Operative Techniques in Otolaryngology (2010) 21, 171-174

Facial degloving approach to the midface

James J. Jaber, MD, PhDa, Francis Ruggiero, MDa, Chad A. Zender, MDb
From the aDepartment of Otolaryngology-Head and Neck Surgery, Loyola University Medical Center, Maywood, Illinois;
and the bDepartment of Otolaryngology-Head and Neck Surgery, University Hospitals-Case Western Reserve,
Cleveland, Ohio.
KEYWORDS
Minimally invasive
facial approaches;
Skull base approches;
Skull base tumors;
Paranasal sinus tumors

The purpose of this article is to describe the facial degloving approach for ablative surgery for various
pathologies involving the midface skeleton. The main advantages of the facial degloving procedure are
wide exposure of the midface skeleton, the associated low morbidity, and excellent cosmetic outcome
that avoids external scars.
2010 Elsevier Inc. All rights reserved.

The techniques of sinusectomy have changed dramatically since the first maxillectomy was performed by Lizars
in 1826.1 A paradigm shift in this technique was attributed
to Fergusson who described the classic approach still in use
today.2 In trying to preserve functional tissue integrity, a
midface degloving procedure was first suggested by Portmann in 1927, but the modern technique had its origin in
1974 with the report by Casson and colleagues.3 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.4 In 1984, Sacks and coworkers
reported a composite experience of 46 patients in whom
inverted papilloma was removed with the degloving approach.5 Several reports thereafter have suggested that it can
be of great benefit for the management of various lesions,
allowing adequate bilateral maxillary and lower nasal cavity
exposure without cosmetic dysfunction. Other authors have
elaborated on the usefulness of this technique either alone or
as part of a craniofacial approach to tumors.
The indications for midfacial degloving are to expose
and treat lesions, mainly tumors, of the facial cavities,
paranasal sinuses, nasopharynx, orbits, and central compartment of the anterior and middle cranial fossae. Its main
advantages over other procedures, such as Denkers, Caldwell-Luc, and a lateral rhinotomy, are wide exposure, avoidAddress reprint requests and correspondence: Chad A. Zender,
MD, Department of Otolaryngology-Head and Neck Surgery, UH Case
Medical Center, 11100 Euclid Ave, Cleveland, OH 44106.
E-mail address: Chad.Zender@UHhospitals.org.
1043-1810/$ -see front matter 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2010.07.003

ance of external incisions and scars, the ability to perform

bilateral surgery, and avoidance of palatal dysfunction. The
degloving approach in its simplest form combines a maxillary vestibular incision with intranasal incisions to elevate
the entire midface skin to allow great exposure of the bony
midface skeleton with minimal patient cosmetic morbidity.

Surgical technique
The operation is performed with the patient under general
oral endotracheal anesthesia. Infiltration of a vasoconstrictor into the highly vascularized maxillary vestibular mucosa
intercartilaginous area and columella is performed to reduce
the amount of bleeding during incision and dissection.
The procedure is performed with a maxillary vestibular
incision and three intranasal incisions to expose the entire
midface skeleton that include (1) bilateral intercartilaginous, (2) complete transfixion, and (3) bilateral piriform
aperture incisions (see Figures 1-5). The intercartilaginous
incision divides the junction between the upper and lower
lateral cartilages. The lower lateral cartilage will eventually
be displaced superiorly during the degloving procedure,
whereas the upper lateral cartilage will remain attached to
the midface skeleton. The ala is retracted using a double
skin hook, which helps to identify the scroll area. Then, the
incision and dissection are carried out so the lower lateral
cartilage is elevated, leaving the inferior edge of the upper
lateral cartilage protruding into the vestibule. An incision is

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Operative Techniques in Otolaryngology, Vol 21, No 3, September 2010

Figure 1 An intercartilaginous incision that begins at the inferior border of the upper lateral cartilage, beginning at the lateral
end and extending medially curved into the membranous septum
anterior to meet transfixion incision. Laterally, the incision must be
sufficient so that it extends to the piriform aperture.

made along the inferior border of the upper lateral cartilage,

beginning at the lateral end and extending medially curved
into the membranous septum anterior to meet transfixion

Figure 2 A complete transfixion incision is used to separate the

membranous septum/columella from the cartilaginous septum and
converges with the intercartilaginous incision.

Figure 3 Dissection through the intercartilaginous incision allows access to the nasal dorsum and releases soft tissue from the
underlying bony structures.

incision (Figure 1). Laterally, the incision must be sufficient

so that it extends to the piriform aperture.
A complete transfixion incision is used to separate the
membranous septum/columella from the cartilaginous septum. An incision is made along the caudal border of the
septal cartilage from the medial end of the intercartilaginous
incision toward the anterior spine and is most effectively
accomplished with a scalpel (Figure 2). A Brown Adson
forceps can be used to grasp the columella right behind the
caudal septum to avoid inadvertent transection of the medial
crura. The third intranasal incision is made by a full-thickness incision down through the periosteum of the piriform
margin and the nasal floor and completes the circumvestibular release. Alternatively, this incision can be made

Figure 4 The standard sublabial incision in the maxillary vestibule is made approximately 3-5 mm superior to the mucogingival
junction.

