**12. Orbital exenteration with total maxillectomy**

This patient has squamous cell carcinoma of the right maxillary sinus invading the orbit through the periosteum (**Figure 48**). Contrast enhanced CT scan of the paranasal sinuses reveals soft tissue mass involving the right maxillary sinus completely and eroding floor of the orbit and extending into the orbit through the periosteum (**Figure 49**). To remove the tumor en-bloc, orbital exenteration with total maxillectomy is indicated. Orbital exenteration of a functioning eye with normal vision is only indicated if the procedure is done with curative intention. A lateral rhinotomy incision with midline lip is split is extended laterally as upper and lower lid incisions circumferentially encompassing the palpebral fissure of the eye (**Figure 48**). The skin incision begins in the midline of the upper lip up to the root of the columella. Here the incision extends into the floor of the nasal cavity and then returns back outside of the nasal cavity around the ala of the nose up to the medial canthus to join circumferential orbital incision (**Figure 48**). The skin incision is deepened through the subcutaneous tissues and musculature of the upper lip and the right cheek. The cheek flap is elevated laterally with a mucosal incision along the upper gingivobuccal sulcus. The skin incision for the sub-ciliary extension begins at *Extended Orbital Exenteration: A Step-by-Step Approach DOI: http://dx.doi.org/10.5772/intechopen.104763*

#### **Figure 48.**

*Clinical picture of advanced squamous cell carcinoma of the right maxillary sinus invading right orbit.*

#### **Figure 49.**

*Coronal CT scans show a large left maxillary sinus mass that has destroyed most of the sinus walls. The tumor extends into the orbit through the periosteum.*

about the level of the medial canthus of the eye 2 mm beyond the eyelid margin. The skin incision here should be placed meticulously without tearing as the skin over the eyelid is thin. The cheek flap is elevated to about 1 cm beyond the lateral canthus to provide adequate access to the anterolateral wall of the maxilla. After elevation of the cheek flap, attachment of the orbital periosteum to the orbital rim is incised in its superior half. A periosteal elevator is used to separate the orbital periosteum from the bony roof of the orbit all the way up to the apex of the orbit. Periosteum of the lower half of the orbit is kept intact, so as not to violate the surgical field. The attachment of the masseter muscle on the inferior border of the zygoma is divided next with use of the cautery.

A mouth gag is placed on the contralateral side to open the oral cavity and a tongue depressor is used to depress the tongue. A mucosal incision is made between the lateral incisor and the canine tooth, which marks the anterior line of resection of the alveolar process of the maxilla. An incision is now made in the mucosa of the hard palate along midline from the junction of the soft and hard palate and it is further extended to the incision of the alveolar process between the canine and lateral incisor (**Figure 51**). Posterior end of the midline palatal incision is turned laterally behind the maxillary tubercle to connect the upper gingivobuccal-sulcus incision. This incision is deepened through the mucoperiosteum of the hard palate. Posteriorly the incision is deepened through the attachments of the medial pterygoid muscle to free up soft-tissue attachments to the maxilla.

Nasal vestibule is opened through the piriform aperture to expose the nasal process of the maxilla. All the soft tissue attachment of the maxilla and the orbit are thoroughly divided before proceeding for bone cuts. All the bone cuts are marked by electrocautery. Superior bone cut is through the nasal process of maxilla, laterally the maxilla is separated from the zygomatic arch along the inferior orbital fissure and inferiorly the maxilla is divided through its alveolar process between the lateral incisor and canine tooth up to the midline to the posterior margin and from there onward through the midline up to its posterior margin (**Figures 50** and **51**). Posterolateral wall is separated from the pterygoid plates through its hamulus by placing a curved osteotome in between and gentle tap with mallet (**Figure 52**). All the bone cuts are accomplished by oscillating power saw. Once all the bone cuts are completed with the power saw, an osteotome is used to mobilize the specimen en-bloc (**Figures 53**–**55**). Soft-tissue and muscular attachments on the posterior aspect of the maxilla are divided with heavy curved scissors. The surgical defect

**Figure 50.** *Medial and lateral bone cuts shown on skull.*

**Figure 51.** *Palatal bone cuts shown on skull.*

**Figure 52.** *Posterior separation line between maxilla and pterygoid plates.*

*Extended Orbital Exenteration: A Step-by-Step Approach DOI: http://dx.doi.org/10.5772/intechopen.104763*

**Figure 53.** *A anterolateral view of the specimen.*

**Figure 54.** *A lateral view of the specimen.*

**Figure 55.** *A palatal view of the specimen.*

following total maxillectomy with orbital exenteration is shown is shown in (**Figures 55** and **56**). Surgical defect was reconstructed by primary closure and prosthetic rehabilitation (**Figure 57**).
