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 »  Case report
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Year : 2000  |  Volume : 48  |  Issue : 4  |  Page : 361-4

Bilateral fronto-orbito-zygomatic craniotomy--a combined extended frontal and orbitozygomatic approach.

Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

Correspondence Address:
Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India.

  »  Abstract

In extensive skull base lesions involving the spheno-ethmoido-clival region and extending into both the cavernous sinuses and infratemporal regions, a combination of approaches is usually required, either in the same operation or at a second stage. The bilateral fronto-orbito-zygomatic craniotomy described in this report is a combination of an extended frontal approach and fronto-orbito-zygomatic craniotomy. This gives a wide exposure of the spheno-ethmoido-clival regions of both the cavernous sinuses and both the infratemporal regions. The exposure is thus greatly improved with minimal frontal lobe retraction. The single bone piece can be speedily replaced obviating the need for a complicated reconstruction technique and gives a superior cosmetic result. The operative technique is described in detail.

How to cite this article:
Gupta S K, Khosla V K, Sharma B S. Bilateral fronto-orbito-zygomatic craniotomy--a combined extended frontal and orbitozygomatic approach. Neurol India 2000;48:361

How to cite this URL:
Gupta S K, Khosla V K, Sharma B S. Bilateral fronto-orbito-zygomatic craniotomy--a combined extended frontal and orbitozygomatic approach. Neurol India [serial online] 2000 [cited 2022 Dec 10];48:361. Available from: https://www.neurologyindia.com/text.asp?2000/48/4/361/1499

   »   Introduction Top

Ray and Mclean[1] ushered in the era of anterior skull base surgery with the report of a combined transcranial and transorbital resection of a retinoblastoma. The concept of using orbital osteotomies to approach cranial base lesions has been described by various workers.[2],[3],[4],[5],[6] Several authors have made contributions to the resection of malignant lesions of anterior cranial base.[4] In the present communication, we describe a single flap bilateral fronto-orbito-zygomatic craniotomy providing good access to a large skull base tumour involving the spheno-ethmoidal-clival region and extending into both the cavernous sinuses and intratemporal regions.

   »   Case report Top

A 25 years old man presented with gradually progressive visual loss in both eyes, of 3 years duration. On neurological examination he was found to be blind and had bilateral primary optic atrophy. CT scan and MRI revealed an extensive tumour involving the spheno-ethmoido-clival region, extending into both cavernous sinuses and into both infratemporal fossae. The clivus was partially eroded and the mass was indenting the brainstem [Figure. 1].

