Copyright © 2018 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. A Minimally Invasive Endoscopic Approach to Midcheek Mass: Showcase for Technical Description Vincenzo Abbate, MD,  Giovanni Dell’Aversana Orabona, MD, PhD,  Antonio Romano, MD, PhD,  Fabio Maglitto, MD,  Giorgio Iaconetta, MD, PhD, y and Luigi Califano, MD, PhD  Background: Surgical approaches to the midcheek area are chal- lenging. This area is included between the lower eyelid above, and the upper lip below. The peculiar anatomical location makes it really important for attractiveness, thus the need to obtain a correct balance between the operation’s safety and minimally invasive aspect. To the authors’ knowledge, this is the first showcase and technical description of a novel minimally invasive endoscopic approach for midcheek mass removal. Methods: Making 3 incisions in concealed area an endoscopically aided facial dissection was performed to remove a solitary venus malformation of the left midcheek region. Results: After the surgical procedure was performed, no hematoma, no edema, or facial nerve paralysis were observed. To date, during the follow-up period, no recurrence of the lesion has been observed, and the quality of life of the patient was good with a minimally scar outcome. Magnetic resonance imaging, performed 2 weeks postoperatively, demonstrated a complete removal of the mass Conclusion: The authors’ finding experience suggests that the minimally invasive approach provides an excellent surgical window that achieves greater exposure for the dissection of the midcheek area. Further clinical applications are required to assess advantages and/or limitations of this procedure. Key Words: Endoscope-assisted surgery, head and neck surgery, midcheek mass, minimally invasive approach, solitary venous malformation (J Craniofac Surg 2018;00: 00–00) S urgical approach to the midcheek area is always considered challenging for surgeon. This area, included between the lower eyelid above, and the upper lip below (Fig. 1), has a critical role in facial attractiveness. Due to these features, the best surgical management should consider both the aesthetic and clinical outcomes. Thus, a correct balance between the creation of safety surgical approaches and the minimally invasive aesthetic aspects should be achieved. Therefore, the endoscopic procedure can be considered a good strategy to conciliate both the needs. Many surgical approaches to the midcheek area have been described, but none of them completely fulfils the purpose of a complete tumor removal with low morbidity, minimal scars, and the preservation of the surrounding key anatomic structures. 1–3 As already highlighted by Dell’Aversana Orabona et al 4 in their review in 2014, the use of the endoscopic approach based on anatomical studies may be effective when compared with traditional approaches. Abbate et al 5 in 2016 identified, in their anatomical study, a safe surgical corridor to gain endoscopically the access in midcheek region. Basing on these studies, in the following showcase we want to demonstrate how the use of minimally invasive endoscopic approach could be applied successfully for the treatment of well- selected midcheek mass. To our knowledge, this is the first showcase descriptions of such a minimally invasive endoscopic approach for midcheek mass removal. TECHNICAL REPORT A 16-year-old male patient suffering for a solitary venous malfor- mation (VM) of the left lateral midcheek area was admitted in March 2015 to our Department of Maxillo-Facial Surgery of the University of Naples ‘‘Federico II.’’ The patient complains facial asymmetry for a left side facial swelling (Fig. 2A). Prior to surgical treatment a clinical and instrumental examination was performed. Preoperative Preparations A careful head and neck examination was performed to disclose other symptoms like difficulty in chewing, presence of enlarged node, and intraoral disease. On the clinical examination, the mass was soft on palpation, mobile, with clear boundaries. There was no facial palsy, no clinical sign of of Stensen duct obstruction. The patient underwent ultrasound-sonography (US), and mag- netic resonance (MR) imaging. These diagnostic tools revealed hyper-intense oval-shaped lesions with clear boundaries, an intact envelope, and a low-level echo with no uniform density (Fig. 2B). Twenty-four hours before surgery, endoarterial chemo-emboliza- tion was performed to reduce the risk of bleeding (Fig. 2C). Surgical Procedure The patient’s head was placed on the operative table in lateral rotation. Three incisions have been performed: the first 1 cm long incision in the temporal area above the hairline, the second one 1 cm From the  Department of Maxillofacial Surgery, University of Naples ‘‘Federico II,’’ Naples; and y Department of Neurosurgery, University of Salerno, Salerno, Italy. Received April 20, 2017. Accepted for publication December 16, 2017. Address correspondence and reprint requests to Vincenzo Abbate, MD, Department of Maxillofacial Surgery, University of Naples ‘‘Federico II,’’ Via Pansini 5, Naples 80131, Italy; E-mail: vincenzo.abbate@unina.it The authors report no conflicts of interest. Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofacialsurgery.com). Copyright # 2018 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000004363 CLINICAL STUDY The Journal of Craniofacial Surgery  Volume 00, Number 00, Month 2018 1