Method of resection of upper jaw and zygomatico-orbital complex

Abstract

FIELD: maxillofacial surgery; oncology; plastic reconstructive surgery.SUBSTANCE: through an access in the scalp of the temporal region, under video assistance control, using a raspatory and under visual control, the upper and lower temporal septa and the lateral orbital thickening are crossed. Dissection is performed in the subperiosteal layer of the temporal and parietal regions. Next, a transconjunctival approach is performed, mobilizing the orbicularis oculi muscle along with the skin. Preseptal dissection is performed to the base of the orbital septum. The periosteum of the lower edge of the orbit is dissected along its entire length. The orbital floor is mobilized subperiosteally. The retaining ligament of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the large and small zygomatic muscles, the muscle that lifts the angle of the mouth and the upper lip, and the maxillary osteocutaneous ligament from the orbit are cut off. Dissection is performed up to the level of the alveolar cavity. The lateral canthal ligament of the lower eyelid is cut off. The zygomatic bone is skeletonized subperiosteally to the border between the anterior and middle thirds of the zygomatic arch. The tendons of the masseter muscle are cut off. The mucous membrane of the oral cavity is dissected along the transitional fold of the upper jaw from the level of the first incisor to the tubercle of the upper jaw. An incision is made along the midline to the border of the transition of the hard palate to the soft palate. The mucous membrane of the oral cavity is dissected along the posterior edge of the hard palate, connecting the incisions of the oral cavity into a single line in the area of the tubercle of the maxilla. An osteotomy of the palatine process of the maxilla and the body of the zygomatic bone is performed. The tubercle of the maxilla is cut off from the pterygoid process of the sphenoid bone. The upper jaw and the body of the zygomatic bone are removed as a single block and the wound is sutured layer by layer. The skin is sutured with an intradermal suture. A continuous wrapping suture is applied to the conjunctiva of the lower eyelid.EFFECT: improving the quality of life of patients in the postoperative period after resection of the maxilla and zygomatico-orbital complex, reducing the risk of damage to the facial nerve, injury and cicatricial deformation of the facial tissues, and shortening the length of hospital stay.1 cl, 1 ex

Description

[0001] The proposed invention relates to medicine, namely to maxillofacial surgery, oncology and plastic reconstructive surgery, and can be used in resection of the upper jaw and zygomatico-orbital complex.

[0002] It is known that during resection of the maxilla and zygomatico-orbital complex, the Weber-Fergusson approach is used, which leads to aesthetic defects due to dissection of the skin, superficial muscular-aponeurotic system, facial muscles, the risk of damage to the branches of the facial nerve and the formation of cicatricial deformation of the midface [1]. Also known is a method of resection of the upper jaw and zygomatico-orbital complex through the Weber-Fergusson approach modified by Lynch, which leads to the subsequent formation of a scar in the upper eyelid area [2]. The problem of restoring the primary anatomical and physiological characteristics of the middle third of the face, as well as reducing the risk of damage to the facial nerve, is of primary importance in terms of improving the quality of life of patients, especially when using video assistance technologies.

[0003] Analogue. Method of resection of the maxilla and zygomatico-orbital complex through the Weber-Fergusson approach [1]. An incision is made along the lower edge of the orbit from the medial edge to the lateral edge, the incision is continued outward and downward. A second incision is made from the medial edge of the incision along the base of the lateral surface of the bridge of the nose, bending around the ala of the nose to the base of the nasal septum. The upper lip is dissected with a vertical incision along the midline. Along the entire length, the incision is deepened to the bone, and the resulting flap is separated. The mucous membrane of the oral cavity is dissected along the transitional fold from the level of the first incisor to the tuberosity of the maxilla. The tissue is separated from the bone, the anterior edge of the masseter muscle is exposed, and with a scalpel, the masseter muscle is separated from the lower edge of the zygomatic bone. The orbital septum is dissected along the lower edge of the orbit along its entire length, the orbital septum is moved upward. An incision is made along the midline to the border of the transition of the hard palate to the soft palate.A raspatory is used to separate the soft tissues on either side of this incision. A transverse incision is made from the midline to the maxillary tuberosity, and the frontal process of the maxilla is cut with rongeurs or dissected with a chisel. A chisel or osteotome is used to resect the zygomatic bone. Using a chisel or osteotome, the alveolar process and hard palate are transected from anterior to posterior. The junction of the pyramidal process of the palatine bone with the pterygoid process of the pterygoid bone is dissected. The maxilla is grasped by the alveolar process with bone forceps and dislocated along with the zygomatic bone. Hemostasis is achieved. The wound is closed layer by layer, and the skin is sutured with interrupted sutures.

