Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 7384

Transfacial approaches to the cranial base

Sidney B. Eisig, DDS,*a James Tait Goodrich, MD, PhDb,c
Division of Oral and Maxillofacial Surgery, Columbia University School of Dental and Oral Surgery, New York Presbyterian Hospital, 630 West 168th Street, New York, NY 10032, USA b Department of Neurosurgery, Pediatrics and Plastic and Reconstructive Surgery, Albert Einstein College of Medicine, Monteore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA c Leo Davido Department of Neurological Surgery, Albert Einstein College of Medicine, Monteore Medical Center, 111 East 210th Street, Bronx, NY 10467, USA
a

One of the most challenging and dicult problems a surgeon is required to treat is a neoplasm of the cranial base (Fig. 1). The requirement to obtain disease-free margins without signicant morbidity is often a daunting task. The cranial base is surrounded by structures that are vital for life and normal function. Many cranial base lesions are slow growing and nonmetastasizing, which makes them amenable to surgical treatment. These same characteristics often make these lesions resistant to radiation therapy. The last two decades have seen tremendous advances in neurosurgery, neuroradiology, anesthesia, otolaryngology, and craniomaxillofacial surgery. These advances include rigid xation and bone grafting techniques, angiography and embolization, and navigation surgery, which make surgical treatment of these neoplasms (and certain aneurysms) possible. [1] This article describes midline and lateral approaches to the cranial base that the oral and maxillofacial surgeon can perform.

Treatment planning All patients with cranial base tumors are treated using the team model. Pertinent studies, including CT, MR imaging, angiography, and plain radiographs, are obtained and discussed at a treatment planning conference. The exact location, the anatomic constraints of the lesion, anesthetic considerations, and the surgical approach are discussed. Anticipated morbidity from the various surgical approaches is weighed. The two-piece Le Fort I osteotomy with or without a mandibulotomy has proved useful for approaching lesions medial to the internal carotid arteries.

Two-piece Le Fort I osteotomy Anatomy The oor of the central zone of the anterior and middle cranial fossa consists of the clivus or spheno-occipital synchondrosis (Fig. 2). The sphenoid sinus and the hypophyseal fossa that contain the pituitary gland border this zone anteriorly and superiorly. The rst cervical vertebrae are below the tip of the clivus, and the foramen magnum is posterior to it. The clivus is triangular in cross-section with the wider base resting just below the sphenoid sinus (Fig. 3). Marrow

* Corresponding author. E-mail address: sbe2002@columbia.edu (S.B. Eisig) 1061-3315/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 6 1 - 3 3 1 5 ( 0 1 ) 0 0 0 0 5 - 1

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Fig. 1. Representative MR and CT axial images of two dierent cranial base lesions.

is contained between the two cortices of bone. After the deep cortical bone is removed, dura mater is encountered. Lateral to the clivus are the optic, oculomotor, trochlear, trigeminal, and abducen nerves and their foramina. Of greater importance is the presence of the internal carotid artery as it courses through the petrous portion of the temporal bone to enter the middle cranial fossa (Fig. 4). Other surgical approaches have signicant morbidity. The frontal approach requires extensive frontal lobe retraction, and lateral approaches may require extensive traction on the facial nerve and internal carotid artery. [24] Lateral rhinotomy approaches result in facial scarring. These approaches provide an acentric approach to a midline lesion. The midline approach using the true two-piece Le Fort I osteotomy and, in select cases, a mandibulotomy with a oorof-mouth split provides excellent access and visualization from sella turcica to C-4 [59] (Fig. 5).

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Fig. 2. Highlighted area is the spheno-occipital synchondrosis, or clivus, as viewed from above.

Surgical approach Before surgery the patient undergoes either an MR or CT for navigation surgery and is then brought to the operating room and anesthetized. A lumbar drain is placed if a dural incision is anticipated. If a mandibulotomy is required, the airway is secured with a tracheotomy. Split arch bars are applied to the dentition. The full length of the soft and hard palates is incised with a number 11 blade beginning just lateral to the uvula and carried to the midline. This incision extends anteriorly to include the gingival papilla on the palatal aspect of the central incisors (Fig. 6). The soft palate incision is a fullthickness incision through oral mucosa, muscle, and nasal mucosa. The greater palatine vessels are preserved because the two palatal aps are elevated just enough to perform the osteotomy.

Fig. 3. The clivus is triangular in cross-section with the base of the triangle located below the sphenoid sinus and the hypophysis.

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Fig. 4. The clivus as viewed from above (A) and below (B). The internal carotid artery crosses over foramen lacerum (arrow).

