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SKULL BASE TUMOR SURGERY 0030-6665/01 $16.00 + .OO

THE MIDFACIAL DEGLOVING

PROCEDURE FOR
NASAL, SINUS, AND
NASOPHARYNGEAL TUMORS
J. Dale Browne, MD

The concept of a midfacial degloving procedure was first introduced in

the 1920s with sublabial approaches, such as those described by Portmann and
Retrouvey" in 1927. The modern version of an extended sublabial technique with
degloving of the midface was later popularized by Conley4and Maniglia.','' The
chief advantage of this technique is the ability to acquire excellent bilateral ante-
rior exposure of the maxilla, paranasal sinuses, and nasopharynx without facial
incisions. It has been successfully used in the surgical treatment of sinonasal dis-
ease in children and adults (Fig. l).",l2
The adjacent skull base also can be accessed for tumor removal with con-
comitant adjunctive procedures. The degloving technique provides the same ip-
silateral exposure as the lateral rhinotomy incision, but can be expanded to allow
visualization of both sides of the nasal septum if necessary.2.3 Wide exposure of
the nasopharynx necessitates resection of the posterior and lateral nasal walls. Ex-
posure of the infratemporal fossa usually requires temporary resection of the lat-
eral maxillary buttress and inferior zygoma. Although hardly a disadvantage, this
approach is technically more involved than a lateral rhinotomy and requires a ba-
sic level of proficiency and understanding of closed rhinoplasty incisions and the
anatomy of the nose, paranasal sinuses, and skull base structures. Current appli-
cations of the midfacial degloving procedure allow expansion of indications for
the technique through the use of complementary endoscopic and subcranial skull
base approaches that permit the exposure and removal of extensive skull base le-
sions without disfiguring facial incision^.^, 5, ', l2 Fundamental in these approaches
is the basic midfacial degloving technique, which is discussed in this article, along
with applications for the treatment of skull base lesions.

From the Department of Otolaryngology-Head and Neck Surgery, Wake Forest University
School of Medicine, Winston-Salem, North Carolina

OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA

VOLUME 34 NUMBER 6 DECEMBER 2001 1095

1096 BROWNE

Figure 1. Chondrosarcoma in an 11-year-old girl resected by way of a midfacial degloving

procedure, illustratingthe excellent functional and cosmetic results possible in the pediatric
population.undergoing this procedure. A, Coronal CT scan showing the tumor arising from
left lateral nasal wall. B, lntraoperative view of midfacial degloving exposure for the medial
maxillectomy. C, One-year postoperative view; her left medial pyriform aperture bone was
well separated from the tumor and was replaced at the conclusion of the resection to prevent
soft-tissuecollapse in this area. D, One-year postoperativeCT scan.

TECHNIQUE

After general orotracheal anesthesia is accomplished, subcutaneous injec-

tions of 1% lidocaine and epinephrine (1:200,000 concentration) are instilled un-
der the nasal skin, both canine fossae, and the subcutaneous tissues of the anterior
maxilla bilaterally in a subperiosteal fashion. Good local injections are achieved
 MIDFACIAL DEGLOVING PROCEDURE 1097

with blanching of the anterior septum, nasal tip, floor of the nose, and skin of the
nasal vestibule. Special attention is given to injecting the intercartilaginous area
between the upper and lower lateral nasal cartilages, and laterally against the
maxillary bone of the pyriform aperture. Nasal packs of cotton instilled with
oxymetazoline 0.05% solution are inserted for 10 minutes for additional hemosta-
sis. A cotton-roll throat pack is placed in the posterior pharynx. Temporary tarsor-
raphies of 6-0 silk are used for ocular protection. A betadine preparation of the
face is performed. Preoperative parenteral staphcidal antibiotics and dexametha-
zone (20-30 mg for adults; 1 mg/kg pediatric) are given.
A 360" incision is made in each nasal vestibule with a scalpel, beginning with
bilateral hemitransfixion incisions (Figs. 2 4 ) . These incisions are extended into
intercartilaginous incisions, which then are curved laterally and inferiorly around
the inside of the vestibule, juxtaposed to the maxillary bone of the pyriform aper-
ture. Through each intercartilaginousincision, the soft tissue of the nasal dorsum
is undermined, with care to widely undermine the soft tissue overlying the nasal
bones to the levels of the medial canthus on each side. A complete transfixion inci-
sion is made in the anterior septum, and the septa1 angle is released completely in
the dissection so that all soft tissue attachments to the nasal bones and septum are
detached. It is imperative to elevate the nasal soft tissue over the nasal and adja-
cent maxillary bones in a subperiosteal fashion and to continue this elevation well
onto the face of the maxillary bones bilaterally to allow for easy connection with
the sublabial portion of the dissection.
Intraoral retractors are used to elevate the upper lip for exposure of the ca-
nine fossa mucosa. A mucosal incision is made with electrocautery cutting current

