Surgery

The most common perioperative complications which may accompany surgical resection of sinonasal malignancies include intraoperative or postoperative bleeding, wound infection, cere-brospinal fluid leak, and visual or orbital injury if orbital preservation was planned. Visual complications including diplopia, lacrimal duct dysfunction, ectropion, and exposure keratopathy may occur in cases of maxillectomy with orbital preservation. Local morbidity from a maxillectomy defect depends on the extent of resection. Although histor ically maxillectomy defects have not always been reconstructed, the significant functional and cosmetic deficits from this procedure coupled with a larger selection of surgical and prosthetic reconstructive options now available make the reconstuc-tion of maxillectomy defects a desired goal.

Hard palate defects from limited and subtotal maxillectomy may be fitted with a palatal obturator to separate the oral cavity from the sinus and nasal cavities. This closure is essential for swallowing and speech. The obturator is fabricated preoperatively with dental impressions taken by the prosthodontist and then fitted intraoperatively according to the extent of the surgical resection. A split-thickness skin graft is used to cover the undersurface of the cheek flap as well as the remaining bare bony interior of the maxillary sinus. Xeroform gauze packing is placed in the cavity and supported by fixation of the palatal obturator to remaining teeth or alveolus. The obturator allows for immediate swallowing function. One week postoperatively the initial obturator is removed with the packing, and an interim obturator is fashioned and fitted by the prosthodontist. The final permanent palatal obturator is placed in another 6 to 8 weeks.52 A significant correlation has been established between the degree of obturator function and measurements of the patient's quality of life.56

Microvascular free tissue transfer may be used in selected cases for palatal reconstruction, obviating the need for a dental obturator. The radial forearm free flap may be used to reconstruct the hard or soft palate by folding it over and using one skin layer to line the nasal side, and the other the oral side of the defect57-58 (Figures 11-12 and 11-13). The scapular free flap offers the additional option of vascularized bone with soft tissue for hard palate reconstruc-tion.59 Bone reconstruction may be particularly desirable in patients requiring osseointegrated dental implants. The latissimus dorsi may be transferred in conjunction with a bony scapular free flap as an additional soft tissue source.60

Surgical reconstruction of the lacrimal duct system and medial canthal ligament should always be addressed to avoid postoperative epiphora and pseudo-telecanthis, respectively. During elevation of the cheek flap at the time of maxillectomy, the lacrimal sac and duct are elevated out of the lacrimal fossa and transected flush with the orbital rim. The medial canthal ligament is detached from the nasal bone and retracted laterally with the orbital periosteum with a silk suture left long for identification. The interrupted lacrimal system is later restored during closure with the creation of a dacryocystorhinos-tomy. The medial canthal ligament is later sutured back to a drill hole in the nasal bone at the same level as the contralateral medial canthus.52 During this reattachment, McCary has recommended a slight overcorrection in the superior direction to compensate for later inferior globe displacement.61

In cases of maxillectomy with orbital floor resection, reconstruction of the floor is critical to retaining the function of a preserved globe. Stern reviewed 18 patients treated with maxillectomy and orbital floor resection without reconstruction, 9 of whom also received radiation therapy. Only 3 patients (17%) retained any useful function within the preserved eye.62 A globe that has been preserved without the support of the orbital floor is unlikely to retain significant function, especially if radiation therapy is used. Stern concluded that orbital exenteration should be considered in this setting. However, another interpretation is that there is a need to perform a reconstructive procedure restoring the support of the orbital floor for cases with orbital preservation.

Cordeiro successfully reconstructed maxillec-tomy and orbital floor defects in 14 patients who had orbital preservation. The orbital floor was restored using a nonvascularized bone graft such as split rib, split calvaria, or iliac crest (Figures 11 -14 and 11-15). A rectus free flap was used in 12 patients and temporalis transposition in 2 elderly patients for soft-tissue reconstruction. There were no flap failures but there was one postoperative death. All 13 remaining patients were left with adequate functional vision. All of the orbital floor bone grafts were covered with well vascularized tissue and remained intact without evidence of resorption or infection, even in cases with postoperative radiation therapy. As Stern's findings had suggested, Cordeiro found that attention to orbital floor reconstruction assists in preserving ocular function.63

Total maxillectomy defects, particularly in cases with orbital exenteration or skin and soft-tissue defects, may be reconstructed in a single stage with

Figures 11-12. Intraoperative photograph of the radial forearm free flap placed in a right partial maxillectomy defect.

microvascular free tissue transfer. One of the most effective sources for maxillectomy and orbital defect reconstruction is the rectus abdominis free flap, a reliable source of tissue which provides both tissue bulk and skin64 (Figure 11 -16). The rectus flap may be folded on itself within the surgical defect such that the cutaneous flap restores the palate. To restore the volume defects and recontour the malar eminence, the maxillary cavity should be overcorrected initially and maximally filled with the flap; atrophy will later reduce its volume by up to one-third. Sus-

Figure 11-13. Postoperative intraoral view of a hard and soft palate reconstruction using a radial forearm free flap.

pension sutures around the flap prevent prolapse of the flap into the oral cavity.65

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