Midfacial Degloving
John C. Price
INTRODUCTION
Management of pathology lying deep to the midface has long been a challenge to surgeons. Problems of access, exposure, instrumentation, hemorrhage, and cosmesis often prove to be compounding and prohibitive factors. The first report of the midfacial degloving approach in the 1970s dealt with its application for the management of trauma and reconstruction. The versatility of the approach was subsequently established as multiple centers reported on its use for the removal of benign tumors and low-grade malignant tumors of the paranasal sinuses, nasal cavity, and nasopharynx. The combination of the basic midfacial degloving technique with other intraoral and/or scalp incisions extended its usefulness to high-grade malignant tumors of the sinuses and skull base. The primary advantage of this technique is that it improves visualization and access while minimizing disruption of function and cosmesis in the critical focal point of the midface.
HISTORY
Many patients who go on to have the midface degloving procedure will present with asymptomatic coincidental findings from CT or other scans or endoscopy or upon evaluation for injury. Progressive unilateral nasal obstruction, unilateral rhinorrhea, and epistaxis are the classic symptoms occurring either alone or in combinations. Ocular symptoms such as numbness, pain, swelling, protrusion of the globe, and changes in visual acuity or diplopia are less common and may indicate advanced disease. The patient should be queried about facial pain, numbness, and any perceived asymmetry. The surgeon should inquire about numbness, or pain in the teeth and an obvious bulge on the palate. Otologic symptoms of pain, hearing loss, and pulsatile tinnitus may indicate middle ear effusion and vascular or invasive pathology. Cranial nerve involvement may be heralded by pain, anesthesia, or paralysis. The surgeon must inquire as to prior nasal examinations, surgeries, and biopsies. Many patients present for treatment having undergone diagnostic and imaging studies: CT scans with and without contrast, magnetic resonance studies, and isotopic scans. Each should be obtained along with the existing reports for review.
PHYSICAL EXAMINATION
The surgeon should personally conduct the examination of the head and neck and review all pertinent data. The face and head must be inspected and palpated for asymmetry, mass, and paralysis. Palpation is essential to confirm a suspected mass or potential skin change such as thinning, fixation, edema, or peau d’orange. The neck must also undergo inspection and palpation for mass and motion.
Assessment of all cranial nerve function is mandatory. Evaluation of motor and sensory nerves to the face, mouth, and pharynx is essential.
Complete examination of the eyes is critical and must include observation of extraocular muscle dysfunction, fixation, and conjugate gaze. Inspection for position of the eyes may reveal proptosis or enophthalmos. The corneal reflex should be evaluated. Visual acuity, visual field evaluation (to confrontation), and evaluation for diplopia complete the examination.
Comprehensive examination of the nose starts with inspection for symmetry or a mass. Palpation of the skin for thinning, fixation, and a subcutaneous mass must be noted. Complete detailed examination of the nasal cavity and nasopharynx includes anterior rhinoscopy, mirror, and endoscopic examination with rod lens and/or flexible fiberoptic instruments. The information obtained is critical to the planning and success of the surgery.
INDICATIONS
Casson’s original report dealt primarily with the use of the midfacial degloving approach for the repair of fractures and reconstructive procedures, including midfacial grafting and osteotomies for advancement and recession. It is an excellent approach for recontouring of the maxilla involved with fibrous dysplasia. Conley and Price, in 1979, reported 26 cases of tumors managed by this method. In 1984, Sacks and Conley et al. reported a composite experience of 46 cases of inverted papilloma removed using the midfacial degloving technique. Terzian, in 1985, reported 25 cases using this technique combined with a microsurgical control to remove juvenile angiofibroma. Price, Holliday, and Kennedy and coworkers further elaborated on the usefulness of this technique applied in combination with a microsurgical approach for management of tumors of the skull base and fungal diseases of the sinuses.