Figure 2. Coronal CT scan showing a Ewing's sarcoma arising in the left maxillary sinus of a
25-year-oldwoman.
1098 BROWNE

Figure 3. Early steps in the midfacial degloving procedure to resect the tumor in
Figure 2. A, Bilateral circumferential incisions within the nasal vestibule. B, A complete trans-
fixion incision is made and the septa1 angle is released. C, The nasal dorsum in undermined
through the intercartilaginous incisions bilaterally and extended onto the medial maxillary
bone. D, Electrocautery is used to perform a sublabial incision through each canine fossa
and extended onto the medial maxillary bone.
Illustration continued on following page

parallel to the full extent of the maxillary alveolar ridge and extended down onto
the medial maxillary bone. Care is-taken to position the incision well above the
gingivae and the openings of Stensen’s ducts. Blunt periosteal dissectors are used
to elevate the mucosa off the anterior maxilla and connect this with the previ-
ous nasal dissection, with elevation continued superiorly to the level of the in-
fraorbital nerve on each side. Subcutaneous attachments around the lateral and
inferior aspects of each pyriform aperture are released sharply with dissecting
scissors. A.Penrose drain is placed through each nostril and removed through
the sublabial incision, allowing for atraumatic, superior retraction of the anterior
maxillary and nasal soft tissues.
With soft tissue retraction accomplished, blunt subperiosteal elevation can be
performed medially to the level of the medial canthus on each side. Although
most lesions are unilateral, maximum exposure of the pathologic side is accom-
plished through bilateral elevation of soft tissue. Bilateral disease easily is ex-
posed through this identical exposure. For resections that involve the removal of
the infraorbital nerve, this nerve can be sectioned as it exits the anterior max-
illa to allow exposure of the orbital rim on the involved side. The final expo-
sure achieved by the midfacial degloving brings the anterior maxilla and nasal
 MIDFACIAL DEGLOVING PROCEDURE 1099

Figure 3 (Continued). €, The circumferential vestibular incisions, complete transfixion in-

cision, and sublabial incisions are connected. F, The soft tissue is reflected off the ante-
rior wall of each maxilla and extended to the level of the infraorbital foramen on each side.
Dissection can continue to the level of the medial canthus along the nasalhnaxillary bone
junction if necessary. G, The surgical resection has been performed. H, Reconstruction of
the defect is performed; in this case, cranial bone grafts are used to reconstruct the or-
bital rim with the orbital floor replaced with titanium mesh. A transconjunctival approach was
used to facilitate orbital floor resection and reconstruction.

bones into direct visualization. If oncologically sound, a section of medial maxil-

