The principles and practice of modern surgery

by Roswell Park

Removal of the upper jaw is a rather formidable procedure, frequently made so by extent of the disease which requires its performance. The presence of an extensive and ulcerating tumor, by which normal anatomical outlines are obliterated, will cause mechanical difficulties as well as unusual liability to hemorrhage. During some portion of its performance a temporary control of the vessels of the neck may be of assistance. This can be usually afforded by external digital pressure. In serious cases a ligation of the external or the common carotid may be of assistance. If soft, vascular tumors protrude into the nasopharynx a preliminary tracheotomy should be performed, tamponing the pharynx in order to prevent escape of blood down the throat. The position of the patient with the down-hanging head may be also of assistance in these cases. Of the various incisions employed one should be selected according to the nature of the case. Most of the operations include a splitting of the upper lip near the middle, with continuation of the incision along the margin of the nose, upward toward the orbit and outward along the orbital border, as originally suggested by Fergusson. This permits of completely raising the cheek from the underlying bone in one extensive flap and turning it backward, with complete exposure of the anterior surface of the superior maxillary. The operator next proceeds according to the desired extent of removal. If the roof of the mouth is to be sacrificed the osteoperiosteal and soft tissues composing the palate should be divided as far from the middle line as may be permitted, then reflected, and the bone divided with chisel or with cutting forceps. It may be necessary to remove one of the incisor teeth to permit the insertion of the chisel for division of the anterior part of the jaw. Bone forceps or a chain or wire saw will serve for division of the zygoma and the external or lower wall of the orbit, while with chisel or forceps the nasomaxillary region is divided. The loosened bone can now be seized with strong lion-jaw forceps and wrenched from its attachments, which may then be divided with scissors or knife as they are encountered ([Fig. 474]).

Fig. 474

Resection of superior maxilla. (Farabeuf.)

Hemorrhage will be profuse at this juncture, when the internal maxillary artery is, with many of its branches, thus torn across or severed. The surgeon should be ready with tampons and forceps to check the bleeding and secure the vessels. The complete Fergusson operation includes removal of the entire upper maxilla, but oftentimes much less than this will suffice. On the other hand it is necessary sometimes to go still farther and remove more bone from the orbit or the nasal cavity, or perhaps to clean out the orbit entirely. A case which necessitates one of the more formidable operations is too unpromising to make it often judicious to perform it.

When the tumor involves the overlying skin this should also be sacrificed, and a plastic operation should be made to cover the defect. The skin flaps required for this purpose may be taken from the temple, the forehead, the neck, or adjoining parts of the face.

Bardenheuer has suggested the raising of osteoplastic flaps for removal of tumors lying within the jaw, and their replacement at the conclusion of the operation. He has also devised ingenious methods of making immediate plastic repair which are worthy of study, but which are so seldom required as to not justify description in this place.

After operation the bleeding should be checked by torsion, by ligation, by sutures en masse, by application of hot water, and by securely tamponing with antiseptic gauze, by whose pressure oozing is checked and protection from infection afforded. The patient is allowed to sit up as early as possible, meanwhile being made to lie upon the affected side in order to avoid danger of aspiration pneumonia, and using an antiseptic mouth-wash with relative frequency.

It is sometimes possible to perfect an artificial substitute for tissues removed, which can be inserted after the operation. The loss of tissue will cause more or less disfigurement by sinking in of the cheek and side of the face. After the parts are healed an apparatus made of gutta-percha or metal, and adapted to each case, by which most of the lost symmetry may be restored, should be worn, in the same manner as an artificial denture.

The lower jaw seldom requires complete removal. It is rarely necessary to go so high as the joint or the coronoid process, although occasionally the condyle must be avulsed and the coronoid either cut away or its temporal tendon detached. Most of the exsections in this location are confined to some portion of the horizontal ramus. Except in rare instances it is not possible to make a complete excision of the lower jaw through the mouth, and nearly all operations are practised through external incision, carried along the lower border for a sufficient length, and extended upward along the posterior border beyond the angle, if necessary. In most instances the facial vessels are directly exposed and should be secured before division. Masseteric attachments are separated and the instruments are kept as near to the bone as the circumstances of the case will justify. In well-marked ulcerating cancer, however, the surgeon should go nearly an inch beyond its apparent border and remove still more if it be visible, taking everything which seems involved. Here the bone is usually divided with a chain saw, although stout cutting forceps may suffice. It may be necessary to remove a tooth in order to clear a place for the action of the chain saw. Growths involving the skin necessitate not merely linear incisions, but extensive oval excisions of the overlying tissues. All the involved structures should be removed in one mass; if it be necessary to remove the floor of the mouth the divided bone section is seldom cut away until it can be removed with the rest of the tumor. The healthy mucous membrane should be preserved and brought together with catgut sutures at the conclusion of the operation, as the more carefully the cavity of the mouth can be shut off from the balance of the wound the more prompt and satisfactory the healing ([Fig. 475]).