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Transconjunctival incision for total maxillectomy—an alternative for subciliary incision
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British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
Transconjunctival incision for total maxillectomy— an alternative for subciliary incision Amit Goyal a,∗ , Isha Tyagi a , Shilpa Jain b , Rajan Syal a , Alok Pratap Singh c , Rajeev Kapila a a
Neuro-otology Unit, Department of Neuro-surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India b Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India c Neuro-ophthalmology Unit, Department of Neuro-surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India Accepted 4 July 2010 Available online 31 July 2010
Abstract 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. © 2010 British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Maxillectomy; Weber–Ferguson incision; Subciliary incision; Conjunctiva; Lid
Introduction The Weber–Ferguson incision has been used routinely for more than half a century for good exposure of the maxilla during total maxillectomy. It was originally described by Gensoul in 1827, so has withstood the test of time. It has two parts: a vertical one that extends from the medial canthus to the upper lip curving round the ala, and a horizontal one that
∗ Corresponding author at: Department of E.N.T., North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong (Meghalaya) – 793 018, India. Tel.: +91 94367 66200/364 2538055/107; fax: +91 364 2538107/003. E-mail address: [email protected] (A. Goyal).
extends laterally from the medial canthus to the zygoma. The horizontal limb of the incision requires a subciliary incision on the lower lid, and is usually associated with certain complications. If the incision is placed too close to the margin of the lid the chance of ectropion and epiphora increases; if the incision is too far from the margin of the lid there will be an ugly scar, depression, and massive oedema as a result of impaired lymphatic drainage. It also requires dissection of the delicate skin of the lower lid from the orbicularis oculi muscle, which may cause damage to skin, or muscle, or both. Various attempts have been made to reduce these complications during maxillectomy.1,2 We could find no published article that mentioned or discussed the transconjunctival incision for this purpose, though
0266-4356/$ – see front matter © 2010 British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.07.002
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
443
it has been used during various other maxillofacial and orbital operations.3–5 We present our experience of 17 total maxillectomies during which we used a transconjunctival instead of a subciliary incision, together with the vertical limb of the Weber–Ferguson incision or a sublabial incision. Surgical technique, complications, advantages, and disadvantages were recorded.
Patients and methods We reviewed the case records of 17 patients who had had total maxillectomies through a transconjunctival incision at our hospital. Most of the cases were operated on by the senior surgeon, with a few cases done by junior surgeons under supervision. Those included were the ones that were done through either a vertical limb of Weber–Ferguson incision, together with a transconjunctival or sublabial incision, combined with a transconjunctival incision to expose the inferior orbital rim and zygoma. Only the total maxillectomies were included. Isolated involvement of the orbital floor or zygoma by the tumour was not a contraindication for this incision. We did not use a transconjunctival incision for maxillectomy if: orbital exenteration or any other associated procedures were done; there was ethmoid or intracranial extension by the tumour; the patient had preoperatively reduced vision, or dry eyes, or epiphora; the patient had dacrocystitis, conjunctivitis, or conditions of the margin of the lid such as stye or blepharitis; if there was any deformity of the eye; if the conjunctiva, globe, or periorbital lid were affected by the tumour; or if it was the only serving eye. Preoperatively, informed consent was taken from each patient for the use of the transconjunctival incision. Postoperatively patients were followed up at regular intervals and their ophthalmic and oncological states were recorded. Surgical technique Relevant anatomy Conjunctiva covers the globe in the form of bulbar conjunctiva, then turns above and below to form palpebral conjunctiva on the lids beyond the fornices, and continues over the inner surface of the lids up to their free margins. There are palpabral ligaments medially and laterally. At the medial end there are lacrimal puncta on both the lids from which canaliculi run medially and join to form the common canaliculus. This goes medially and deeper to drain into the lacrimal sac that lies in the lacrimal fossa. Technique Adrenaline diluted in normal saline (1:200,000) is injected into the subconjuctival layer of the lower fornix. The medial palpebral ligament is felt with the index finger (like a thick cord just medial and deep to the medial canthus). The lower lid is retracted to expose the lower fornix taking care to
Fig. 1. Transconjunctival incision with canthal incisions for the right side (shown by the dashed line).