lary bone forming the lateral pyriform aperture can be removed temporarily with
an oscillating saw to allow greater exposure of the tumor. This bone can be re-
placed at the conclusion of surgery with craniofacial plating to prevent retraction
of lateral nasal soft tissues. Portions of the lateral maxilla of maxillary buttress
and zygoma potentially can be resected temporarily to provide exposure of the
pterygomaxillary and infratemporal fossae. These approaches can be combined
with any combination of endoscopic, orbital, or subcranial approaches best suited
for effectiveremoval of the disease.
After resection, the soft tissues are allowed to return to anatomic position.
The canine fossa inucosa incisions are closed with a running absorbable su-
ture, such as 3-0 chromic suture. The intranasal incisions are closed with in-
terrupted 4-0 chromic suture in four quadrants on each side. Nasal packing is
positioned bilaterally using a soft nasal tampon to be removed after 24 hours.
An external nasal splint is placed and removed 2 to 3 days later, depending on
edema. Following splint removal, rhinoplastic paper taping of the nasal tip and
dorsum is performed for the next 3 days if there is persisting tip edema.
Figure 4. The nasal vestibule and sublabial incisions are closed. Nasal tampons are in-
serted,followed by an external splint.

TECHNICAL MODIFICATIONS AND

COMPLEMENTARY PROCEDURES

The main limitation of the anteriorly directed midfacial degloving technique

in cranial base pathology is related to exposure of the anterior and middle fos-
sae skull base. Less problematic is the potentially awkward exposure of the orbital
floor for resection and reconstruction. Because surgical resection can create a
bloodied operative field with multiple areas of mucosal disruption, visualization
of critical skull base interfaces by way of the degloving technique alone can be
further hampered at a critical moment. Direct exposure of the cribriform plate,
ethmoid roof, lateral sphenoid sinus, and skull base of the superior infratempo-
ral fossa is accomplished after tumor removal when an anterior transmaxillary
approach is used. Pathologic tissue must be debulked and pulled away from the
skull base as it is removed rather than visualized and retracted from the tumor be-
fore definitive removal. SimilarIy, because of this anterior-inferior angulation of
the approach, frontal sinus pathology also cannot be addressed easily by the sole
use of the midfacial degloving technique. Though the inferior angulation of the
approach to the orbit by way of a midfacial degloving technique provides expo-
sure of this region, it does not provide the optimal anterior line of sights parallel
to the orbital floor that a more traditional orbital exploration approach offers. For
this reason, other orbital techniques may be required at times to safely extirpate a
tumor or reconstruct the orbital rim and orbital floor.
Tumors that invade the frontal sinus, ethmoid roof, superior septum, crib-
riform plate, floor of the anterior and middle fossae, and walls of the sphenoid
sinus place the skull base at risk for iatrogenic injury and require surgical re-
section for complete tumor removal. Malignant disease optimally is removed en
bloc, making the addition of a subcranial or frontal-temporal craniotomy ap-
proach a requirement if the skull base is involved. As with skull base lesions in
general, CT scanning is essential to evaluate subtle or complete bone erosion of
the skull base, and MR imaging is useful to evaluate dural or perineural inva-
sion. Because the condition of the skull base bone is vital in the choice of tech-
nique, a high-resolution coronal CT scan should be performed to examine the
 MIDFACIAL DEGLOVING PROCEDURE 1101

superior extent of the tumor to be removed whenever a midfacial degloving ap-

proach is considered. If such imaging studies demonstrate the bony interface of
the skull base is intact or would not require resection to achieve complete tumor
removal, a midfacial degloving technique alone may be sufficient. Equally impor-
tant in this latter consideration is the determination of whether a partial removal
is an acceptable technique for tumor removal, a situation generally limited to be-
nign disease.
Technical advances in endoscopic sinus surgery have enhanced the visualiza-
tion of the deeper recesses of the sinonasal cavity and the skull base interface.', l2
As discussed, though the bulk of any tumor that is approachable using the de-
gloving technique can be removed under direct visualization, it is the most pos-
terior and superior aspects removed last that contain the highest morbidity from
the procedure. Modifications in the traditional approach have been described
that combine temporary resection of portions of the pyrifom aperture with ele-
vation of the cartilaginous septum and anterior nasal spine with the soft tissues
to increase e x p o s ~ r eThrough
.~ such technical improvements, the safety and ex-
tent of such resections approachable through the midfacial degloving technique
have been expanded. Enhanced endoscopic optics and lighting, endoscopic bipo-
lar cautery, and motorized dkbridement and irrigation systems provide the means
to closely evaluate and dissect along the skull base interface in selected cases.
Image-guided technology can provide invaluable assistance in endoscopic local-
ization, especially in a narrow field of dissection containing the potential for in-
jury to the dura and adjacent brain, carotid artery, and optic nerve.
When there is a wide dissolution of the bony skull base, dura is in contact
with the tumor (Fig. 5 ) . Resection through the midfacial degloving technique
alone may be unsafe and technically unsound if it is necessary to peel the tumor

