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degloving approach to remove tumors of nasal cavities
approach which was popularised by Casson et al and Conley is best
suited for inferiorly located tumors with minimal ethmoidal
involvement. This is more suited for bilateral lesions. This
procedure is not suited for extensive tumors which extent higher into
the anterior labyrinth with involvement of frontal sinus area.
This surgery is ideally performed under general anesthesia. Bilateral temporary tarsorraphy is performed. The area of surgery is liberally infiltrated with 1% xylocaine mixed with 1 in 200,000 units adrenaline. Infiltration minimizes troublesome bleeding during surgery. The areas to be infiltrated include:
procedure is started with complete transfixion incision, which is
connected to bilateral intercartilagenous incisions. Elevation of
soft tissue from the nasal dorsum is performed through the
intercartilagenous space. The soft tissue elevation over dorsum of
nose is continued over the anterior wall of maxilla on both sides.
Elevation of soft tissue should also continue over the glabella and
frontal bone. Supero laterally the elevation should extend up to the
medial canthal region. The intercartilagenous incision is extended
laterally and caudally across the floor of the vestibule to be
connected with the transfixation incision. This results in a full
circumvestibular incision on both sides.
the transnasal incisions are completed the sublabial incision is
performed. It extends from the first molar on oneside across the
midline up to the first molar on the opposite side. This incision
can be extended up to the third molar if more exposure is needed. The
incision is carried down the submucosa, and muscles over anterior
wall of maxilla. At the pyriform aperture region this incision is
connected to intranasal incisions. Periosteal elevators are used to
elevate the soft tissue over the anterior walls of both maxilla up to
the level of the orbital rim taking care to protect the infraorbital
vessels and nerve. The entire midfacial skin is stripped from the
dorsum of the nose and anterior wall of maxilla. This flap includes
the lower lateral cartilages, columella with its medial crura. The
elevation is continued till the level of glabella superiorly and
medial canthus laterally. The bony nasal pyramid and the attached
upper lateral cartilages are exposed completely. Two rubber drains
(Penrose type) are passed through the nose and upper lip and are used
to retract the midfacial flap along with the upper lip. Once in
every 15 minutes one of the drain should be released to allow blood
supply to the middle portion of the upper lip.
the nasal incisions made in midfacial degloving approach
The anterior wall of the maxilla is drilled out. Infraorbital neurovascular bundle should be identified and preserved. Bone removal continues superomedially towards the ethmoidal complex. Nasolacrimal sac and duct need to be managed before bony cuts of maxillectomy are performed. Nasolacrimal duct can be transected at the orbital floor level.
whole anterior wall of maxillary sinus is drilled out including the
lateral portion of nasal bone including the edge of the pyriform
Figure showing the extent of resection
Bone cuts for medial maxillectomy:
Cut along the nasal bone from the pyriform aperture to the glabella a few millimeters anterior to the nasomaxillary groove.
A horizontal cut is made just below the glabella directed posteriroly towards the frontoethmoid suture line.
Antero posterior cut along the fronto ethmoidal suture line.
Oblique cut of the orbital floor from the orbital rim medial to the infraorbital foramen extending postero medially to join the fronto ethmoid cut in the posterior ethmoid region. All these bone cuts should include the attached soft tissues.
The posterior attachment to the ascending process of palatine bone is severed using a heavy scissors.
Complications of midfacial degloving: