Imaging Studies
Most frequently, a CT scan is performed for preoperative evaluation in both the cancer patient (with contrast) and the trauma patient (noncontrast). CT provides the optimal level of detail of bone loss or tumor involvement of bone. When available, direct axial and coronal images can help predict the precise 3-dimensional midface defect that must be reconstructed. Coronal imaging can also be reformatted from fine-cut axial CT data. Further, these data can be used to format 3-dimensional images that precisely outline the anticipated defect. This can also be used to create scale models to assist in operative planning.
Magnetic resonance imaging (MRI) can also be of use to determine soft tissue involvement (in particular, perineural tumor involvement) or concurrent intracranial injury following trauma.
Other Tests
Additional testing should be directed by the patient’s history. Particular attention should be paid to the history and physical examination of the cancer patient to determine whether additional lab or imaging studies should be performed to rule out metastatic disease. At a minimum, this would typically include chest radiographs and contrast-enhanced CT scanning of the neck.
Diagnostic Procedures
In addition to the above noted imaging and preoperative evaluation, all palatomaxillary tumors require definitive preoperative pathologic confirmation. Further, any suspicious findings in the neck or chest should be pursued to determine the presence and/or extent of metastatic disease.
Staging
A complete discussion of the pathologic staging of palatomaxillary tumors is beyond the scope of this article, but a brief discussion follows:
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T0 - No evidence of tumor is found.
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T1 - The tumor is limited to the maxillary sinus mucosa without bone erosion.
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T2 - The tumor causes bone destruction, extends to the middle meatus or hard palate, but does not extend to the posterior wall of the maxillary sinus or pterygoid plates.
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T3 - The tumor invades the posterior wall of the maxillary sinus, pterygoid fossa, ethmoid sinuses, subcutaneous tissue, and floor or medial orbital wall.
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T4a - The tumor invades the cheek skin, orbit, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid, or frontal sinus (resectable).
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T4b - The tumor invades the skull base/dura/brain parenchyma, involves the orbital apex, or extends into the nasopharynx or clivus (unresectable).
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Maxillectomy defect demonstrating significant midface bone and palatal soft and hard tissue defect.
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Harvested fibula free flap demonstrating composite hard and soft tissue for reconstruction of maxillectomy defect as well as vessels for microvascular anastomosis. Note that the split-thickness graft has been harvested from skin paddle to allow closure of the donor site. This precludes the need for additional skin graft donor sites.
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Fibula bone inset and secured with midface reconstruction hardware. The cutaneous portion of flap has been inset to reconstruct palatal soft tissue. Note the maintenance of midface projection and bony contour.
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Wounds closed following fibula flap inset and microvascular anastomosis. Note the maintenance of midface projection and bony contour.
