*10.1.1.2.3 Extended subtoal maxillectomy*

The main objective of this approach is to expose the maxillary antrum and remove its medial, anterior and posterolateral walls along with perpendicular plate of palatine bone. Orbital floor and alveolar arch are left intact. This converts the maxillary sinus, nasal cavity, nasopharynx, pterygopalatine fossa and infratemporal fossa into a single large accessible cavity.

This wide exposure is required for large tumors spilling in the infratemporal fossa. Lateral most aspect of these tumors is identified. Feeder vessel in the form of internal maxillary artery (most common feeder vessel) is identified as it enters the lateral aspect of the tumor in the infratemporal fossa and ligated before starting with the tumor dissection. Ascending pharyngeal artery maybe seen entering and supplying the tumor at its posterior aspect. It is also identified and ligated. This allows for minimal blood loss during the tumor dissection and delivery. Tumor delivery is done in-toto through transnasal/ transoral route or in a piecemeal fashion.

Two pathways for this approach have been described:


#### *10.1.1.2.4 Le fort-I approach*

An incision is made in the gingivobuccal sulcus between the two upper second molars. Periosteum is elevated to expose maxilla in its anterior and lateral aspect. Horizontal osteotomies from pyriform aperture to pterygomaxillary fissure and from pyriform aperture to palatine canals are made. Nasal septum is freed from anterior nasal spine and maxillary crest. Pterygoid dysjuctioning allows easy down fracturing of maxilla to achieve a wide exposure of the tumor extending into multiple paranasal sinuses, infratemporal fossa or intracranial space. After tumor excision, fixation of mid facial skeleton is achieved using titanium plates. This approach provides the widest possible exposure without any external scar [44].

#### *10.1.1.3 Transfacial approach*

#### *10.1.1.3.1 Maxillary swing*

A Weber-Ferguson incision is combined with the splitting of the hard palate [45, 46]. Multiple osteotomies are done and maxilla is disarticulated. Overlying skin and muscles are NOT dissected. Rather they are raised as a single flap along with underlying maxillary and zygomatic bone (**cheek masseter maxillary flap**). After tumor excision, maxilla is repositioned and fixed with titanium plates followed by layered suturing of the skin incision.

This approach provides accessibility to nasopharynx, paranasal sinuses, infratemporal fossa, parapharyngeal space and intracranial space. Malocclusion of upper jaw and palatal fistula are some uncommon but difficult to manage complications associated with this procedure [47].

#### *10.1.1.3.2 Maxillary removal and reinsertion (MRR)*

MRR starts as a midfacial degloving approach through a sublabial incision [48]. Partial osteotomy at nasofrontal angle allows extended degloving of midface. Multiple osteotomies are made to resect and remove the maxillary bone. Tumor is resected. Maxilla is repositioned at its original anatomical position and secured with titanium plates/ absorbable plates.

Wide exposure for tumor resection from infratemporal fossa, parapharyngeal space, and middle and anterior cranial fossa is achieved. Such extensive resections can cause malocclusions, visual disturbances and disruption of growth centres in the maxillary bone, resulting in future cosmetic deformities.

#### *10.1.1.4 Infratemporal fossa approach*

**Fisch Type C** and **Fisch Type D** are the two most commonly used approaches for extensive JNAs. Infratemporal approaches are suitable for gaining excess to infratemporal fossa, middle cranial fossa and lateral cavernous sinus [49]. Good resection rates are achieved with low recurrence rates. Major complications of Fisch Type C approach are a permanent conductive hearing loss, cosmetic deformity and loss of facial sensation. Fisch Type D approach was later added with the advantage of avoiding a visible facial scar, hearing loss and ability to convert as Type C approach as and when required [50, 51]. However, these approaches fail to resect tumors extending medial to the abducent cranial nerve in the cavernous sinus [52].

*Juvenile Nasopharyngeal Angiofibroma DOI: http://dx.doi.org/10.5772/intechopen.95923*
