The Modified Midfacial Degloving for Treatment of Large Juvenile Angiofibromas

Purpose: Open surgery remains the mainstay treatment for juvenile angiofibromas (JAF). The midfacial degloving approach provides excellent access to a wide range of nasomaxillary lesions with excellent cosmesis. Major limits of the standard approach are the control of the roof of the infratemporal fossa and of the intrapetrous internal carotid artery, of the anterior third of the cribriform plate. In order to better expose these areas we adopt a modified degloving technique with bilateral nasal osteotomies (as described by Paavolainen and Malmberg). This approach is employed in craniofacial surgery for nasoethmoidal malignancies and in the treatment of large JAF with intracranial extradural extension (type III B and IV Fisch).

Patients and Methods: Forty-four young male patients with JAF were operated at our institution with a transfacial approach between 1993 and 2006, of whom 6 were by means of a lateral rhinotomy and 38 with a midfacial degloving (MFD) approach. Six of these cases presented with intracranial extradural extension and the MFD approach was modified by means of bilateral nasal osteotomies and elevation of the nasal pyramid pedicled to the soft tissues (total rhinotomy). Preoperative angiography and embolization were performed in all cases. Surgical technique and results are described in detail.

Results: All 44 patients but 2 had complete tumor clearance with no residual tumor. One early recurrence in a stage III B tumor was detected in the infratemporal fossa and was removed via a subtemporal-preauricular-infratemporal approach 6 months after the first procedure. One intracranial intradural parasellar residual is actually under strict follow-up and will be treated in case of documented growth. No major complications were observed. All patients had excellent cosmetic results and were discharged within 7 days from the procedure.

Conclusions: MFD is a very versatile approach and is typically indicated for coanal, retrocoanal and retromaxillary lesions. Modifications of the standard technique such as those employed by the authors allow for eradication of far more extended lesions with the same cosmetic and functional results. The approach is also suitable for combined transfacial-transcranial surgery via anterior (subfrontal) or lateral (infratemporal) routes.