cover the cornea with the help of the upper lid. The lower lacrimal puncta are therefore exposed, and after palpation of the medial palpebral ligament, the upper end of the vertical limb of Weber–Ferguson incision is curved laterally below the medial palpebral ligament. Care is taken to avoid acute sharp angulation in the incision. The lower canaliculus is cut 2 mm away from the puncta to avoid injury to the common canaliculus (Fig. 1). Now with the help of long tissue cutting scissors, the conjunctiva is incised from its medial to its lateral end. Laterally again we remain below the lateral palpebral ligament and, if further lateral exposure is needed, we extend the incision into the skin over the orbital rim and laterally about 2 cm in a zig-zag fashion. Then the posterior margin of the conjunctival incision is sutured temporarily to the margin of the upper eyelid to protect the cornea. The lacrimal sac does not usually get in the way as with a subciliary incision. The incision is now deepened deep to the tarsal plate in the subcutaneous plane to expose the infraorbital rim. The cheek flap is raised to expose the infraorbital rim and the anterolateral surface of the maxilla; it is then retracted laterally, taking the lower lid with it. The remaining maxillectomy is completed in the usual fashion, and the orbital floor is managed in the same way as with a classic Weber–Ferguson incision depending on the requirements of the individual case. We did not find any difference from the usual Weber–Ferguson approach in terms of exposure of the tumour or management of the orbital floor. In the end, the cheek flap is replaced, and after the sutured conjunctiva has been released from the upper lid it is sutured with 5/0 or 6/0 polyglactin 910 (Vicryl); knots are buried in the subconjunctival plane and not on the conjunctival side. Two sutures are generally sufficient in the lower conjunctival sac. Care is taken to align the margin of the lower lid properly with that of the upper lid. The wound is closed in layers. The skin sutures are removed on the 7th postoperative day except for the canthal stitches, which are removed on the 12th postoperative day. The upper lacrimal puncta were syringed after one month and again after six months to confirm the patency of the lacrimal drainage system.
444
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
Table 1 Indications for total maxillectomy with intraorbital involvement. (Numbers in parentheses are those operated on by sublabial incision with a transconjunctival incision; the others had a Weber–Ferguson incision with transconjunctival incision). Diagnosis
Intraorbital extension (n = 9)
No intraorbital extension (n = 8)
Total (n = 17)
Ewing sarcoma Osteosarcoma Squamous cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Low grade mesenchymal tumour Ameloblastoma
0 2 4 2 (1) 1 (1) 0
1 0 2 1 0 2 (1)
1 2 6 3 1 2
0
2 (1)
2
When using a sublabial incision for total maxillectomy, the medial canthal incision (with or without a lateral canthal incision) is made with the transconjunctival incision to expose the sites of medial and lateral osteotomies. The rest of the osteotomies were made through the sublabial route, and the maxillectomy completed.
Results There were 11 male and 6 female patients, age range from 12 to 67 years of age. The indications for maxillectomy are shown in Table 1. Thirteen had the vertical Weber–Ferguson incision with a transconjunctival incision, and 4 a sublabial incision with a lower conjunctival incision. All operations were done with the patient hypotensive throughout the operation. The minimum postoperative follow up was 12 months. The commonest complication was mild to moderate conjunctival oedema for up to two days in all cases. Four patients developed mild oedema of the lid, which resolved within two days. One case had ectropion with mild transient epiphora as a result of early removal of the medial canthal sutures (on
the 7th postoperative day). All patients had patent lacrimal drainage systems at one and six months’ postoperatively. Though it is not a comparative study, we found no differences in terms of exposure of the tumour during operation or postoperative recurrence with those found when we used the subciliary incision in similar cases.