Jaber et al

Figure 5

The Midface Degloving Approach to the Facial Skeleton

Facial degloving to expose entire midface skeleton.

through the nasal mucosa after the maxillary vestibular

incision has been made.
Dissection through the intercartilaginous incision allows access to the nasal dorsum and bones (Figure 3).
Sharp subperichondrial dissection with a scalpel or a
blunt dissection with scissors frees the soft tissues above
the upper lateral cartilage as in a standard open rhinoplasty. The dissection should be within the subperichondrium plane to prevent injury to the overlying musculature and blood vessels of the nose. Elevation extends
laterally to the nasomaxillary sutures and superiorly to
the glabella. Retraction of the freed soft tissues allows
sharp incision to be made with a scalpel or with sharp
periosteal elevators through the periosteum at the inferior
edge of the nasal bones. Elevation of the soft tissue
laterally to the piriform aperture is also performed so
that, when a maxillary vestibular dissection is made, it
will easily connect to this pocket.
The standard incision in the maxillary vestibule is
made approximately 5 mm superior to the mucogingival
junction, leaving a cuff of loose mucosa on the alveolus
facilitates closure (Figure 4). The incision extends as far
posteriorly as necessary to provide exposure; however,
the incision typically extends from the first molar to the
contralateral first molar around the maxillary tuberosity
down to periosteom. Periosteal elevators are used to
elevate the tissues in the subperiosteal plane first over the
anterior maxilla, and then extending widely to encompass
posterior tissues behind the zygomaticomaxillary buttress. The infraorbital neurovascular bundle is identified
superiorly and should be preserved unless involved in
malignancy. Dissection medially and laterally facilitates
its preservation. Subperiosteal dissection along the piriform aperture strips the attachments of the nasal labial

173

musculature to allow its complete release from the midface skeleton (Figure 5).
The entire face of the zygoma can easily be exposed, but
reaching the zygomatic arch necessitates detachment of the
some of the masseter muscle attachment. As elevation continues, the entire midface skin is separated from the maxilla
and the nasal pyramid. The flap also includes the lower
lateral cartilages and the columella. Once exposure is complete, midfacial osteotomies can be performed depending on
the needs of the surgical procedure. For example, the anterior maxilla can be removed to expose the maxillary and/or
ethmoid sinus.
Restitution of the soft tissue of the face is paramount to
limit cosmetic and/or functional deficits. If the medial canthal tendons were removed during surgery, they must be
carefully reattached to the frontal process of the maxilla and
lacrimal bone. The soft tissues are then redraped and the
nasal tip brought back into position. The precise placement
of the transfixion sutures is critical in determining the final
position of the nasal tip and to prevent vestibular stenosis.
The intranasal incisions are closed with 4.0 resorbable sutures. The maxillary vestibule is closed after properly reapproximating the nasolabial musculature, resetting the ala
base, eversion of the vermillion, and finally closure of the
oral mucosa.

Complications
The most common complication directly related to the midface degloving procedure is temporary infraorbital anesthesia or hypesthesia. However, most patients fully recover
midface sensation within 1-5 months. The rate of permanent
infraorbital anesthesia has been reported to be less than
3%.6 Nasal cosmetic deformities are rare complications and
can be avoided with precise intranasal reapproximation.
However, nasal obstruction appears to be more common due
to nasal vestibule stenosis. Other complications may arise
secondary to midface osteotomies, such as epiphora during
a medial maxillectomy.

Conclusions
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 surgeons armamentarium.

References
1. Sisson GA, Toriumi DM, Atiyah RA: Paranasal sinus malignancy: a
comprehensive update. Laryngoscope 99:143-150, 1989

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2. Fergusson W: Operations of the upper jaw, in Fergusson W (ed): A System of

Practical Surgery (ed 2). Philadelphia, Lea and Blanchard, 1845, pp 523-532
3. Casson PR, Bonanno PC, Converse JM: The midfacial degloving procedure. Plast Reconstr Surg 53:102-103, 1974
4. Conley J, Price JC: Sublabial approach to the nasal and the nasopharyngeal cavities. Am J Surg 38:615-618, 1979

5. Sacks MA, Conly J, Rabuzzi DD, et al: The degloving approach for
total excision of inverting papilloma. Laryngoscope 94:1595-1598,
1984
6. Browne JD: The midfacial degloving procedure for nasal, sinus, and
nasopharyngeal tumors. Otolaryngol Clin North Am 34:1095-1201,
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