CASO CLÍNICO

 

Treatment of midfacial fracture by midfacial degloving. Case report

Tratamiento de fractura del tercio medio facial mediante la técnica de ‘midfacial deglobing’. Reporte de un caso

 

 

A.R. Méndez Tenorio¹, I. Sahagun Pille²

¹ Cirujano Oral y Maxilofacial. Práctica privada. Ciudad de México.
² Médico adscrito al Servicio de Cirugía Maxilofacial
Hospital de Traumatología Victorio de la Fuente Narváez IMSS. Ciudad de México. México

Correspondence

 

 

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ABSTRACT

Surgical access to midface structures in maxillofacial trauma traditionally has been obtained by sublabial incisions and cutaneous incisions for orbital trauma (subciliary, infraorbital, Lynch, "H" or "open-sky" and gull-wing incisions). The midfacial degloving procedure was developed by associating sublabial incisions with rhinoplasty incisions and used to gain access to and treat superficial sinonasal neoplasms, according to a report by Casson in 1974. There have been a few reports of the use of this procedure in facial trauma. We used this technique as a internal approach for a patient with panfacial fractures. The technique demonstrated several advantages over conventional techniques for approaching the midfacial bones. It provided an extended surgical field, eliminated cutaneous incisions and their esthetic sequelae, and had a complication-free postoperative course. Our results showed that the midfacial degloving procedure is a useful and safe technique for securing access in facial trauma.

Key words: Midfacial fractures; Surgical access; Midfacial degloving procedur.

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RESUMEN

Tradicionalmente, el abordaje quirúrgico hacia las estructuras del tercio medio de la cara en trauma maxilofacial ha sido a través de incisiones intraorales sublabiales y de incisiones cutáneas10. La técnica de disección del tercio medio facial ha sido desarrollada con el uso combinado de incisiones sublabiales y de rinoplastia por Casson, quien en 1974 describe la técnica para tener acceso a esta zona en el tratamiento de lesiones neoplásicas sinonasales superficiales. Existen pocos reportes en la literatura referente a su uso en trauma facial. En este artículo se reporta la aplicación de esta técnica como abordaje estético para fracturas del tercio medio facial. Los resultados obtenidos en este caso coinciden con los reportados en la literatura y demuestran que la técnica presenta diversas ventajas ante los abordajes convencionales, ya que proporciona un amplio campo visual a la zona quirúrgica, evita el uso de incisiones cutáneas con sus secuelas estéticas cursando con un postoperatorio satisfactorio. Como conclusión, de acuerdo con los resultados obtenidos en el caso, la técnica de disección de tercio medio facial fue aplicable y segura como abordaje quirúrgico en trauma facial, y presenta diversas ventajas que la favorecen al planear el abordaje quirúrgico a utilizar.

Palabras clave: Fracturas del tercio medio facial; Abordajes quirúrgicos; Disección del tercio medio facial.

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Introduction

The traditional surgical approach to midfacial structures in maxillofacial trauma has been through a sublabial incision and cutaneous incisions for floor and medial wall injuries of the orbit. The midfacial degloving technique was developed using a combination of sublabial incisions and rhinoplasty to obtain access to this area to treat superficial sinonasal neoplastic lesions. In 1974, Casson proposed the procedure as an approach to the midfacial bones for indications such as facial fracture, resection of maxillary tumors, midfacial osteotomy, or bone grafts procedures.¹ Various authors popularized its use, such as Mangiglia,² Hollyday,³ and Romo,⁴ and it has been used mainly in head and neck surgery for the resection of benign and malignant neoplasms of the paranasal sinuses. The first report of the use of midfacial degloving as a surgical approach to facial trauma was by Baumann and Ewers,⁵ who used it in 14 patients with midfacial fractures.

This technique allows midfacial structures to be exposed without using external skin incisions. The midfacial degloving procedure requires skill in both paranasal sinus surgery and basic rhinoplasty because the approach involves a bilateral sublabial incision and raising the soft tissues of the dorsal nose. The irrigation of the deinserted skin is supplied by the infraorbital and facial arteries, so other incisions can be made to enhance exposure without compromising the vascularization of the area.³

 

Clinical indications

1. Resection of benign sinonasal processes, particularly inverted papilloma, angiofibroma, and fibro-osseous disease

2. Septodermoplasty and repair of large septal perforations

3. Midfacial fractures

4. Midfacial osteotomy

5. Midfacial bone grafts for reconstruction of the facial contour

6. Certain malignant tumors that can be approached properly using this exposure, e.g., angiofibroma and inverted papilloma.