Discussion The Weber–Ferguson incision is most widely used for total maxillectomy. It has two components: vertical and horizontal. The horizontal limb is usually associated with complications to the lower lid. Even during an intraoral maxillectomy with a sublabial incision alone, a subciliary incision is required to expose the zygoma and lateral extensions of the tumour. We have presented our experience of 17 total maxillectomies during which we used a transconjunctival incision instead of a subciliary incision. The vertical limb of the Weber–Ferguson incision was used in 13 cases and the sublabial incision in 4. A subciliary incision may leave a scar that is cosmetically unacceptable, particularly below the lid. Our modification avoids this incision, and gives an acceptable postoperative scar (Fig. 2) with less chance of ectropion, damage to the orbicularis oculi muscle, epiphora, lid oedema, or subciliary depression. There was transient conjunctival oedema in all cases, resulting from the conjunctival manipulation. Mild oedema of the lid was found in 4. Only one had ectropion, as a result of early removal (day 7) of canthal sutures. It did not develop after we started removing canthal sutures on the 12th postoperative day. Sharp angulation at the medial canthus should also be avoided while the incision is being made as it can cause delayed healing or necrosis of the surrounding skin. A gently curved incision lessens the chances of ectropion and sagging of the medial canthus. No patient had ugly scarring, severe ectropion from eversion of the lower lid, or depres-
Fig. 2. (A) Preoperative computed tomogram showing large left maxillary low grade mesenchymal tumour with intraorbital extension. (B) Preoperative photograph of the same patient showing intraorbital extension. (C) Photograph on postoperative day 12 of the same patient showing a cosmetically acceptable scar with no evidence of complications to the lower lid.
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
sion, that are usually seen after a classic Weber–Ferguson incision. Only one patient had transient epiphora as a result of ectropion. None had severe troublesome oedema of the lid, as the lymphatic drainage system was not damaged. Special care was taken to keep our incision and dissection below the level of the medial palpebral ligament, to spare the lacrimal sac and upper and common canaliculi. Postoperatively, the lacrimal drainage system was tested by syringing of the upper puncta after one month and again after six months; in all cases the system was patent. Though physiologically the lower lacrimal puncta are said to be responsible for about 60% of lacrimal damage under normal conditions,6,7 we had no complaints of persistent epiphora. Many authors have concluded that the upper puncta alone are capable of maintaining normal lacrimal drainage if the lower puncta are not functioning, and minimal impairment of lacrimal drainage is found on monocanalicular occlusion (either lower or upper).8–15 Daubert et al.9 noted no significant difference in the overall basal flow rate of tears when one canaliculus was blocked compared with that when the whole system was patent. Intraorbital extension of the tumour is not a contraindication for the use of the incision provided that the lids and conjunctiva are free of disease and orbital exenteration is not planned (Fig. 2). Results in terms of exposure of tumour, its removal, and subsequent local recurrence, are not affected by the incision as subsequent steps to expose the infraorbital rim are the same as those with a subciliary incision. Postoperative radiotherapy can also be given if indicated as with subciliary incision, as conjunctiva heals faster than skin.
Fig. 3. Photograph about 10 months postoperatively of a patient who had an adenoid cystic carcinoma of the left maxilla without orbital extension operated on through a sublabial incision together with a transconjunctival incision showing a virtually scar-free maxillectomy.
conditions of the margin of the lid such as stye, or infective blepharitis; involvement of the conjunctiva, globe, orperiorbital region by the tumour; or other indications for orbital exenteration. The transconjunctival incision is an approach used during many ophthalmic and maxillofacial operations, but to our knowledge this is the first series that has described its use during total maxillectomy.
Conflict of interest Authors declare that they have no competing interests and financial funding for this work.
Advantages
Acknowledgements
The advantages include: fewer complications with the lower lid; there is no need for a skin incision in the lower lid, so there are no chances of an ugly scar; it is cosmetically acceptable without compromising oncological safety in selected cases; it can be used for lateral exposure during lateral rhinotomy or medial maxillectomy (where only a medial canthal incision is used together with a conjunctival incision without lateral canthal incision); and it gives a virtually scar—free maxillectomy if combined with maxillectomy by the sublabial route (Fig. 3).
The authors thank Mr. Anil Kumar for his art work.
Disadvantages The disadvantages, however, include: the need to cut the lower canaliculus; the need for conjunctival manipulation, which leads to conjunctival oedema; there are chances of injury to the eye, so there is a need to take extra care, and in particular to cover the cornea; and it is not useful in patients with extensive involvement of the orbit and the lid. The contraindications to the incision are dacrocystitis; conjunctivitis; the presence of deformity or disease of the eye;
445
References 1. Sobol SM, Wood B, Levine H. An approach to total maxillectomy with emphasis on orbital preservation. Plast Reconstr Surg 1982;69: 945–50. 2. Vural E, Hanna E. Extended lateral rhinotomy incision for total maxillectomy. Otolaryngol Head Neck Surg 2000;123:512–3. 3. Kakibuchi M, Fukazawa K, Fukuda K, et al. Combination of transconjunctival and endonasal–transantral approach in the repair of blowout fractures involving the orbital floor. Br J Plast Surg 2004;57: 37–44. 4. Graham SM, Thomas RD, Carter KD, Nerad JA. The transcaruncular approach to the medial orbital wall. Laryngoscope 2002;112: 986–9. 5. Liu D. Conjunctival incision for primary conjunctivodacryocystorhinostomy with Jones tube. Am J Ophthalmol 2000;129:244–5. 6. Murgatroyd H, Craig JP, Sloan B. Determination of relative contribution of the superior and inferior canaliculi to the lacrimal drainage system in health using the drop test. Clin Exp Ophthalmol 2004;32: 404–10. 7. Nagashima K, Kido R. Relative roles of upper and lower lacrimal canaliculi in normal tear drainage. Jpn J Ophthalmol 1984;28:259–62.
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8. Yen MT, Pflugfelder SC, Feuer WJ. The effect of punctal occlusion on tear production, tear clearance, and ocular surface sensation in normal subjects. Am J Ophthalmol 2001;131:314–23. 9. Daubert J, Nik N, Chandeyssoun PA, el-Choufi L. Tear flow analysis through the upper and lower systems. Ophthalmol Plast Reconstr Surg 1990;6:193–6. 10. White WL, Glover AT, Buckner AB, Hartshorne MF. Relative canalicular tear flow as assessed by dacryoscintigraphy. Ophthalmology 1989;96:167–9. 11. Ogut MS, Bavbek T, Kazokoglu H. Assessment of tear drainage by fluorescein dye disappearance test after experimental canalicular obstruction. Acta Ophthalmol (Copenh) 1993;71:69–72.
12. Reed S, Lissner G. Clinical study on the effectiveness of tear drainage with a single canalicular system under environmental stress. Ophthalmol Plast Reconstr Surg 1993;9:27–31. 13. Ortiz MA, Kraushar MF. Lacrimal drainage following repair of inferior canaliculus. Ann Ophthalmol 1975;7:739–41. 14. Lemp MA, Weiler HH. How do tears exit? Invest Ophthalmol Vis Sci 1983;24:619–22. 15. Meyer DR, Antonello A, Linberg JV. Assessment of tear drainage after canalicular obstruction using fluorescein dye disappearance. Ophthalmology 1990;97:1370–4.
British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
Transconjunctival incision for total maxillectomy— an alternative for subciliary incision Amit Goyal a,∗ , Isha Tyagi a , Shilpa Jain b , Rajan Syal a , Alok Pratap Singh c , Rajeev Kapila a a
Neuro-otology Unit, Department of Neuro-surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India b Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India c Neuro-ophthalmology Unit, Department of Neuro-surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareily Road, Lucknow (UP) – 226 014, India Accepted 4 July 2010 Available online 31 July 2010
Abstract 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. © 2010 British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved. Keywords: Maxillectomy; Weber–Ferguson incision; Subciliary incision; Conjunctiva; Lid
Introduction The Weber–Ferguson incision has been used routinely for more than half a century for good exposure of the maxilla during total maxillectomy. It was originally described by Gensoul in 1827, so has withstood the test of time. It has two parts: a vertical one that extends from the medial canthus to the upper lip curving round the ala, and a horizontal one that
∗ Corresponding author at: Department of E.N.T., North Eastern Indira Gandhi Regional Institute of Health & Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong (Meghalaya) – 793 018, India. Tel.: +91 94367 66200/364 2538055/107; fax: +91 364 2538107/003. E-mail address: [email protected] (A. Goyal).
