LETTER TO THE EDITOR

MAXILLARY SWING APPROACH TO THE NASOPHARYNX

TO THE EDITOR:

It is always difficult to know who should receive the recognition for describing a particular surgical technique, and there are few who can claim to have a truly original idea since we all build on what we have learned from others. Thus, I was not surprised when we wrote an article on a “new” operation’ to find it described by other authors’ shortly afterward. Indeed it is not unlikely that many so-called new operative techniques are simply redescriptions or modifications of methods published long before but which are now lost in the depths of obscure scientific journals. It was the Guy’s Hospital surgeon Sir Heneage Ogilvie who said, more than 50 years ago, “All that is recent is not necessarily an advance, and all advances are not necessarily recent.” My reason for writing is to comment on the article by Wei et a13 on the maxillary swing approach. This is an excellent means of gaining access to the nasopharynx and retromaxillary region which I have found most useful for tumors in this area. Nevertheless, it is not exactly new. The technique first came to my notice when presented a t the 7th Congress of the European Association for Maxillofacial Surgery in 1984.435An English language paper was subsequently published by Altemir in 1986.6 It is clear on reading this that he first described the technique in the Spanish literature in 1982, and I feel he should be given some credit for this elegant approach. This is always assuming that, as is surprisingly often the case with maxillofacial operations, it was not actually described in the German literature of the last century! A. E. Brown, FRCS, FDSRCS Queen Victoria Hospital East Grinstead Sussex, United Kingdom

1. Brown AE, Obeid G. A simplified method for the internal

fixation of fractures of the mandibular condyle. Brit J Oral Maxillofac Surg 1984;22:145- 150.

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Letter to the Editor

2. Wennogle CF, Delo RI. A pin-in-groove technique for reduction of displaced subcondylar fractures of the mandible. J Oral Maxillofac Surg 1985;43:659-665. 3. Wei WI, Lam KH, Sham JST. New approach to the nasopharynx: the maxillary swing approach. Head Neck 1991;13:200-207. 4. Curioni C, Padula E, ToscanoO P, Marragia A. The maxill0 cheek flap. Presented at 7th Congress of the European Association for Maxillofacial Surgery, Paris, 1984. 5. Martinez-Lage JL, Acero J, Lorenzo F. Temporary maxillectomy. Presented a t 7th Congress of the European Association for Maxillofacial Surgery, Paris, 1984. 6. Altemir FH. Transfacial access to the retromaxillary area. J Maxillofac Surg 1986;14:165-170.

REPLY:

I cannot agree more with the sentiment expressed by Mr. Brown, that uncertainty often surrounds the claim to originality of new surgical procedures. Indeed, “there is nothing new under the sun” (Ecclesiastes, chapter 1, verse 9). We developed our maxillary swing approach initially for access to the orbit,’ in which the blood supply to the mobilized maxillary wall depended on the masseter muscle. This technique, conceived in 1986 independently of the description of an approach to the retromaxillary area by Altemir? was employed for resection of benign tumours lying close to or arising from the floor of the orbit. Our success prompted us to move a larger piece of bone on the muscle in the treatment of a postradiotherapy recurrent soft palate tumour. Partial avascular necrosis of the bone suggested that blood supply after radiotherapy was marginal and should be increased by way of the cheek flap as the carrier. Faced with the problem of postradiotherapy recurrent nasopharyngeal carcinoma, we extended the maxillary swing approach, made certain modifications, and applied it in the salvage surgical treatment of this d i ~ e a s e All . ~ our patients have had a radical course of irradiation. At the same time, resection often entailed removal of infratemporal fossa contents, thereby dividing the internal maxillary artery. Maintenance of blood supply is, therefore, highly dependent

HEAD & NECK

JanuaryIFebruary 1992

on attachment of the bone to the cheek flap, and an intact facial artery. This vessel has to be preserved when a synchronous neck dissection is carried out, or the neck dissection should be done on a separate occasion. One major difference between the procedure of Dr. Altemir and ours is the site of osteotomy on the maxilla. To approach the nasopharynx, in.contrast to approaching the orbit, the orbital walls do not need to be violated, even temporarily. The osteotomy on the anterior wall of the maxilla lies below the orbital rim. Exposure of the nasopharynx and the parapharyngeal space is quite adequate, and potential ocular complications are avoided. We also believe that modifications

Letter to the Editor

of this technique will develop when varied situations arise. William 1. Wei, MS, FRCSE, DLO University of Hong Kong Department of Surgery Queen Mary Hospital Hong Kong

1. Lam KH,Lau WF, Yue CP, Wei WI. Maxillary swing approach to the orbit. Head Neck 1991;13:107-113. 2. Altemir FH. Transfacial access to the retromaxillary area. J Max-Fac Surg 1986;14:165-170. 3. Wei WI, Lam KH, Sham JST. New approach to the nasopharynx: the maxillary swing approach. Head Neck 1991;13:200-207.

HEAD & NECK

JanuaryiFebruary 1992

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Maxillary swing approach to the nasopharynx.

LETTER TO THE EDITOR MAXILLARY SWING APPROACH TO THE NASOPHARYNX TO THE EDITOR: It is always difficult to know who should receive the recognition f...
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