Johan Fagan

Tumours of the hard palate and superior alveolus may be resected by inferior maxillectomy (Figure 1). A Le Fort 1 osteotomy may also be used as an approach to e.g.  angiofibromas and the nasopharynx.

A sound understanding of the 3-dimensional anatomy of the maxilla and the surrounding structures is essential to do the operation safely. Hence the detailed description of the relevant surgical anatomy that follows.

Fig 1
Figure 1: Bilateral inferior maxillectomy

A sound understanding of the 3-dimensional anatomy of the maxilla and the surrounding structures is essential to do the operation safely. Hence the detailed description of the relevant surgical anatomy that follows.

Surgical Anatomy

Bony anatomy

Figures 2, 3 & 4 illustrate the detailed bony anatomy relevant to maxillectomy. Critical surgical landmarks to note include:

Figure 2 illustrates the bony anatomy of the lateral wall of the nose. The inferior turbinate (concha) may be resected with
inferior maxillectomy, but the middle turbinate is preserved.

Fig 2
Figure 2: Lateral view of maxilla with windows cut in lateral and medial walls of maxillary sinus
Fig 3
Figure 3: Bony anatomy of the lateral wall of the nose
Fig 4
Figure 4: Bony anatomy in cadaver

Figure 5 demonstrates the coronal anatomy at the anterior limit of a maxillectomy. Specifically note the lacrimal sac in the lacrimal fossa (Figure 4, 5) which may be transected at surgery, and the relative heights of the floors of the antrum and the nasal cavity.

Fig 5
Figure 5: Coronal CT through lacrimal fossa

Figure 6 demonstrates the coronal anatomy midway back along a maxillectomy. Specifically note the infraorbital nerve in the orbital floor, the thin lamina papyracea and the relative heights of the floors of the antrum and the nasal cavity.  

Fig 6
Figure 6: Anatomy in the coronal plane through the anterior ethmoids midway along a maxillectomy

Figures 7 & 8 demonstrate the value of using the anterior and posterior ethmoidal arteries and frontoethmoidal suture line (Figure 4) to determine the level of the floor of the anterior cranial fossa when opening the lamina papyracea from the orbital side during medial or total maxillectomy.

Fig 7
Figure 7: Note the position of the anterior ethmoidal artery where it passes through its foramen which is located in the frontoethmoidal suture line
Fig 8
Figure 8: Coronal slice through posterior ethmoids demonstrating posterior ethmoidal foramen and optic nerve

Figure 9 demonstrates the coronal anatomy immediately posterior to the maxillary sinus, which is in the plane through which an inferior or total maxillectomy is done, and in which the internal maxillary artery and its branches as well as the sphenopalatine ganglion and its branches are encountered within the pterygopalatine fossa. The pterygopalatine fossa communicates laterally with the infratemporal fossa via the pterygomaxillary fissure, and medially with the nasal cavity via the spheno-palatine foramen.

Fig 9
Figure 9: Coronal cut immediately behind the maxillary sinus through the orbital apex, pterygoid plates and pterygopalatine fossa.

Figures 10 & 11 show axial views of the anatomy of the maxillary sinus. The posterior resection lines of total and inferior maxillectomies pass through the pterygopalatine fossa and pterygomaxillary fissure and the anterior aspect of the pterygoid plates.

Fig 10
Figure 10: Axial cut at level of infraorbital nerve and orbital floor
Fig 11
Figure 11: Axial cut at level of infraorbital foramen and pterygoid plates

The bony anatomy of the hard palate is illustrated in Figure 12.

Fig 12
Figure 12: Anatomy of hard palate


An understanding of the blood supply of the maxilla permits the surgeon to anticipate when and where to encounter bleeding, and to plan the sequence of the surgery to reserve the bloodier parts of the surgery until last so as to minimise blood loss and to avoid blood obscuring the surgical field.

The only significant vein encountered during maxillectomy is the angular vein (Figure 13) at the medial canthus.

Fig 13
Figure 13: Vasculature around the orbit

The arterial blood supply to the maxilla and paranasal sinuses originates from both the external and internal carotid artery systems. During inferior maxillectomy one can expect to encounter some bleeding from the descending palatine artery, which originates from the maxillary artery in the pterygopalatine fossa, passes inferiorly through the pterygopalatine canal, and emerges from the greater palatine foramen as the greater palatine artery to supply the hard palate.

The arterial supply relevant to inferior maxillectomy is as follows:

Fig 14
Figure 14: Facial artery and origin of internal maxillary artery, both branches of the external carotid artery
Fig 15
Figure 15: Branches of internal maxillary artery; blue shaded area is the 2nd part of artery before it enters the pterygopalatine fossa

Branches of the internal maxillary artery of surgical significance include:


The maxillary division of V (V2) enters the pterygopalatine fossa via the foramen rotundum. The only branch of surgical significance is the infraorbital nerve. It runs in the floor of the orbit/roof of the antrum to exit from the infraorbital foramen (Figure 16).