[0004] The disadvantages of the Weber-Fergusson approach include an aesthetic defect resulting from the dissection of the skin, superficial muscular-aponeurotic system, facial muscles, the risk of damage to the branches of the facial nerve and the formation of cicatricial deformation of the midface.

[0005] Closest analogue. Method of resection of the maxilla and zygomatico-orbital complex through the Weber-Fergusson approach [1]. An incision is made along the lower edge of the orbit from the medial edge to the lateral edge, the incision is continued outward and downward. From the medial edge of the incision along the base of the lateral surface of the bridge of the nose, a second incision is made, bending around the ala of the nose to the base of the nasal septum. A vertical incision is made across the upper lip along the midline. Along its entire length, the incision is deepened to the bone, and the resulting flap is separated. The mucous membrane of the oral cavity is dissected along the transitional fold from the level of the first incisor to the tuberosity of the maxilla. The tissue is separated from the bone, the anterior edge of the masseter muscle is exposed, and the masseter muscle is separated from the lower edge of the zygomatic bone with a scalpel. The orbital septum is incised along the inferior margin of the orbit along its entire length, and the orbital septum is retracted superiorly. An incision is made along the midline to the junction of the hard palate and soft palate.A raspatory is used to separate the soft tissues on either side of this incision. A transverse incision is made from the midline to the maxillary tuberosity, and the frontal process of the maxilla is cut with rongeurs or dissected with a chisel. A chisel or osteotome is used to resect the zygomatic bone. Using a chisel or osteotome, the alveolar process and hard palate are transected from anterior to posterior. The junction of the pyramidal process of the palatine bone with the pterygoid process of the pterygoid bone is dissected. The maxilla is grasped by the alveolar process with bone forceps and dislocated along with the zygomatic bone. Hemostasis is achieved. The wound is closed layer by layer, and the skin is sutured with interrupted sutures.

[0006] The disadvantages of the Weber-Fergusson approach include an aesthetic defect resulting from the dissection of the skin, superficial muscular-aponeurotic system, facial muscles, the risk of damage to the branches of the facial nerve and the formation of cicatricial deformation of the midface, as well as the number of days of hospitalization equal to 15 days.

[0007] Objectives: To develop a method for resecting the maxilla and zygomatico-orbital complex that addresses the risk of facial nerve damage, trauma and cicatricial deformation of facial tissues, and length of hospital stay using video assistance.

[0008] The essence of the invention is: through approaches in the scalp of the temporal regions under the control of video assistance with the help of a raspatory under visual control, crossing the superior and inferior temporal septa, lateral orbital thickenings, performing dissection in the subperiosteal layer of the temporal, parietal regions, performing transconjunctival access, mobilizing the orbicularis oculi muscle together with the skin, performing preseptal dissection to the base of the orbital septum, dissecting the periosteum of the lower edge of the orbit along the entire length, subperiosteal mobilization of the bottom of the orbit, cutting off the retaining ligament of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the large and small zygomatic muscles, the muscles that raise the angle of the mouth and the upper lip, the maxillary osteocutaneous ligament from the orbit, performing dissection to the level of the alveolar bay, cutting off the lateral canthal ligament of the lower eyelid,subperiosteal skeletonization of the zygomatic bone to the border between the anterior and middle thirds of the zygomatic arch, cutting off the tendon of the masseter muscle, dissecting the mucous membrane of the oral cavity along the transitional fold of the upper jaw from the level of the first incisor to the tuberosity of the upper jaw, making an incision along the midline to the border of the transition of the hard palate to the soft palate, dissecting the mucous membrane of the oral cavity along the posterior edge of the hard palate with the connection of the incisions of the oral cavity into a single line in the area of ​​the tuberosity of the upper jaw, performing an osteotomy of the palatine process of the upper jaw, the body of the zygomatic bone, cutting off the tuberosity of the upper jaw from the pterygoid process of the sphenoid bone, removing the upper jaw and the body of the zygomatic bone as a single block, suturing the wound layer by layer, suturing the skin with an intradermal suture, applying a continuous locking suture to the conjunctiva of the lower eyelid.

[0009] Technical result. The advantages include reduced trauma, preservation of facial aesthetics and functionality, and a shorter hospital stay. This method involves transconjunctival and intraoral approaches, as well as the use of video assistance, which improves patients' quality of life in the postoperative period.