The degloving technique has been used successfully in the management of the following benign sinonasal tumors: inverting papilloma, nasopharyngeal angiofibroma, chondroma, glioma, and chordoma. This technique has also been used in the management of certain low-grade malignancies, such as chondrosarcoma, mucoepidermoid carcinoma, acinic cell carcinoma, woodworker’s adenocarcinoma of the ethmoid, carcinoma ex pleomorphic adenoma, and esthesioneuroblastoma. High-grade malignancies, including very limited cancers of the anterior and inferior maxillary sinus, carcinoma of the hard palate, and small cancers of the nasal septum, may also be managed with this technique. The combination of the degloving technique with other incisions facilitates the removal of tumors of the base of the skull and larger lesions of the sinuses. Maniglia reported the use of this technique for total maxillectomy with orbital exenteration.
This technique has also been useful in the management of extensive benign conditions such as massive polypoid rhinosinusitis, large septal perforations, hereditary hemorrhagic telangiectasias, rhinoscleroma, and nasal sarcoidosis.
Patients for whom this procedure might be appropriate should be carefully selected on the basis of both patient and pathologic indications. Avoidance of a facial scar is most desirable in an adolescent, a child, or a public figure. Degloving may also avoid complications in patients prone to keloid formation and should be used in any patient who resists a necessary operation on the basis of a possible facial scar. Inverting papilloma is the ideal pathologic lesion for the degloving approach. An en bloc excision of the lateral nasal wall can be readily accomplished, and extensions into the maxillary, ethmoid, and sphenoid sinuses are easily removed. The cribriform plate when involved by tumor may be removed by frontal craniotomy and repaired using a pericranial flap. Management of the frontal sinus requires an additional incision.
The degloving technique should be considered a major alternative method for the resection of juvenile angiofibromas, since both internal maxillary arteries are easily accessible for ligation. Extensions into the pterygomaxillary space and cheek are readily managed, and transtemporal and frontal craniotomies allow control of nearly all lesions with dural extensions. Exposure of the maxillary, ethmoid, and sphenoid sinuses is superior to that gained through the transpalatal approach. Once medial maxillectomy and ethmoidectomy have been completed and the tumor has been removed, the pharyngobasilar fascia over the clivus is widely exposed and can be stripped and cauterized under direct control. The large sinonasal cavity that is established makes postoperative surveillance by nasal endoscopy a simple task. Another significant advantage of this technique is the lack of risk of oral nasal fistula and palatal dysfunction. Extensive exposure of the sphenoid sinus and clivus is superior to that provided by any other surgical technique other than maxillectomy making this the ideal procedure for management of chordomas of the clivus.
CONTRAINDICATIONS
There are few specific contraindications for employment of this technique other than those that would mitigate against any prolonged surgical procedure. The general condition of the surgical field is of major concern. Severe damage to the tissues by prior therapy is a specific contraindication be it radiation, chemotherapy, trauma, or major surgery. Stiffening of the tissues with consequent loss of elasticity would severely limit retraction of the facial skin rendering exposure nearly impossible. Attendant obliteration of the microvascular circulation makes
poor wound healing a probability. Disease involvement of the skin or soft tissue overlying the nose or maxillary sinuses requires a much wider resection with removal of significant portions of the midfacial skin or portions of its blood supply. Resection of disease that requires other incisions that would compromise the blood supply to the midface likewise represents a contraindication.
poor wound healing a probability. Disease involvement of the skin or soft tissue overlying the nose or maxillary sinuses requires a much wider resection with removal of significant portions of the midfacial skin or portions of its blood supply. Resection of disease that requires other incisions that would compromise the blood supply to the midface likewise represents a contraindication.
Tumors involving the lateral infratemporal fossa require a more lateral approach than that offered via the usual midface technique. Certain situations, such as very extensive disease, may present opportunities for a combined approach. The petrous apex is not generally accessible using this technique.
PREOPERATIVE PLANNING
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