The midfacial degloving procedure is ideal for children and adolescents, in which external incisions can be particularly undesirable. It also can be performed in adults.

 

Advantages

1. Good exposure of the nasal cavities, midface, and central skull base is obtained.

2. It allows additional modification and extension

3. There are no external scars

4. Postoperative complications are minimal.

5. A wide variety of diseases can be controlled successfully.

6. Patient tolerance is good.

 

Disadvantage

The only disadvantage is the occasional occurrence of nasal vestibule stenosis.

 

Surgical technique

The patient is informed before the procedure about the surgical trauma and facial edema that are involved and how it would resolve with time. Intranasal scab formation is mentioned, particularly in patients who undergo the removal of more extensive lesions. The patient is advised that paresthesia may occur after the operation.

The operation is performed under general anesthesia; an endotracheal tube is placed in the center of the mouth and affixed to the chin. The patient is placed in supine inverted Trendelenburg position with the head flexed upward about 15°. Xylocaine with epinephrine 1:200 000 is infiltrated in the planned incision sites of the nasal soft tissues, buccogingival sulcus, and anterior face of the maxilla to control bleeding.

1. Tarsorrhaphy sutures or corneal protectors are placed bilaterally.

2. A bilateral sublabial incision is made and extended laterally to the maxillary tuberosity on both sides (Fig. 1).

3. The periosteum on the anterior face of the maxilla is lifted bilaterally with the soft tissues, taking care to identify and preserve the infraorbital nerves.

4. Rhinoplasty type intercartilaginous incisions are then made (Fig. 1). The soft tissues of the nose are separated from the superior lateral cartilages. The periosteum overlying the nasal bones is raised laterally and superiorly as much as possible to the root of the nose. A transfixion incision is now made (Fig. 1) along the dorsal and caudad edges of the cartilaginous septum from the medial prolongation of the inferior lateral cartilages. That incision is extended along the floor of the nasal fossa to the lateral aspect of the pyriform fossa and connected with the intercartilaginous incision to completely free the circumvestibular area (Fig. 1). The procedure is completed by cutting lateral dissection to connect the deinserted nose with the previously dissected areas of the maxilla.

5. The midfacial skin is deinserted superiorly from the skull to the line of the frontonasal suture and infraorbital rim and laterally to the zygomatic process. The mouth is drawn far enough laterally to dissect behind the maxillary sinus to the infratemporal fossa.

 

Special considerations

A. Considerable retraction force is required during this operation and care should be taken to avoid injuring the infraorbital nerve.

B. The blood supply to the facial flap derives from the facial, infraorbital, supratrochlear, and transverse arteries of the face. This vascularization allows lateral nasal and medial orbital incisions to be added, which are required for extensive exposure.

C. The infraorbital canal, foramen, and vasculonervous package can be released by osteotomies along each side of the canal. Improved flap mobility and increased access to the orbits is achieved.

The nasal structures are repositioned carefully and resorbable sutures are made. The sublabial incisions are closed carefully. The use of nasal dressing and a splint helps to immobilize the nose, reduce facial edema, and avoid the development of hematoma.

 

Complications

Major complications with this technique are rare, the most common being stenosis of the nasal vestibule, which occurs in approximately 5% of patients^6,7 No disturbance in the facial growth of children, atrophic rhinitis, epiphora, or oroantral fistula has been reported.

Given the fact that conventional cutaneous approaches are disfiguring, the midfacial degloving technique was used in a patient with panfacial fracture to allow surgical treatment without skin incisions. (Fig. 2)

 

Clinical case

A 41-year-old male patient suffered an accident at home consisting of a fall from the third floor, from an approximate height of 10 meters, which originated multiple fractures of the face, right femur, and right radius and ulna. He was admitted to the intensive care unit of "Victorio de la Fuente Narváez" Traumatology Hospital with a Glasgow index of 8.¹⁰ Emergency tracheostomy was performed. Laboratory examinations and CT of the skull and face were performed to evaluate the injuries present. After airway stabilization, an opinion was requested from the maxillofacial surgery department. The panfacial fracture was diagnosed on the basis of tomographic findings and had the following components (Fig. 3):

• Nasal-orbital-ethmoidal fracture

• Type 2 and 3 fracture of the left zygomatic-malar complex without displacement and type 4 fracture of the right side.¹⁰