[0010] The problems of the risk of damage to the facial nerve, injury and cicatricial deformation of the facial integumentary tissues, the length of the patient's stay in the hospital, subject to the use of video assistance, are solved by crossing the temporal regions through approaches in the scalp under the control of video assistance with a raspatory under visual control of the upper and lower temporal septa, lateral orbital thickenings, performing dissection in the subperiosteal layer of the temporal, parietal regions, performing a transconjunctival approach, mobilizing the orbicularis oculi muscle together with the skin, performing preseptal dissection to the base of the orbital septum, dissecting the periosteum of the lower edge of the orbit along the entire length, subperiosteal mobilization of the orbital floor, cutting off the retaining ligament of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the large and small zygomatic muscles, the muscles that raise the angle of the mouth and the upper lip, the maxillary osteocutaneous ligaments from the orbit,dissection to the level of the alveolar bay. Dissection of the lateral canthal ligament of the lower eyelid, subperiosteal skeletonization of the zygomatic bone to the border between the anterior and middle thirds of the zygomatic arch, dissection of the tendon of the masseter muscle, dissection of the oral mucosa along the transitional fold of the upper jaw from the level of the first incisor to the tuberosity of the upper jaw, making an incision along the midline to the border of the transition of the hard palate to the soft palate, dissection of the oral mucosa along the posterior edge of the hard palate with the connection of the oral incisions into a single line in the area of ​​the tuberosity of the upper jaw, performing osteotomy of the palatine process of the upper jaw, the body of the zygomatic bone, dissection of the tuberosity of the upper jaw from the pterygoid process of the sphenoid bone, removal of the upper jaw and the body of the zygomatic bone in a single block, suturing the wound layer by layer, suturing the skin with an intradermal suture, applying a continuous locking suture to the conjunctiva of the lower eyelid.

[0011] The method was tested on ten patients during 2023-2024.

[0012] The method is carried out as follows: through approaches in the scalp of the temporal regions under the control of video assistance with the help of a raspatory under visual control, the upper and lower temporal septa, lateral orbital thickenings are crossed, dissection is performed in the subperiosteal layer of the temporal, parietal regions, transconjunctival access is performed, the orbicularis oculi muscle is mobilized together with the skin, preseptal dissection is performed to the base of the orbital septum, the periosteum of the lower edge of the orbit is dissected along the entire length, the bottom of the orbit is mobilized subperiosteally, the retaining ligament of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the large and small zygomatic muscles, the muscles that raise the angle of the mouth and the upper lip, the maxillary osteocutaneous ligament from the orbit, dissection is performed to the level of the alveolar bay, the lateral canthal ligament of the lower centuries,The zygomatic bone is skeletonized subperiosteally to the border between the anterior and middle thirds of the zygomatic arch, the tendon of the masseter muscle is cut, the mucous membrane of the oral cavity is dissected along the transitional fold of the upper jaw from the level of the first incisor to the tuberosity of the upper jaw, an incision is made along the midline to the border of the transition of the hard palate to the soft palate, the mucous membrane of the oral cavity is dissected along the posterior edge of the hard palate with the connection of the incisions of the oral cavity into a single line in the area of ​​the tuberosity of the upper jaw, an osteotomy of the palatine process of the upper jaw, the body of the zygomatic bone is performed, the tuberosity of the upper jaw is cut off from the pterygoid process of the sphenoid bone, the upper jaw and the body of the zygomatic bone are removed as a single block, the wound is sutured layer by layer, the skin is sutured with an intradermal suture, a continuous locking suture is applied to the conjunctiva of the lower eyelid.

[0013] Example:

[0014] 1. The patient was admitted with a diagnosis of neoplasm of the mucous membrane of the hard palate on the right.

[0015] Local status: The facial configuration is unchanged. A through-and-through defect is noted in the oral cavity in the area of ​​the hard palate on the right, communicating with the nasal cavity. The mucous membrane around the defect is hyperemic. The mucous membrane is altered in the projection of teeth 1.3-1.8, extending into the retromolar region.

[0016] CT scan: Signs of destruction of the alveolar process of the maxilla and zygomatic bone on the right. Destruction of the horizontal plate of the right palatine bone.

[0017] A decision was made to perform resection of the maxilla and zygomatico-orbital complex on the right through transconjunctival, intraoral and video-assisted approaches.