extends laterally from the medial canthus to the zygoma. The horizontal limb of the incision requires a subciliary incision on the lower lid, and is usually associated with certain complications. If the incision is placed too close to the margin of the lid the chance of ectropion and epiphora increases; if the incision is too far from the margin of the lid there will be an ugly scar, depression, and massive oedema as a result of impaired lymphatic drainage. It also requires dissection of the delicate skin of the lower lid from the orbicularis oculi muscle, which may cause damage to skin, or muscle, or both. Various attempts have been made to reduce these complications during maxillectomy.1,2 We could find no published article that mentioned or discussed the transconjunctival incision for this purpose, though
0266-4356/$ – see front matter © 2010 British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2010.07.002
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
443
it has been used during various other maxillofacial and orbital operations.3–5 We present our experience of 17 total maxillectomies during which we used a transconjunctival instead of a subciliary incision, together with the vertical limb of the Weber–Ferguson incision or a sublabial incision. Surgical technique, complications, advantages, and disadvantages were recorded.
Patients and methods We reviewed the case records of 17 patients who had had total maxillectomies through a transconjunctival incision at our hospital. Most of the cases were operated on by the senior surgeon, with a few cases done by junior surgeons under supervision. Those included were the ones that were done through either a vertical limb of Weber–Ferguson incision, together with a transconjunctival or sublabial incision, combined with a transconjunctival incision to expose the inferior orbital rim and zygoma. Only the total maxillectomies were included. Isolated involvement of the orbital floor or zygoma by the tumour was not a contraindication for this incision. We did not use a transconjunctival incision for maxillectomy if: orbital exenteration or any other associated procedures were done; there was ethmoid or intracranial extension by the tumour; the patient had preoperatively reduced vision, or dry eyes, or epiphora; the patient had dacrocystitis, conjunctivitis, or conditions of the margin of the lid such as stye or blepharitis; if there was any deformity of the eye; if the conjunctiva, globe, or periorbital lid were affected by the tumour; or if it was the only serving eye. Preoperatively, informed consent was taken from each patient for the use of the transconjunctival incision. Postoperatively patients were followed up at regular intervals and their ophthalmic and oncological states were recorded. Surgical technique Relevant anatomy Conjunctiva covers the globe in the form of bulbar conjunctiva, then turns above and below to form palpebral conjunctiva on the lids beyond the fornices, and continues over the inner surface of the lids up to their free margins. There are palpabral ligaments medially and laterally. At the medial end there are lacrimal puncta on both the lids from which canaliculi run medially and join to form the common canaliculus. This goes medially and deeper to drain into the lacrimal sac that lies in the lacrimal fossa. Technique Adrenaline diluted in normal saline (1:200,000) is injected into the subconjuctival layer of the lower fornix. The medial palpebral ligament is felt with the index finger (like a thick cord just medial and deep to the medial canthus). The lower lid is retracted to expose the lower fornix taking care to
Fig. 1. Transconjunctival incision with canthal incisions for the right side (shown by the dashed line).
