacial symmetry was accomplished in 10 of 12 patients; 2 patients had moderate asymmetry due to extirpation of facial musculature and/or soft tissue. Minor revisions were necessary for lower lid ectropion and exposure of the titanium plate. Two patients required adipofascial free flap coverage of exposed intraoral bone after radiation therapy.

CONCLUSIONS

This technique provides excellent restoration of eye position and function and also allows for implant-based prosthetic rehabilitation. It has become our procedure of choice for orbitomaxillary reconstruction.

Cancers of the nose, sinus, and skull base

Malignancies of the nose, sinus, and skull base are rare. The most common histologies are squamous cell carcinoma and adenocarcinoma. The most common primary sites are the nasal cavity and maxillary sinus. Management of these tumors is technically challenging because they often present in advanced stages with extensive disease invading important structures such as the orbit and the skull base. In the last few decades advances in surgical resection techniques, as well as improved strategies to deliver adjuvant radiation, have substantially improved the outcomes in patients with malignancies of the sinonasal tract and skull base.

Maxillary reconstruction using vascularized fibular osteomyocutaneous flap and iliac bone through modified lateral lip-submandibular approach

OBJECTIVES

The objective of this study was to demonstrate total maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment alone and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach. At the same time, three-dimensional virtual technology was performed as well.

METHODS

Nine patients suffering from total maxillary defects, who had undergone maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac bone through the modified lateral lip-submandibular approach, were reviewed for this study. Before the surgery, patients' computed tomography scan data were virtually analyzed using SimPlant Pro software (version 11.04).

RESULTS

Healing courses were uneventful in all patients; acceptable maxillomandibular relationship, mouth opening, and speech were assessed as normal in all. There were no long-term functional limitations of the lower limb, even though all complain of dysfunction of the first toe, which developed the deformity of the claw toe in the end. Other complications did not occur such as diplopia, ectropion, flap necrosis, facial paralysis, and sensory numbness in the lower lip.

CONCLUSIONS

The maxillary reconstruction using 1 vascularized fibular osteomyocutaneous flap segment and nonvascularized iliac crest bone through the modified lateral lip-submandibular approach is a feasible and acceptable technique because of multiple advantages. Combined with the three-dimensional virtual technology, the technique can improve the postoperative outcomes.

Joseph Gensoul and the earliest illustrated operations for maxillary sinus carcinoma

Surgery has evolved along with anatomical illustrations through the ages. Joseph Gensoul (1797-1858), an important figure of the great Lyonnaise medical tradition of the 19th century, was occupied with many different surgical diseases, mostly diseases of the face. Apart from his many contributions stand various techniques on ophthalmological, otorhinolaryngological and oral and maxillofacial surgery. In this context, two rare illustrations depicting an innovative facial surgical operation performed by the great surgeon Joseph Gensoul are thoroughly analyzed. The two illustrations represent the "before" and "after" phases of Gensoul's most eminent operation, most probably practiced for a maxillary sinus carcinoma. This surgical operation is probably the earliest recorded of its kind in the history of surgery, even though the development of maxillary surgery is connected with the practice of Irwin Moure, who also practiced a type of lateral rhinotomy about a century later than Gensoul. Surgical illustrations are closely related to the history of surgery in every corner of the world.

Transconjunctival incision for total maxillectomy--an alternative for subciliary incision

A subciliary incision may be associated with various complications of the lower eyelid when it is used during a total maxillectomy. The use of the transconjunctival incision instead is an alternative in suitable patients. The records of 17 patients were reviewed in whom a transconjunctival incision was used during total maxillectomy. These included 13 in whom the Weber-Ferguson incision was used, and 4 who had a sublabial incision. There was mild conjunctival oedema in all the cases during the immediate postoperative period but it did not last for more than two days. Four patients had mild to moderate oedema of the lid that resolved within two days. One had mild ectropion with transient epiphora, which was caused by early removal of the medial canthal sutures. We found the approach to be cosmetically acceptable as it avoids a scar in the subciliary region. The transconjunctival incision can be used in place of the subciliary incision for lateral exposure during total maxillectomy. There are few complications associated with the lower lid, and it has good cosmetic results; if it is combined with a sublabial incision in suitable patients, the maxillectomy is virtually scar-free.