Traditional transfacial open approaches utilize natural skin creases to access the maxillofacial region. These incisions include lateral rhinotomy or Weber-Ferguson incisions to access the maxillary region, Lynch incision to access the frontal sinus, and Dieffenbach incision and its modification to access the orbital region or malar eminence.

Partial maxillectomies may be performed transorally or through a transfacial approach. After performing the Weber-Ferguson incision, the anterior maxillary wall is widely exposed (Figs. 4.4, 4.5, and 4.6). The infraorbital nerve is identified and preserved if possible. The bone is inspected carefully to identify its integrity and areas of tumor infiltration (Fig. 4.7). The mucosa is first incised with monopolar cautery. Osteotomies along the anterior, inferior, and medial walls of the maxilla are now performed with a motorized reciprocating saw. The lines of the osteotomies are the fossa canina (above the dental roots) as the inferior border; the orbit, superior; the malar eminence, lateral; and the nasal cavity, medial (Fig. 4.8). The medial wall and part of the anterior wall of the maxilla are now retracted anteriorly with a Babcock grasper, and the tumor is freed from its attachments with a Mayo scissors and Freer elevator. If necessary, the rest of the tissue is extirpated with a Kerrison rongeur. Hemostasis is performed with warm saline irrigation. The cavity is inspected and hemostasis is completed with bipolar electrocautery. In most cases, branches of the sphenopalatine artery can be identified at the posterior wall of the maxilla lateral and superior to the choana. These are clamped with medium-size clips to prevent further bleeding. The maxillary defect is reconstructed with an artificial implant during surgery (Figs. 4.9 and 4.10).

This approach, which leaves no incisions and scars on the face, may be used in cases of tumors involving the midface and midpalate like the tumor shown in Fig. 4.11. Midfacial degloving can be approached through the mouth or by a combined transoral midfacial degloving approach. The operation starts with an incision of the mucosa at the gingivobuccal sulcus, approximately 5 mm above the teeth from first molar to first molar. Next, a complete transfixion incision is made and connected bilaterally with a complete intercartilaginous incision. This incision separates the upper lateral cartilages from the lower lateral cartilages. The upper lateral cartilages are left attached to the nasal frame and septal cartilage, and the lower lateral cartilages are included with the superiorly retracted flap. The procedure continues with undermining through the intercartilaginous incision over the face of the anterior maxillary sinus and superiorly over the frontal bone, releasing the soft tissue envelope from the nasal skeleton and nasal septal angle. The intercartilaginous incision is then continued caudally and medially through the periosteum of the nasal floor and pyriform aperture and connected to the transfixion incision (Fig. 4.12). A “degloving” of the facial soft tissues from the nasal skeleton and maxilla is now performed. The flap is held by placing a Penrose drain through each nostril and around the upper lip. Next, osteotomy of the anterior maxillary wall is performed ipsilaterally or bilaterally (Fig. 4.13). An incision is now performed around the tumor perorally (Fig. 4.14). The tumor is removed en bloc with the use of a fine osteotome and Mayo scissors, and the site is reconstructed with an obturator (Fig. 4.15).