Fig 16
Figure 16: V2, pterygopalatine ganglion and infraorbital nerve

Inferior Maxillectomy

Inferior maxillectomy is employed with tumours limited to the palate and floor of the maxillary sinus and nasal cavity. It entails resection of the hard palate and may include the walls of the maxillary sinus and nasal floor and inferior turbinate, but spares the orbital floor and ethmoid sinuses (Figures 17).

Fig 17
Figure 17: Yellow area indicates extent of bony resection of inferior maxillectomy

Coronal CT scanning is essential in order to determine the superior extent of a tumour to determine the suitability for an inferior maxillectomy (Figures 18-20).

Fig 18
Figure 18: Mucoepidermoid carcinoma of hard palate suited to unilateral inferior maxillectomy with sparing of inferior turbinate and nasal septum
Fig 19
Figure 19: Polymorphous low grade adenocarcinoma of palate suited to unilateral inferior maxillectomy with resection crossing midline and including the base of the nasal septum
Fig 20
Figure 20: Adenoid cystic carcinoma of hard palate suited to inferior maxillectomy, including inferior turbinate

Surgical steps

The following description refers to a tumour that requires resection of half the hard palate.

Figure 21 illustrates the extent of the bone resection following a unilateral inferior maxillectomy with preservation of the inferior turbinate.

Fig 21
Figure 21: Coronal CT demonstrating bone removed with unilateral inferior maxillectomy (Inferior turbinate intact)

Preoperative consent includes discussing facial incisions, potential injury to the infraorbital nerve, reconstructive options and the loss of dentition and ability to wear dentures or to have dental implants.

The operation is done under general anaesthesia, with orotracheal intubation, or nasotracheal intubation if only half the palate is to be removed. A temporary tracheostomy is done to ensure an adequate airway in case soft tissue swelling or bleeding occurs. Perioperative broad spectrum antibiotics are administered for 24hrs.

The operation may be considered in 3 stages: soft tissue dissection/bone exposure; bone resection; and closure/reconstruction. Soft tissue dissection/bone exposure

It is important to complete the soft tissue dissection and bone exposure before doing any bone work so as to avoid excessive blood loss.

Fig 22
Figure 22: Midfacial degloving approach

At this point the soft tissue dissection is complete

Bony resection (Figs 23-29)

Fig 23
Figure 23: Antrostomy
Fig 24
Figure 24: Anterior view of osteotomies
Fig 25
Figure 25: Lateral view of osteotomies, including through pterygomaxillary fissure
Fig 26
Figure 26: Osteotomies including osteotomy between maxillary tuberosity and pterygoid plates and of palate
Fig 27
Figure 27: Curved osteotome
Fig 28
Figure 28: Palatal osteotomies. Note osteotomy passes between palate and pterygoid plates
Fig 29a
Figure 29a: Inferior maxillectomy defect
Fig 29b
Figure 29b: Inferior maxillectomy defect

Figures 30 a, b & c show a limited inferior maxillectomy for a minor salivary gland tumour which was reconstructed with a combination of a local rotation flap and a buccinator flap.

Fig 30a
Figure 30a: Minor salivary gland tumour of hard palate
Fig 30b
Figure 30b: Partial inferior maxillectomy suited to an obturator, or reconstruction with buccinator, temporalis muscle, naso-labial or radial free forearm flaps
Fig 30c
Figure 30c: Partial inferior maxillectomy defect closed with two flaps: buccinator myomucosal and local rotation flaps

With more extensive tumours, bilateral inferior maxillectomy (Figures 1, 31a &, b), or more extensive resections (Figure 32) may be required.

Fig 31a
Figure 31a: Malignant melanoma of superior alveolus and hard palate
Fig 31b
Figure 31b: Bilateral inferior maxillectomy for melanoma
Fig 32
Figure 32: (L) inferior maxillectomy with (R) total maxillectomy for sarcoma crossing the midline of the palate


The objectives are to restore palatal integrity so as to separate the oral cavity from the nose and antrum, to maintain midfacial projection, and to facilitate dental restoration. This may be achieved in the following ways:

  1. Denture: Retention may be difficult
  2. Local flaps: Buccinator (Figure 30c), or Nasolabial (Figures 33, 34) flaps
Fig 33
Figure 33: Flap turned in to reconstruct the defect
Fig 34
Figure 34: Nasolabial flap inset into the defect and donor site and lip-split closed
  1. Temporalis muscle flap: This is very well suited, but care has to be taken not to injure the deep temporal arterial pedicle during maxillectomy (Figure 33). A bilateral flap can be used for bilateral inferior maxillectomy defects (Figure 35). It does however preclude the use of dentures
Fig 35
Figure 35: Reconstruction of inferior maxillectomy defect with temporalis muscle flap
Fig 36
Figure 36: Mucosalised bilateral temporalis muscle following bilateral inferior maxillectomy
  1. Radial free forearm flap
  2. Anterolateral thigh free flap (may be too bulky)
  3. Free fibula flap (permits dental implants)
  4. Scapula free flap

Author and Editor

Johan Fagan MBChB, FCORL, MMed
Professor and Chairman
Division of Otolaryngology
University of Cape Town
Cape Town
South Africa