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Maxillectomy

Maxillectomy is the removal of all or part of the maxilla bone. It is indicated for tumors of the hard palate, nose, maxillary sinus or other tumors that have grown to involve the maxilla.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

Depending on the reconstructive plan, you might need to get an impression of your palate made to assist in creating a prosthesis. You should see a prothodontist pre-operatively so this can be ready for you.

On the day of surgery, you will need to arrive at the hospital or surgery center a few hours before the scheduled operation. This allows the nurses and anesthesiologist to confirm everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

You will require general anesthesia for this procedure.

Depending on where the tumor is located, different types of maxillectomies might be performed:


Different Types of Maxillectomy Procedures

 skullfront
Medial maxillectomy In this procedure, the part of the maxilla next to the nose is removed. The eye and the hard palate are preserved. This is used mainly for tumors inside the nose. The nasolacrimal apparatus must be addressed to prevent chronic tearing (epiphora).This can be performed as an open procedure with an incision next to the wall of the nose on the face or, in some cases, through the nostril using telescopes and special instruments. No major reconstruction is needed for any of these.
Infrastructure maxillectomy In this procedure, the orbital floor is kept intact. The hard palate and lower part of the maxilla are removed. The teeth are removed as part of this procedure. This will require either an obturator or a free flap to reconstruct the area.
Suprastructure maxillectomy In this procedure, the hard palate is kept intact. The orbital floor is removed along with the upper part of the maxilla. The orbit may or may not be removed. The nasolacrimal apparatus must be addressed to prevent chronic tearing (epiphora).This will require a reconstruction to create a new orbital floor so the eye does not sink down into the cheek.
Subtotal maxillectomy This is some variation of the above procedures without removing the entire maxilla. The associated procedures and reconstruction will depend on the tumor and the extent of the resection.
Total maxillectomy A total maxillectomy involves removal of the hard palate and the orbital floor, along with the entire maxilla on one side of the face.This will require a major reconstruction such as a free flap. Alternatively, a prosthetic obturator may be used.

Associated surgical procedures might include orbital exenteration, neck dissection, tracheotomy and/or feeding tube placement.

If a primary reconstruction is not performed after removal of the cancer, you might require a skin graft to be placed into the maxillary defect. As the skin graft scars in, it will help with securing the prosthesis (if that is the reconstructive method that is chosen). After the skin graft, this large area of open space will be packed tight with some sort of gauze, and then a temporary palate prosthesis will be secured in place to keep the packing from falling out. You should be on antibiotics while this amount of packing is in place.

After one to two weeks, the packing will be removed and if a prosthesis was the reconstructive method of choice, it can be fitted at this time. Weekly adjustments of the prosthesis might be required as the surgical bed changes and scars over time.

If a primary reconstruction using a flap was performed, you will not require the use of a prosthesis to eat and speak.

Another associated procedure might include a dacryocystorhinostomy (this helps your tear duct empty into your nose). As part of this procedure, you might have tubes placed into your tear ducts in the corner of your eye, emptying into your nose as everything heals up. These are temporary and can be removed in the office after a few weeks.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. With some surgeries, you could go home after a few hours of observation in the recovery room (for example with a limited intranasal medial maxillectomy). However, most maxillectomy procedures will require a stay in the hospital of a few days. If a major reconstruction is performed, you might stay in the hospital for one to two weeks. A stay longer than two weeks is usually due to some sort of post-operative complication that your doctors are working to improve.

If you do stay in the hospital for recovery, the recovery course can happen in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. Asking for assistance to get out of bed to move around will help your recovery.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for the next steps.

Risks

As with any procedure, there are risks in undergoing a maxillectomy that you need to be aware of:

  • Bleeding, including hematoma: If there is severe bleeding after the procedure, your surgeon might need to quickly take you back to the operating room to stop the bleeding.
  • Infection: Neck dissections are done under completely sterile conditions. Still, as with any surgical procedure, there is always risk of an infection after the surgery. This might require antibiotics and/or drainage of the infection.
  • Blood clots: Patients who undergo major surgeries, especially patients who have cancer, are at an increased risk of developing blood clots in their legs (deep venous thrombosis). Sometimes these blood clots can travel through the veins and into the lungs, causing a pulmonary embolus. This can be a serious complication, causing problems with oxygenation of your blood. If such a problem occurs, you will likely require anticoagulation (blood-thinning medication) to prevent more clots from forming and ending up in your lungs. This blood-thinning medicine, though necessary to prevent more clots, might itself cause another complication, such as bleeding, especially immediately after surgery. This is why it is important for you to get out of bed early and move your legs. If you are not up and moving about, dynamic compression stockings should be used (these are like massage boots for your calves to keep the blood flowing). Also, you will probably be given a low dose of blood-thinning medication immediately after surgery to help prevent clots.
  • Persistent tumor: After the cancer is removed, the maxilla bone (and associated tissue) will be analyzed by a pathologist. This requires up to about a week to completely analyze the tissue. If there is evidence of cancer on the margins of the bone resection, your doctor might recommend you undergo an additional surgical resection to obtain clear margins.
  • Enophthalmos: This is a functional deformity in which the eye sinks down into the cheek. A good reconstruction of the orbital floor should help prevent this from happening.
  • Cheek numbness: The nerve that provides sensation to the cheek exits the maxilla bone just under the orbit. This nerve might need to be sacrificed as part of the maxillectomy, which will result in numbness and tingling in this part of the face.
  • Chronic tearing: This is called epiphora and is caused by a blockage of the nasolacrimal duct that empties from the inner corner of the eye, through the maxilla bone, just inside the nose. This can be prevented by performing a dacryocystorhinostomy along with nasolacrimal tubes as discussed above.