see also: Basic Soft Tissue Room Setup

return to: Paranasal Sinus Surgery Protocols

Note: last updated before 2010

GENERAL CONSIDERATIONS

1. The facial degloving technique as described here includes the elevation of the soft tissue of the external nose such that the nasal bony dorsum is completely exposed.
2. Indications
   1. Approach to the midface and paranasal sinus tumors
   2. Approach to the midface and paranasal sinus fractures

PREOPERATIVE PREPARATION

1. Additional Preoperative Evaluations
   1. None required
2. Consent Inclusions
   1. Description of the procedure
   2. Risk of:
      1. Infection and bleeding
      2. Intraoral scar
      3. Facial numbness due to possible injury to the infraorbital nerves
      4. Nasal vestibule stenosis due to circumvestibular incisions
      5. Nasal asymmetry due to postoperative scar contracture
      6. Postoperative lip and facial swelling

NURSING CONSIDERATIONS

1. Room Setup
   1. See Basic Soft Tissue Room Setup
      1. Back table
      2. Mayo x 2
2. Instrumentation and Equipment
   1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Sinus Tray
      3. Obwegeser Retractor Tray 2
      4. Nasal Sharp Tray
      5. Nasal Prep Tray
      6. Tracheotomy Tray (available only)
   2. Special
      1. Neurosurgical cottonoids 0.5 x 3 in
3. Medications (specific to nursing)
   1. Antibiotic ointment
   2. 1% lidocaine with 1:100,000 epinephrine
   3. Oxymetazoline HCL nasal spray, 0.05%
   4. Surgicel
4. Prep and Drape
   1. Half-strength betadine solution (saline dilution) prep to face
   2. Drape:
      1. Head drape
      2. Square off with towels around the neck
      3. Split sheet
5. Drains and Dressings
   1. Xeroform gauze or
   2. Iodoform gauze, 5%, 0.5-in x 5 yards coated with antibiotic ointment
   3. Nasal splint and gauze taped to the bottom of the nose
6. Special Considerations
   1. The facial degloving approach will be combined with other procedures
   2. Craniofacial resection, medial maxillectomy, trauma repair

ANESTHESIA CONSIDERATIONS

1. General Anesthesia
   1. Tube position: midline oral RAE tube
   2. Tracheotomy may be part of the procedure
   3. Paralysis required for improved tissue retraction
2. Systemic Medications
   1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
   2. Steroids: dexamethasone 10 mg IV
3. Positioning
   1. Supine
   2. Mayfield headrest may be useful
4. Estimated Blood Loss
   1. 100 cc (50 to 250)

OPERATIVE PROCEDURE

1. Opening
   1. Inject local anesthesia (1% lidocaine with 1:100,000 epinephrine) into upper labial sulcus and onto the face of the maxilla, as well as the nasal vestibule and nasal bony dorsum.
   2. Create a complete transfixion incision, bilateral intercartilaginous incisions, complete with squared-off angles (with the goal to prevent circumferential scarring) continued around piriform margin, "circumvestibular release."
   3. Sublabial incision across the midline extending laterally to just above the third molars.
   4. Elevate soft tissue over nasal dorsum widely in the subperiosteal plane.
   5. Tissues of face are elevated over the anterior maxilla from the nasal bones medially to the zygomatic bone laterally.
   6. Subperiosteal dissection is carried on each side of the midline to the piriform margin.
   7. Working through the nose, the remaining attachments are released from the columella and anterior maxillary spine, connecting the nasal and sublabial incisions.
   8. Retract soft tissue of midface superiorly.
   9. Weber-Fergusson or frontoethmoid incisions can be accomplished safely (without jeopardizing blood supply) if exposure through this approach is found to be inadequate.
2. Hemostasis
   1. Serial packing with vasoconstrictive agents and use of bipolar cautery; occasionally, the judicious use of hemostatic collagen packing may be required.
3. Closure
   1. The nasal tip is carefully repositioned with the transfixion suture at the nasal bones and a second transfixion stitch placed at the base of columella.
   2. The vestibular skin is then sutured to the piriform margin with a minimum of 3 4-0 absorbable stitches.
   3. The frenulum is carefully approximated and a one-layer, running, interlocking closure completed with an absorbable suture.
4. Dressing
   1. Nasal packing is commonly required due to the accompanying surgical procedures.
   2. Rhinoplasty taping and a self-adhering splint are applied to reduce nasal edema.

POSTOPERATIVE CARE

1. Head elevation and ice packs may decrease postoperative facial edema

REFERENCES

Traynelis VC, McCulloch TM, Hoffman HT. Craniofacial resection of the anterior skull base. Neurosurgical Operative Atlas. 3rd ed. Baltimore: Williams and Wilkins. 1993;5:329-340.