Using the bilateral fronto-orbito-zygomatic approach, an excellent exposure of the tumour was achieved. The tumour was very vascular, firm and was densely adherent to the dura and to the maxillary division of 5th nerve on the left side. Tumour removal was done with the help of ultrasonic aspiration. Postoperative CT scan showed residual tumour. Histopathology revealed it to be invasive pituitary adenoma. The patient was subjected to radiotherapy and was later put on bromocriptine. At one year follow up, he was doing fine, although there was no improvement in vision.
Surgical technique : The patient was positioned supine after general anaesthesia. The head end was elevated by about 20 degrees and neck extended by 15 degrees. The head was fixed in the Sugita multipurpose head frame. At the time of skin incision, mannitol (1gm/kg) was given to get a lax brain. A bicoronal scalp incision was given, starting about 1 cm anterior to the tragus just below the inferior border of the zygomatic arch and going onto a similar point on the opposite side. The scalp flap was raised exposing both the frontotemporal regions, both superior orbital rims, the glabella and the nasion, the lateral orbital rims, the malar eminences and the zygomatic arch on both sides. The pericranium was dissected separately and left attached anteriorly. The frontal branch of facial nerve lies in the subgaleal pad of fat. To minimise injury to this nerve, dissection was done deep into the superficial temporalis fascia. The periorbita was separated from the roof, lateral wall and upper part of medial walls of orbit on both sides. The deep temporal fascia which fuses with the periosteum of the zygomatic arch was sharply dissected to expose both the superior and inferior surfaces of the zygomatic bone. The temporalis muscle and fascia were incised along the superior temporal line, leaving a narrow myofascial cuff attached to the bone for later reapproximation. The skin flap was reflected anteriorly with the help of fish hooks to complete the bony exposure. The temporalis muscle and fascia were reflected over the zygoma at this stage. Burr holes were made as depicted in [Figure. 2] and [Figure. 3]. Cuts were made in the roof and lateral orbital walls on both sides [Figure. 2] and [Figure. 3]. The bony cuts in the roof were made as posteriorly as possible to minimise rongeuring of bone. The zygomatic bone on both sides was divided just above the malar eminence.
The bony cuts on the roof of the orbits extended medially on both sides through the junction of nasal process of frontal bone and nasal bone to meet each other. During all these bony cuts, the periorbital was adequately protected. Through the anterior midline burr hole, a dissector was passed to free and separate the dura from the anterior-most part of midline anterior cranial fossa. The bony cut of the nasion was extended deep to meet this bone of the anterior fossa. The root of zygomatic process on both the sides were cut obliquely. Next, the cuts in the lateral orbital wall were extended to meet the pterional burr hole on both sides.
Now the entire bilateral fronto-orbito-zygomatic single bone flap was attached at 3 small bony islands: a small part of the sphenoidal ridge on both sides and in the midline in the region just anterior to the cribriform plate. The entire bone flap was lifted and by exerting a little force, these three bony islands were easily fractured and the bone flap lifted as a single piece [Figure. 4],[Figure. 5] and [Figure. 6]. The medial orbital roofs, both the anterior clinoids the planum sphenoidale and the tuberculum sellae were drilled away. The lateral temporal fossa was ronguered flush to the middle fossa floor to expose the region of cavernous sinuses and infratemporal fossae on both sides.
This gave an excellent exposure of both infratemporal fossa, the spheno-ethemoido-clival region and the cavernous sinus region bilaterally. After tumour removal the defect in the floor was repaired by rotating the pericranial flap along the anterior cranial fossa floor. The bone flap was replaced and fixed in place by nonabsorbable sutures. The temporalis muscle fascia were rotated back and sutured to the myofascial cuff on both sides.

   »   Discussion Top

The extended frontal approach is an extension of the subfrontal approach to the cranial base involving the addition of an orbital osteotomy or an orbito frontoethmoidal osteotomy. The concept of removing orbital rims to improve the exposure of skull base was introduced by Frazier,[7] while Derome[8] reported the transbasal approach to the skull base. This technique has been used primarily for tumours involving the skull base, such as sphenoclival and planum sphenoidal meningiomas, chordomas, chondromas, chondrosarcomas, esthesioneuroblastomas, paranasal sinus carcinomas, juvenile angiofibromas, adenoid cystic carcinomas etc.[9] It has also been utilised for giant skull base aneurysms and for complex traumatic lesions of the anterior cranial fossa.[10] This approach greatly improves the exposure of cranial base structures while minimising frontal lobe retraction. In extensive lesions involving cavernous sinus, the middle and infratemporal fossa, other approaches such as frontotemporal transcavernous or subtemporal infratemporal need to be combined with the extended subfrontal approach.[10],[11],[12]
Similarly, the orbito-zygomatic approach evolved from the work of a number of neurosurgeons.[13] Jane et al[2] reported a supraorbital approach for vascular lesions at the anterior skull base, while Al-Mefty[5] incorporated the superior and orbital ridges with the pterional craniotomy. Pellerin et al[14] described the orbitofrontomalar approach for orbital meningiomas using a single craniotomy. Hakuba and coworkers[15] described the orbitozygomatic approach involving 3 separate bone flaps for parasellar tumours, cavernous sinus lesions and basilar tip aneurysms. McDermott et al[16] reported removal of frontotemporal and orbitozygomatic bone flaps separately while Delashaw et al[17] raised a frontotemporal bone flap incorporating the frontal sinus and superior and lateral orbital ridges as one piece with the zygomatic arch removed separately. A recently described new approach to the skull base is the subtemporal intratemporal approach providing access to the cranial base from an anterolateral direction.[11] In extensive skull base tumours such as the one described here, a combination of approaches in the same or a second operation is necessary.[10]
The bilateral fronto-orbito-zygomatic craniotomy described in this report is the combination of extended frontal approach and fronto-orbito-zygomatic craniotomy. This combines the exposure gained through the anterior and anterolateral approaches. The removal of the entire bone in a single piece avoids bone loss and gives superior cosmetic results. It also obviates the need for complicated reconstruction techniques; the bone flap can be speedily and easily replaced. The exposure obtained is quite wide extending from one intratemporal region to the other, giving access to both cavernous sinus regions and both middle fossae, both the orbital areas and the entire spheno-ethemoido-clival region. The large pericranial flap provides a good cover for the anterior skull base after tumour removal. In addition, both the temporalis muscles and fascia are available, if necessary, for basal repair.


