A modified midfacial degloving approach for the treatment of unilateral paranasal sinus tumours
Introduction
The midfacial degloving approach (MFDA) was first described in 1974 and is a popular approach for the resection of tumours originating in the midface, including the paranasal sinus (PNS) (Casson et al., 1974, Maniglia, 1986, Maniglia and Phillips, 1995). The procedure consists of a gingivobuccal incision, a transfixion incision, a circumvestibular incision, and an intercartilaginous incision, exposing the entire bony midface (Kitagawa et al., 2003). Several reports have confirmed that the MFDA allows a surgical approach to midface without cosmetic deformity and has benefits for the management of diverse midfacial lesions (Howard and Lund, 1992, Buchwald et al., 1995, Howard and Lund, 1999, Fliss et al., 2000). The MFDA is generally preferred to other external approaches and, at many institutions, has become the standard approach for tumour surgery of PNS. However?, the classical MFDA technique has clear limitations, including inadequate surgical exposure of the upper or distal part of the midface. If tumours extend into the upper nasal cavity, sphenoid sinus, nasopharynx or skull base, it is difficult to remove them completely using MFDA.
Complications of the MFDA are related to the particular incisions used during the approach (Buchwald et al., 1995). Vestibular stenosis is a common complication after circumvestibular incisions. Cartilaginous trauma after intercartilaginous incisions may cause postoperative cartilage deformity (Browne and Messner, 1994, Buchwald et al., 1995). Gingivobuccal incisions may result in decreased midfacial sensation (Browne and Messner, 1994, Buchwald et al., 1995). In addition, one of the main characteristics of PNS tumours is their unilateral origin, which frequently makes exposure of the entire midface unnecessary. Modification of the classical MFDA may therefore be required to improve exposure of the upper part of midface and to avoid the complications of MFDA.
In this study, we demonstrate the use of a modified MFDA in surgical resection of unilateral PNS tumours and present the surgical outcomes of the modified MFDA. Our modification provides better surgical exposure, resulting in fewer complications and plays a useful role in the surgical management of midfacial lesions, including unilateral tumours.
Section snippets
Patients
This study included 27 patients who underwent a modified MFDA for the treatment of unilateral benign or malignant tumours from 2000 to 2006 by one surgeon at the department of otorhinolaryngology in Severance hospital, Yonsei University, College of Medicine (Seoul, Korea). The group was comprised of 19 male and 8 female patients, ranging from 12 to 81 years, with a mean value of 44.6 years (Table 1). Computerized tomography (CT) and magnetic resonance imaging (MRI) of the PNS were used to
Surgical procedure
The modified MFDA was performed under general anaesthesia. The patient was placed in the supine position and lidocaine (1%) with epinephrine (1:100,000) was injected in the pyriform aperture, the caudal end of septal cartilage and the gingivobuccal sulcus on the side of the lesion. A gingivobuccal incision was made from the first molar of the side with the lesion to the lateral incisor of the other side using a #15-blade and electrocautery (Fig. 2A). Mucosal elevation was performed at the
Results
We treated 27 patients with unilateral benign or malignant tumours of PNS by mass excision or medial maxillectomy through modified MFDA. Adequate surgical exposure was achieved in all cases. No additional incisions were required. Twenty-three (85%) of our patients had benign tumours and four (15%) patients had malignant tumours. The characteristics of tumour are listed in Table 1. The most common benign tumour was inverted papilloma. Malignant tumours included squamous cell carcinoma,
Discussion
The advantages of MFDA are excellent bilateral exposure of the maxilla, PNS, nasal cavity and nasopharynx, essentially no visible post-surgical scars and virtually no functional disability (Nishikawa et al., 1993, Browne and Messner, 1994, Lund and Howard, 1997, Lund et al., 1998, Lund et al., 1999, Browne, 2001, Kitagawa et al., 2003). The MFDA is our preferred approach for the surgical resection of benign or malignant tumours, originating from PNS and we believe that MFDA is an ideal approach
Conclusion
We found that this modified MFDA provides good surgical exposure to a unilateral lesion for medial maxillectomy or mass excision with few surgical or cosmetic complications and suggests this modification as a treatment modality for unilateral benign or malignant PNS tumours.
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These two authors contributed equally to this work.