• Le Fort I maxillary fracture

• Right parasymphyseal fracture

• Fracture of the right mandibular ramus

Intermaxillary fixation was secured with bar arches and elastic traction. The patient was admitted to the intensive care unit for electrolyte imbalance. He was scheduled for open reduction of the facial fractures under general anesthesia 13 days after admission to the hospital. Midfacial degloving was used as an approach for this zone and transconjunctival incisions provided access to both orbital floors. The findings of surgery included fracture at the level of the frontonasal suture, bilateral fracture of the infraorbital rims without orbital floor involvement, fracture of zygomatic pillars, and fracture of the anterior wall of the maxillary sinus and bilateral pyriform rims (Fig. 4). He also had a right parasymphyseal fracture of the mandible. The fracture was reduced and immobilized with the Synthes 2.0 system for midfacial fractures (Fig. 5) and mandibular fractures were managed conservatively because occlusion was restored by intermaxillary fixation. After surgery, the patient was readmitted to the intensive care unit, where he remained for 5 days. When his general condition improved, he was transferred to the ward.

At his follow-up appointments, the patient showed an appropriate postoperative evolution, coursing with edema that resolved slowly and correct healing of the approach incisions, without the development of hematoma or stenosis of the nasal vestibule. Intermaxillary fixation was maintained for 8 weeks, coursing during this period of immobilization without complications and with stable occlusion. After removal of the intermaxillary fixation, no occlusion abnormalities were observed. The spatial relations of the patient’s face were restored by the surgical treatment (Fig. 6). Follow-up radiographs showed the fracture zones with properly positioned miniplates and confirmed the restoration of the anteroposterior, sagittal, and transverse relations of the midface (Fig. 7).

 

Discussion

Ample bibliography exists on the use of midfacial degloving as a surgical approach for the treatment of superficial benign and malignant sinonasal pathology.^1-9

In 1992, the application of the technique to facial trauma was cited, but it was not until 2001 that Baumann and Ewers⁵ first reported in the maxillofacial literature their experience with the use of the technique in 14 patients with midfacial trauma. They obtained good results in relation to the surgical field exposure and the reduction of postoperative complications reported previously in the literature.

In this article, we report a case of severe facial trauma managed with midfacial degloving as an approach to the zone. The results obtained in the case confirmed that the technique is applicable and safe, and the patient’s postoperative course was uneventful. The results of its application in this study are similar to those reported in the literature, confirming that it is a relatively simple surgical technique to execute and that it provides adequate visibility of the operating field, and makes it easier to evaluate and treat midface fractures. The postoperative course was free of complications. The esthetic result also was optimal because there were no skin incisions. It is a good alternative, particularly in young patients, because the technique avoids disfiguring the midface with skin scars.

 

Conclusions

According to the results of the case, midfacial degloving was a useful surgical approach to midface fractures, providing an ample field of vision of the intervention area with a low incidence of transoperative and postoperative complications.

 

Correspondence:
Dr. Andrés R. Méndez Tenorio
Av. Cuauhtemoc 960 1º
México D.F. C.P. 03020
E-mail: a.mendez@gnathosmf.com

Recibido: 16.06.2008
Aceptado: 15.10.2008

 

References

1. Casson PR y cols. The midface deglobing procedure. Plast Reconstr Surg 1974;53: 102-3.        [ Links ]

2. Maniglia A. Indications and techniques of midfacial deglobing: a 15-year experience. Arch Otolaryngol Head Neck Surg 1986;112:750-2.        [ Links ]

3. Holliday M. The versatile midface deglobing approach. Laryngoscope 1988; 98:291-5.        [ Links ]

4. Romo T y cols. Repair of nasal septal perforation utilizing the midface deglobing technique. Arch Otolaryngol Head Neck Surg 1988;114:739-42.        [ Links ]

5. Baumann A, Ewers R. Midfacial deblobing: an alternative approach for traumatic corrections in the midface. Int J Oral Maxillofac Surg 2001;30:272-77.        [ Links ]

6. Dudley H y cols. Rob & Smith’s operative head and neck surgery. part II: Midfacial deglobing technique (sublabial approach) for nasal and paranasal sinus resection. Butterworth-Hewemann LTD 1992. Oxford UK.        [ Links ]

7. Johns ME y cols. Atlas of head and neck surgery. vol. 1: Midfacial deglobing approach to the sinuses. B.C. Becker Inc. Philadelphia 1990.        [ Links ]

8. Anand V, Coley J. Sublabial surgical approach to the nasal cavity and paranasal sinuses. Laryngoscope 1983;93:1483-84.        [ Links ]

9. Paavolainen M. Sublabial approach to the nasal and paranasal cavities using nasal pyramid osteotomy and septal transection. Laryngoscope 1986;96:106-8.        [ Links ]

10. Fonseca R y cols. Oral and Maxillofacial Trauma. Vol. 1 & 22nd edition. W & B Saunders Co 1997.        [ Links ]