Figure 5. A large juvenile angiofibroma eroding bone of the middle cranial fossa floor and
involving the ipsilateral cavernous sinus. A midfacial degloving procedure alone is inade-
quate to resect this tumor, which was accomplished successfully with a combined lateral
temporal-subcranial approach along with a pterional craniotorny.
away from broad areas of dura directly to achieve complete removal. In such
cases a bicoronal or preauricular temporal scalp incision can be used to allow the
addition of other techniques for skull base exposure (Fig. 6).2 Useful adjunctive
procedures include the frontal osteoplastic flap with or without an extended sub-
cranial approach for the exposure and resection of the anterior skull base; a lateral
temporahubcranial approach for visualization of infratemporal fossa lesions in-
volving the adjacent skull base; and a frontal-orbital or pterional craniotorny2,

APPLICATIONS

Whereas a traditional midfacial degloving technique (as described in this

article) can be used easily for a variety of sinonasal pathologies, the challenge for
the surgeon is proper patient selection in applying this technique to larger tumors
that arise within or encroach on the skull base. Benign diseases such as osteomas,
hemangiomas, large septa1 perforations, ondontogenic tumors, and congenital

Figure 6. A, A large deforming osteoma protruding into the anterior cranial fossa, as well as
the nasal cavity. B, A midfacial degloving procedure was used to resect the nasal portion of
this lesion. C, Because of the intracranial, extradural portion of the osteoma, an anterior
subcranial approach was also necessary to resect this lesion and reconstruct the subse-
quent bony defects.
 MIDFACIAL DEGLOVING PROCEDURE 1103

cysts have been treated successfully with this technique.', 6 , Particularly advan-
tageous is the use of this technique in the management of locally aggressive, his-
tologically benign lesions such as juvenile angiofibromas and inverted papillomas
in which a wide exposure is necessary to achieve a complete removal without fa-
cial incisions. Malignant tumors can be excised in similar fashion with an en bloc
resection achievable through this sublabial te~hnique.~ When combined with or-
bital incisions, wide exposure for an aggessive resection can be obtained with ex-
cellent cosmesis in the postoperative period. In this setting, the transconjunctival
approach for orbital-floor resection and reconstruction can be very useful, further
adding to exposure and allowing a functional reconstruction with attention to
cosmesis.
As mentioned lesions that have caused extensive bone destruction at the
skull base and have a wide tumor or dural interface often cannot be removed
safely using the midfacial technique alone. In these cases, the anterior degloving
technique is useful for the controlled release of the tumor from sinonasal and me-
dial and inferior orbital contents. The portion eroding the skull base is removed
using techniques that provide more direct lateral and superior exposure, such as
a subcranial approach or true craniotomy. A notable exception is the small mid-
line clival lesion, which does not extend laterally to involve the petrous bone, in-
fratemporal fossa, or cavernous sinus structures. In this case, a midfacial deglov-
ing technique alone provides excellent exposure for the controlled, microscopic
removal of such lesions with dural preservation.