cover the cornea with the help of the upper lid. The lower lacrimal puncta are therefore exposed, and after palpation of the medial palpebral ligament, the upper end of the vertical limb of Weber–Ferguson incision is curved laterally below the medial palpebral ligament. Care is taken to avoid acute sharp angulation in the incision. The lower canaliculus is cut 2 mm away from the puncta to avoid injury to the common canaliculus (Fig. 1). Now with the help of long tissue cutting scissors, the conjunctiva is incised from its medial to its lateral end. Laterally again we remain below the lateral palpebral ligament and, if further lateral exposure is needed, we extend the incision into the skin over the orbital rim and laterally about 2 cm in a zig-zag fashion. Then the posterior margin of the conjunctival incision is sutured temporarily to the margin of the upper eyelid to protect the cornea. The lacrimal sac does not usually get in the way as with a subciliary incision. The incision is now deepened deep to the tarsal plate in the subcutaneous plane to expose the infraorbital rim. The cheek flap is raised to expose the infraorbital rim and the anterolateral surface of the maxilla; it is then retracted laterally, taking the lower lid with it. The remaining maxillectomy is completed in the usual fashion, and the orbital floor is managed in the same way as with a classic Weber–Ferguson incision depending on the requirements of the individual case. We did not find any difference from the usual Weber–Ferguson approach in terms of exposure of the tumour or management of the orbital floor. In the end, the cheek flap is replaced, and after the sutured conjunctiva has been released from the upper lid it is sutured with 5/0 or 6/0 polyglactin 910 (Vicryl); knots are buried in the subconjunctival plane and not on the conjunctival side. Two sutures are generally sufficient in the lower conjunctival sac. Care is taken to align the margin of the lower lid properly with that of the upper lid. The wound is closed in layers. The skin sutures are removed on the 7th postoperative day except for the canthal stitches, which are removed on the 12th postoperative day. The upper lacrimal puncta were syringed after one month and again after six months to confirm the patency of the lacrimal drainage system.
444
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
Table 1 Indications for total maxillectomy with intraorbital involvement. (Numbers in parentheses are those operated on by sublabial incision with a transconjunctival incision; the others had a Weber–Ferguson incision with transconjunctival incision). Diagnosis
Intraorbital extension (n = 9)
No intraorbital extension (n = 8)
Total (n = 17)
Ewing sarcoma Osteosarcoma Squamous cell carcinoma Adenocarcinoma Adenoid cystic carcinoma Low grade mesenchymal tumour Ameloblastoma
0 2 4 2 (1) 1 (1) 0
1 0 2 1 0 2 (1)
1 2 6 3 1 2
0
2 (1)
2
When using a sublabial incision for total maxillectomy, the medial canthal incision (with or without a lateral canthal incision) is made with the transconjunctival incision to expose the sites of medial and lateral osteotomies. The rest of the osteotomies were made through the sublabial route, and the maxillectomy completed.
Results There were 11 male and 6 female patients, age range from 12 to 67 years of age. The indications for maxillectomy are shown in Table 1. Thirteen had the vertical Weber–Ferguson incision with a transconjunctival incision, and 4 a sublabial incision with a lower conjunctival incision. All operations were done with the patient hypotensive throughout the operation. The minimum postoperative follow up was 12 months. The commonest complication was mild to moderate conjunctival oedema for up to two days in all cases. Four patients developed mild oedema of the lid, which resolved within two days. One case had ectropion with mild transient epiphora as a result of early removal of the medial canthal sutures (on
the 7th postoperative day). All patients had patent lacrimal drainage systems at one and six months’ postoperatively. Though it is not a comparative study, we found no differences in terms of exposure of the tumour during operation or postoperative recurrence with those found when we used the subciliary incision in similar cases.
