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1 FORMAL SYNOPSIS FORM Title:a Dismasking flap -a extended coronal flap- for approach of craniofcial tumor and trauma; experience of 13 cases Authors: Keisuke Imai, MD, Hiroyuki Komune, MD, Takeru Nomachi, MD, Takuya Fujimoto, MD and Miki Fujii, MD "Dismasking flap" is the cranio-orbito-facial degloving technique employing circum-palpebral with or without piriform margin incisions and presents a wide surgical fields under direct view1) (Fig-1,2). With the use of dismasking flap it was possible to completely resect tumors of the nasal cavity extending the orbit, the maxilla and the anterior cranial base2). Dismasking flap is very useful for craniofacial tumor especially for malignant tumor, severe complex fracture of craniofacial bone and approach of the middle cranial base. This flap is retracted far way down so that there is little traction on the facial nerve branches in the flap and the middle cranial base comes into view with little compression on the brain. Since 1994, 13 patients have undergone Dismaking flap technique. The indicated cases were multiple cranio-facial bone fracture (3 cases) and malignant or premalignant craniofacial tumor (10 cases). The patients ranged in age from 3 to 62 years. The period of postoperative follow-up was from 2 to 7 years. Operative procedure After coronal flap is elevated, supraorbital neuro-vascular bundle is isolated and cut. Then circum-palpebral blephaloplasty incision is placed and dissection is carried out toward the orbital rim between the orbicularis muscle and orbital septum, bilaminating the eyelid into anterior and posterior layer. Medial canthual tendon is left intact, but cut secondarily a little away from the insertion to the bone when entrance into the medial orbital wall is indicated. The skin and the muscle of the lids belong to the coronal flap, which is turned over well below to give direct exposure of the periorbital structures. Infraorbital neurovascular bundle can be isolated more than 10 mm in length, and when piriform margin is incised half way down, the operative field become wider. When infraorbital neurovascular bundle is cut and piriform margin is totally incised, all the structures of the upper two-thirds of the face except perigingival area of the maxilla come into direct view. At the end of the operation infraorbital nerve, if severed, and supraorbital nerve are anastomosed. Small triangular flap of the medial canthal region is securely fastened to the medial canthal tendon by a 2 FORMAL SYNOPSIS FORM buried suture. Several buried sutures suspend periosteum corresponding to the cheek pad with nylon strings to the periostium of the inferior orbital rim. results There were no perioperative major complications. In minor temporary complications, there were lagophthalmos (13 cases), blephaloptosis (4 cases) and sensory disturbance in superior orbital nerve area (13 cases), but no permanent complication in all cases. In this paper, we report the procedure of dismasking flap, its postoperative course and its complication. Fig-1 Fig-2 Fig-1: The design and schema of Dismasking flap Fig-2: Intraoperative photograph Reference 1) Tajima S, Tanaka Y, Imai K and et al.: Extended coronal flap- Dismasking flap- for approach of craniofcial and skull base surgery. Bull. Osaka 3 FORMAL SYNOPSIS FORM Medical College 39:1-8, 1993. 2) Imai K, Tsujiguchi K, Toda C, Sung KC, and et al.: Osteoblastoma of the nasal cavity invading the anterior skull base in a young child. J.Neurosurg. 87:625-628, 1997. 3) Hirano N, Sasaki A, Watanabe T, Hori T, and et al.: Malignant fibrous histiocytoma of the lateral wall of the orbit. Neurol Med Chir. 36:246-250, 1996.