COMPLICATIONS

The most common complications and sequelae from a midfacial degloving

technique are excessive intranasal crusting postoperatively, requiring periodic d6-
bridement and prolonged infraorbital nerve hypesthesia. Most hypesthesias are
transient and resolve in less than 3 months; accordingly, patients should be ap-
propriately informed of this before the operation. Retraction of the infraorbital
nerve is unavoidable to achieve the exposure frequently required for removal of
the lesion; however, the surgeon should be aware of the position of the retractors
and take care to avoid direct contact of any instrument with the nerve as it exits
the foramen. Intranasal crusting is a function of the amount of exposed bone that
must mucosalize following a resection and the size of the cavity created by the
surgery. It can be prolonged at focal areas by craniofacial screws that protrude
into the sinonasal cavity or most significantly by radiotherapy. Periodic nasal
saline irrigations, along with dhbridement in the office setting, help manage this
problem. Less common complications include an oral-antral fistula and nasal
vestibular stenosis, highlighting the need to carefully reapproximate mucosal
edges sublabially and intranasally.
When combined with adjunctive procedures for exposure, complications can
become more significant with the potential for orbital and cranial nerve injuries
and dural disruption with leak of cerebrospinal fluid. Avoidance of such compli-
cations is important when considering patient selection, choice of approach, and
methods of reconstruction. For example, rather than relying on a midfacial de-
gloving technique alone for exposure, a large angiofibroma with an extensive du-
ral interface in the infratemporal fossa may be best addressed with a combined
procedure with a transtemporal, subcranial approach to avoid unnecessary in-
jury to the middle fossa dura (see Fig. 5). It is paramount that the surgeon care-
fully review the skull base and orbital interface of the lesion by preoperative
imaging studies to choose the appropriate technique preoperatively rather than
1104 BROWNE

be forced t o work under the constraints of an inappropriate technique during the

operation.

SUMMARY

The midfacial degloving technique is an extremely useful procedure in the

management of skull base tumors. Combining the advantages of excellent cosme-
sis and wide anterior bilateral exposure of t h e sinonasal cavity, t h e degloving op-
eration provides head and neck surgeons w i t h a flexible tool to address a vari-
ety of pathologies. Though inherently useful alone, it can be of greatest benefit
when combined with endoscopic, orbital, subcranial, and traditional craniotomy
procedures for the management of extensive skull base tumors that involve the
sinonasal or retromaxillary regions. Careful preoperative assessment is vital t o
minimize complications by choosing the correct approach.

References

1. Berghaus A, Jovanovic S: Technique and indications of extended sublabial rhinotomy

("midfacial degloving"). Rhinology 29:105-110,1991
2. Browne JD, Jacob SL Temporal approach for resection of juvenile nasopharyngeal an-
giofibromas. Laryngoscope 1101287-1293,2000
3. Buchwald C, Bonding P, Kirby B, et al: Modified midfacial degloving: A practical ap-
proach to extensive bilateral bening tumours of the nasal cavity and paranasal sinuses.
Rhinology 33:39-42,1995
4. Conley J, Price JC: Sublabial approach to the nasal cavity and nasopharyngeal cavities.
Am J Surg 38615418,1979
5. Fliss DM, Zucker G, Amir A, et al: The combined subcranial and midfacial degloving
technique for tumor resection: Report of three cases. J Oral Maxillofac Surg 58:106-110,
2000
6. Howard D, Lund VJ:The midfacial degloving approach to sinonasal disease. J Laryngol
Otol106:1059-1062,1992
7. Howard D, Lund VJ: The role of midfacial degloving in modem rhinologic practice.
J Laryngol Otol113:885-887,1999
8. Ikeda K, Suzuki H, Oshima T, et al: Midfacial degloving approach facilitated by endo-
scope to the sinonasal malignancy. Auris Nasus Larynx 25:289-293,1998
9. Maniglia AJ: Indications and terhniques of midfacial degloving. Arch Otolaryngol
Head Neck Surg 112750-752,1986
10. Maniglia AJ, Phillips DA: Midfacial degloving for the management of nasal, sinus, and
skull-base neoplasms. Otolaryngol Clin North Am 28:117-143,1995
11. Portmann G, Retrouvey H Le Cancer d u Nez. Paris, Gaston Doin et Cie, 1927
12. Uretzky ID, Mair EA, Schoem SR Endoscopically guided midfacial degloving in infants
for removal of congenital and acquired midfacial masses. Int J Pediatr Otorhinolaryngol
46:149158.1998

Address reprint requests to

J. Dale Browne, MD
Department of Otolaryngology-Head and Neck Surgery
Wake Forest University School of Medicine
Medical Center Boulevard
Winston-Salem, NC 27157

e-mail: [email protected]