[0018] Intraoperatively, the superior and inferior temporal septa and lateral orbital thickenings were crossed through approaches in the scalp of the temporal regions under video assistance control using a raspatory under visual control, dissection was performed in the subperiosteal layer of the temporal and parietal regions, a transconjunctival approach was performed, the orbicularis oculi muscle was mobilized along with the skin, preseptal dissection was performed to the base of the orbital septum, the periosteum of the lower edge of the orbit was dissected along its entire length, the floor of the orbit was mobilized subperiosteally, the retaining ligaments of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the major and minor zygomatic muscles, the muscle that raises the angle of the mouth and the upper lip, the maxillary osteocutaneous ligament from the orbit were cut off, dissection was performed to the level of the alveolar bay.The lateral canthal ligament of the lower eyelid was cut off, the zygomatic bone was skeletonized subperiosteally to the border between the anterior and middle thirds of the zygomatic arch, the tendon of the masseter muscle was cut off, the mucous membrane of the oral cavity was dissected along the transitional fold of the upper jaw from the level of the first incisor to the tuberosity of the upper jaw, an incision was made along the midline to the border of the transition of the hard palate to the soft palate, the mucous membrane of the oral cavity was dissected along the posterior edge of the hard palate with the connection of the incisions of the oral cavity into a single line in the area of ​​the tuberosity of the upper jaw, an osteotomy of the palatine process of the upper jaw, the body of the zygomatic bone was performed, the tuberosity of the upper jaw was cut off from the pterygoid process of the sphenoid bone, the upper jaw and the body of the zygomatic bone were removed as a single block, the wound was sutured in layers, the skin was sutured with an intradermal suture, a suture was applied to the conjunctiva lower eyelid continuous wrap suture.

[0019] Local status: wounds in the oral cavity heal by primary intention, without signs of inflammation.

[0020] CT scan: there is a bone defect in the right upper jaw, body of the zygomatic bone, and hard palate on the right.

[0021] The patient's hospitalization time was 10 days.

[0022] Bibliography:

[0023] 1. Head and Neck Surgery and Oncology. A Handbook for Physicians / Edited by Prof. Jatin Shah.

[0024] 2. Open surgical approach to the anterior skull base and paranasal sinuses. DM Fliss. Romanian Journal of Rhinology.

[0025] 3. Surgical approaches to the facial skull. Manual for physicians / Edited by N.E. Manturova, E.V. Verbo.

[0026] 4. Plastic surgery of the face. Manual for doctors / Edited by K.P. Pshenisnov.

Claims

A method for resection of the maxilla and zygomatico-orbital complex, including transconjunctival, intraoral and video-assisted approaches, characterized in that first, through an approach in the scalp of the temporal region under the control of video assistance with the help of a raspatory under visual control, the superior and inferior temporal septa, the lateral orbital thickening are crossed, dissection is performed in the subperiosteal layer of the temporal, parietal regions, then a transconjunctival approach is performed, mobilization of the orbicularis oculi muscle together with the skin, preseptal dissection is performed to the base of the orbital septum, the periosteum of the lower edge of the orbit is dissected along its entire length, the floor of the orbit is mobilized subperiosteally, the retaining ligament of the orbicularis oculi muscle, the orbicularis oculi muscle to the level of the lacrimal caruncle, the major and minor zygomatic muscles, the muscle that raises the angle of the mouth and the upper lip, the maxillary osteocutaneous ligament from the orbit are cut off,dissection is performed to the level of the alveolar bay, the lateral canthal ligament of the lower eyelid is cut off, the zygomatic bone is skeletonized subperiosteally to the border between the anterior and middle thirds of the zygomatic arch, the tendons of the masseter muscle are cut off, the mucous membrane of the oral cavity is dissected along the transitional fold of the upper jaw from the level of the first incisor to the tubercle of the upper jaw, an incision is made along the midline to the border of the transition of the hard palate to the soft palate, the mucous membrane of the oral cavity is dissected along the posterior edge of the hard palate with the connection of the incisions of the oral cavity into a single line in the area of ​​the tubercle of the upper jaw, an osteotomy of the palatine process of the upper jaw, the body of the zygomatic bone is performed, the tubercle of the upper jaw is cut off from the pterygoid process of the sphenoid bone, the upper jaw and the body of the zygomatic bone are removed in a single block and the wound is sutured layer by layer, the skin is sutured with an intradermal suture, the conjunctiva of the lower eyelid with a continuous twisting suture.