  »   References Top

1.Ray BS, Mclean JM : Combined intracranial and orbital operation for retinoblastoma. Arch Ophthalmol 1993; 30 : 437-445.   Back to cited text no. 1    
2.Jane JA, Park TS, Poberskin LH et al : The supraorbital approach: Technical note. Neurosurgery 1982; 11 : 537-542.   Back to cited text no. 2    
3.Jackson IT, Marsh WR, Hida TA : Treatment of tumours involving the anterior cranial fossa. Head Neck Surgery 1984; 6 : 901-913.   Back to cited text no. 3    
4.Sekhar LN, Janecka IP, Jones NF : Subtemporal infratemporal and basal subfrontal approach to extensive cranial base tumours. Acta Neurochir (Wien) 1988; 92 : 83-92.   Back to cited text no. 4    
5.Al-mefty O : Supraorbital-pterional approach to skull base lesion. Neurosurgery 1987; 21: 474-477.   Back to cited text no. 5    
6.Smith RR, Klopp CT, Williams JM : Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer 1954; 7 : 991-994.   Back to cited text no. 6    
7.Frazier CH : An approach to the hypophysis through the anterior cranial fossa. Ann Surg 1913; 57 : 145-150.   Back to cited text no. 7    
8.Derome P : Les tumeurs spheno-ethmoidales. Possibilites d exerese et de separation chisurgicals. Neurochisurgic 1972; 18 (Suppl. l): 1-164.   Back to cited text no. 8    
9.Sekhar LN, Nanda A, Sen CN et al : The extended frontal approach to the tumours of the anterior middle and posterior skull base. J Neurosurg 1992; 76 : 198-206.   Back to cited text no. 9    
10.Sekhar LN, Wright DC, Sen C : Extended frontal approaches to tumours and aneurysms of the cranial base. Neurosurgery (2nd edn). Wilkins RH, Rangachary SS (eds). McGraw Hill, New York. 1996; 1611-1622.   Back to cited text no. 10    
11.Sekhar LN, Sen C, Snyderman CH et al : Anterior, anterolateral and lateral approaches to extradural petroclival tumours. In: Sekhar LN, Janecka IP (eds). Surgery of the cranial base tumours. Raven Press, New York. 1993; 11 : 157-223.   Back to cited text no. 11    
12.Sekhar LN, Wright DC : Preauricular subtemporalinfratemporal and combined approaches to the cranial base. In: Wilkins Rangachary SS (eds). Neurosurgery (2nd edn). McGraw Hill, New York. 1996; 1655-1666.   Back to cited text no. 12    
13.Zabranski JM, Kiri ST, Sankhle SK et al : Orbitozygomatic craniotomy. Technical note. J Neurosurg 1998; 89 : 336-341.   Back to cited text no. 13    
14.Pellerin P, Lesoin F, Dhellemmes P et al : Usefulness of the orbitofrotito malar approach associated with bone reconstruction for frontotemporosphenoid meningiomas. Neurosurgery 1984; 15 : 715-71 8.   Back to cited text no. 14    
15.Hakuba A, Tanaka K, Suzuki T et al : A combined orbitozygomatic intratemporal epidural and subdural approach for lesions involving the entire cavernous sinus. J Neurosurg 1989; 71 : 699-704.   Back to cited text no. 15    
16.McDermott MW, Durity FA, Rootman J et al : Combined frontotemporal orbitozygomatic approach for tumours of the sphenoid wing and orbito. Neurosurgery 1990; 26 : 107-116.   Back to cited text no. 16    
17.Delashaw JB Jr, Tedeschi H, Rhoton AL : Modified supraorbital craniotomy : Technical note. Neurosurgery 1992; 30 : 954-956.   Back to cited text no. 17    

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