Mid Facial Degloving Procedure : Managing A Case of Multiple Mid Face Fractures with Significant External Deformity

Purpose: The midfacial degloving approach (MFDA) is the primary option for surgical treatment of midface lesion. Usually most benign and malignant paranasal sinus (PNS) tumours are unilateral. So the classic MFDA does not fit for every case. Modifications of the classical MFDA are then tailored accordingly for surgical field exposure to achieve the goal. MFDA was first suggested by Portmann in 1927, but the modern technique had its origin in 1974 with the report by Casson and colleagues. It was not until Conley and Price first suggested that the technique be used for the excision of neoplastic disease in 1979 that its use was fully realized. It can be of great benefit for the management of various lesions, mainly tumors, of the facial cavities, paranasal sinuses, nasopharynx, orbits, and central compartment of the anterior and middle cranial fossae, allowing adequate bilateral maxillary and lower nasal cavity exposure without cosmetic dysfunction. Patients: A male patient of 20 years was admitted with history of faciomaxillary trauma having significant external deformity. Under GA open rhinoplasty and reduction & immobilization of fractured segments were done with adequate exposure of midface using midfacial degloving procedure. Result: We have performed MFDA in one case only for the first time. Utilizing sublabial gingivobuccal incision, a complete transfixion incision, intercartilaginous incision with mucosal detachment of the pyriform aperture nasomaxillary skeleton along with zygoma were exposed adequately. No technical problems and no intraoperative complications related to the surgical procedure were encountered. Cosmetic outcome was also satisfactory. Conclusion: Midfacial degloving can be considered as an excellent, useful, and safe approach for many lesions of the midface that has a low complication rate with excellent cosmetic outcomes. It provides excellent exposure to the midportion of the craniofacial skeleton, yet avoids external incisions and should be in every head and neck surgeon’s armamentarium.


Introduction
The mid facial degloving approach (MFDA) is the primary option for surgical treatment of mid face lesion.MFDA was first suggested by Portman in 1927.The modern technique had its origin in 1974 with the report by Casson and colleagues.But its use was fully realized in 1979 when Conley and Price first suggested the technique for the excision of neoplastic disease.It can be of great benefit for the management of various lesions, mainly tumors, of the facial cavities, paranasal sinuses, nasopharynx, orbits, and central compartment of the anterior and middle cranial fossae, midface fracture (naso-orbitalethmoidal) allowing adequate bilateral maxillary and lower nasal cavity exposure without cosmetic dysfunction.
• Patient was clinically assessed and planned for surgical treatment aiming at reduction of fracture with fixation and stabilization to restore normal anatomical contour and to achieve normal physiology as much as possible.
• Nasal bone fracture with depression of root of the nose and gross external deviation towards right side with gross septal deviation.
• Left side of face was significantly depressed with fracture of anterior wall of maxilla from infraorbital margin up to alveolar ridge.Infraorbital margin was also depressed.
• Malar prominence was lost with zygomatic fracture and completely separated from all attachment with surrounding bone.
Complete blood count /RBS/Serum creatinine were within normal range, HBsAg was Positive.Other findings were, blood group A+, X-ray chest revealed nothing abnormal.X-ray PNS shows nasal bone fracture with gross septal deviation, fracture and depression of left infraorbital margin, depression of zygoma with fracture of all its attachment.OPG was normal.CT scan was also done with 3D image.
Patient was completely well and active one month back.Unfortunately he experienced a tragic RTA.Primary resuscitative measure was taken in three other centers from primary to tertiary level but without definitive treatment (reduction of fracture).

Discussion
Lateral rhinotomy/ Weber Ferguson are traditional approaches for nasal cavity and paranasal sinus tumor surgeries.This approach provides an excellent surgical exposure; notwithstanding, even with such advantage, its use is limited, because it leaves a prominent scar on the face.The degloving approach was first described in 1974, by Casson et al.¹ and has become very popular because of its major advantages of avoiding facial incisions and providing bilateral exposure of the nasal cavity.Thus, the midfacial degloving approach has been used as a first option for medial maxillectomy, radical maxillectomy and non-complicated craniofacial surgeries4-6.Some changes to the degloving approach have been described, in order to avoid vestibular stenosis, which is the most frequent and significant complication 7 .
The standard procedure comprises an extensive gengivobuccal incision, a transfixating septal incision, an intercartilaginous incision and an incision in the nostril.The vestibular stenosis occurs as a consequence of the circumferential incision that is made in the nasal vestibule during the procedure.
Midfacial degloving was used as an approach in 14 patients to correct post-traumatic deformities in the midface.In eight patients, deformities in the naso-orbito-ethmoid region were corrected.In one patient, a midface fracture (Le Fort II/III) was reconstructed after midfacial degloving.There were no postoperative complications such as stenosis of the nasal aperture or disturbances of the mimic musculature.Midfacial degloving offers good exposure, specially of the central part of the midface, without leaving an external scar.It is useful for reconstructive procedures in patients after midface trauma. 8 is known that one of the inconveniencies of the type of surgery under study is that it takes longer than its endoscopic counterpart, and the latter is a feasible and very much efficient alternative for the treatment of nasal cavity tumors in their initial stage, because it is less aggressive and brings less complications to the patient's post-op recovery.Notwithstanding, considering larger lesions, even if benign, the endoscopic approach is not adequate.
The MFD approach was used to access nasoorbital-ethmoidal (NOE) and concomitant midfacial fractures for repair in 9 patients with facial trauma. 3Functional and cosmetic results were assessed during follow-up with serial physical examinations and postreduction films.No significant technical problems were encountered in the treatment of NOE and concomitant fractures.Physical examination and imaging studies showed adequate reduction in all patients, and all patients were satisfied with their short-and long-term functional and cosmetic results. 3spite of some inconvenient points, degloving is efficient in the treatment of extensive lesions involving the nasal cavity and paranasal sinuses with the advantage of not leaving facial scars.

Conclusion:
Surgical exposure was very much adequate in our case to deal with whole of the midface skeleton with almost no surgical or cosmetic complications.From the perspective of managing this case it can be appreciated that the MFDA is an appropriate procedure to handle any kind of midface lesion like benign and malignant sinonasal tumours.With some modification midline or paramedian skull base lesion can also be addressed.Surgeon's viewing angle and control over lesional dissection is better with this approach avoiding any facial scar.Midfacial degloving can be considered as an excellent, useful, and safe approach for many lesions of the midface that has a low complication rate with excellent cosmetic outcomes.MFDA should be considered an important armamentarium by every head-neck surgeon.
We may conclude that the degloving approach to resect sinonasal tumors or to deal with mid face fracture is effective and bears the advantages of broad surgical exposure, excellent cosmetic results, very low post-operative complication rates.