Discussion The Weber–Ferguson incision is most widely used for total maxillectomy. It has two components: vertical and horizontal. The horizontal limb is usually associated with complications to the lower lid. Even during an intraoral maxillectomy with a sublabial incision alone, a subciliary incision is required to expose the zygoma and lateral extensions of the tumour. We have presented our experience of 17 total maxillectomies during which we used a transconjunctival incision instead of a subciliary incision. The vertical limb of the Weber–Ferguson incision was used in 13 cases and the sublabial incision in 4. A subciliary incision may leave a scar that is cosmetically unacceptable, particularly below the lid. Our modification avoids this incision, and gives an acceptable postoperative scar (Fig. 2) with less chance of ectropion, damage to the orbicularis oculi muscle, epiphora, lid oedema, or subciliary depression. There was transient conjunctival oedema in all cases, resulting from the conjunctival manipulation. Mild oedema of the lid was found in 4. Only one had ectropion, as a result of early removal (day 7) of canthal sutures. It did not develop after we started removing canthal sutures on the 12th postoperative day. Sharp angulation at the medial canthus should also be avoided while the incision is being made as it can cause delayed healing or necrosis of the surrounding skin. A gently curved incision lessens the chances of ectropion and sagging of the medial canthus. No patient had ugly scarring, severe ectropion from eversion of the lower lid, or depres-
Fig. 2. (A) Preoperative computed tomogram showing large left maxillary low grade mesenchymal tumour with intraorbital extension. (B) Preoperative photograph of the same patient showing intraorbital extension. (C) Photograph on postoperative day 12 of the same patient showing a cosmetically acceptable scar with no evidence of complications to the lower lid.
A. Goyal et al. / British Journal of Oral and Maxillofacial Surgery 49 (2011) 442–446
sion, that are usually seen after a classic Weber–Ferguson incision. Only one patient had transient epiphora as a result of ectropion. None had severe troublesome oedema of the lid, as the lymphatic drainage system was not damaged. Special care was taken to keep our incision and dissection below the level of the medial palpebral ligament, to spare the lacrimal sac and upper and common canaliculi. Postoperatively, the lacrimal drainage system was tested by syringing of the upper puncta after one month and again after six months; in all cases the system was patent. Though physiologically the lower lacrimal puncta are said to be responsible for about 60% of lacrimal damage under normal conditions,6,7 we had no complaints of persistent epiphora. Many authors have concluded that the upper puncta alone are capable of maintaining normal lacrimal drainage if the lower puncta are not functioning, and minimal impairment of lacrimal drainage is found on monocanalicular occlusion (either lower or upper).8–15 Daubert et al.9 noted no significant difference in the overall basal flow rate of tears when one canaliculus was blocked compared with that when the whole system was patent. Intraorbital extension of the tumour is not a contraindication for the use of the incision provided that the lids and conjunctiva are free of disease and orbital exenteration is not planned (Fig. 2). Results in terms of exposure of tumour, its removal, and subsequent local recurrence, are not affected by the incision as subsequent steps to expose the infraorbital rim are the same as those with a subciliary incision. Postoperative radiotherapy can also be given if indicated as with subciliary incision, as conjunctiva heals faster than skin.
Fig. 3. Photograph about 10 months postoperatively of a patient who had an adenoid cystic carcinoma of the left maxilla without orbital extension operated on through a sublabial incision together with a transconjunctival incision showing a virtually scar-free maxillectomy.
conditions of the margin of the lid such as stye, or infective blepharitis; involvement of the conjunctiva, globe, orperiorbital region by the tumour; or other indications for orbital exenteration. The transconjunctival incision is an approach used during many ophthalmic and maxillofacial operations, but to our knowledge this is the first series that has described its use during total maxillectomy.
Conflict of interest Authors declare that they have no competing interests and financial funding for this work.
Advantages
Acknowledgements
The advantages include: fewer complications with the lower lid; there is no need for a skin incision in the lower lid, so there are no chances of an ugly scar; it is cosmetically acceptable without compromising oncological safety in selected cases; it can be used for lateral exposure during lateral rhinotomy or medial maxillectomy (where only a medial canthal incision is used together with a conjunctival incision without lateral canthal incision); and it gives a virtually scar—free maxillectomy if combined with maxillectomy by the sublabial route (Fig. 3).
The authors thank Mr. Anil Kumar for his art work.
Disadvantages The disadvantages, however, include: the need to cut the lower canaliculus; the need for conjunctival manipulation, which leads to conjunctival oedema; there are chances of injury to the eye, so there is a need to take extra care, and in particular to cover the cornea; and it is not useful in patients with extensive involvement of the orbit and the lid. The contraindications to the incision are dacrocystitis; conjunctivitis; the presence of deformity or disease of the eye;
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