A maxillary vestibular incision is made from premolar to premolar on the opposite side, and a midline gingival incision is made between the central incisors on the facial aspect. Bone plates are prebent and set aside. The nasal mucosa is elevated and the nasal septum is cleaved. From the palatal aspect an osteotomy is performed in the midline of the hard palate. A horseshoe-shaped ostectomy of the hard palate can be performed if additional visualization is anticipated. The standard Le Fort I osteotomy is then performed and the maxilla is gently downfractured to protect nasal mucosa and preserve the descending palatine vessels from above. A spatula osteotome is then used to nish the midline split between the central incisors. Each maxillary half is rotated laterally with a self-retaining retractor (Fig. 7). The maxilla is kept moist during the remainder of the procedure. For additional soft tissue retraction of the face, the face can be degloved using nasal intercartilaginous incisions. A mandibulotomy is used if extreme superior or inferior access is required or if the patient has limited mouth opening. This approach is performed through a stepped incision through the vermilion border of the lip, which then curves around the mentalis muscle to prevent scar contracture. The incision is carried to the level of the hyoid bone or can be extended into the lateral neck if access to the parapharyngeal space also is required. The buccal and lingual mucogingiva is then incised into the oor of the mouth between Whartons ducts. After pretting mandibular bone plates, a stepped osteotomy is performed. The mandible can be rotated laterally (Fig. 8).

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Fig. 5. The transmaxillary and transmandibular approaches can provide extended access to large midline lesions.

At this juncture the surgeon has several options depending on the amount of exposure needed: 1. rotate the mandible and depress the tongue 2. incise the midline of the tongue down to the tongue base to the level of the hyoid bone and rotate the tongue and oor of mouth laterally 3. carry the incision between the mandible and the submandibular duct and retract the tongue laterally with the mandible. After access is obtained, self-retaining retractors are placed to rotate the maxillary and mandibular segments. The inferior turbinates and a portion of the nasal septum and vomer can be

Fig. 6. The palatal incision extends from the uvula to include the gingival papilla on the palatal aspect of the central incisors.

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Fig. 7. A two-piece Le Fort I osteotomy is performed (A) and the two maxillary halves are rotated laterally with a selfretaining retractor (B).

removed. A midline vertical incision is then made in the posterior pharyngeal wall and the clivus can be drilled out. As the clivus is drilled out, bleeding from the marrow space is encountered until the inner cortex is reached. The inner cortex is removed carefully with a diamond bur until dura is visualized. After removal of the lesion by the neurosurgeon closure commences. Because primary closure of the dura is dicult, the authors use brin glue, autogenous fascia lata, and fat to obturate the defect in the clivus and cover the brain. The pharyngeal incision is then closed. The maxillary segments are brought to the midline and the soft palate is closed in three layers. The hard palate is closed with mattress sutures. The patient is then placed in intermaxillary xation with a premade occlusal wafer from dental casts, and the mandible and maxilla are then plated (Fig. 9). The intermaxillary xation is released and the incisions are closed with resorbable suture material. Postoperative management Patients who require a tracheosotomy have their tracheal tube removed when the airway swelling subsides, which generally occurs at one week. The lumbar drain is left in place for 1 to 2 weeks depending on the amount of dural surgery required and the quality of the closure obtained. Prophylactic broad-spectrum antibiotics are administered.

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Fig. 8. Schematic demonstrates access with the two-piece Le Fort I and mandibulotomy.

Fig. 9. The maxillary segments are held together with a wire in the pyriform rim and the palate is closed (A). The maxilla is then plated (B).

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Fig. 9 (continued )

Patients are allowed no oral intake for approximately 7 days if the dura was opened. If the surgery was extradural, patients are allowed no oral intake for approximately 2 to 3 days. Patients are placed on a liquid diet and then slowly advanced to a puree diet until bone healing has occurred.

Lateral transfacial approaches Anatomy Lateral approaches are generally reserved for lesions that are lateral to the internal carotid artery. Osteotomies of the facial bones are made easy by their sutures. Portions of the facial skeleton either can be removed and subsequently plated back into position at the end of surgery or kept attached to the overlying soft tissue. The predominant blood supply to the soft tissue

Fig. 10. Three-dimensional CT demonstrates the relationship between the zygoma, lateral orbital rim, and mandibular ramus to the infratemporal fossa and the middle cranial fossa oor.

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Fig. 11. The coronal incision can be joined to the submandibular incision with dissection of the facial nerve (A). The Weber-Ferguson incision can be joined to the coronal incision with dissection, identication, and tagging of the frontal branch of the facial nerve before its division (B).

envelope and the underlying bone is from branches of the external carotid artery. Deep to the zygoma and posterior to the maxilla are the infratemporal fossa and its contents: the temporalis and medial and lateral pterygoid muscles, the internal maxillary artery and several branches, and the mandibular branch of the trigeminal nerve (Fig. 10). Surgical approaches Depending on the size and location of the lesion, the infratemporal fossa can be accessed through either a coronal incision or a Weber-Ferguson incision. These can be joined by a lateral

Fig. 12. The zygoma and zygomatic arch are exposed. The osteotomy is outlined and plates are applied.

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Fig. 13. The zygoma and a portion of the arch is removed.

incision from the subciliary portion of the Weber-Ferguson incision to the lower limb of the coronal incision just above the tragus (Fig. 11). The Weber-Ferguson approach provides for anterior access to the facial skeleton. The posterior extension to the tragus allows anterior and posterior access to the maxilla, zygoma, and infratemporal fossa. The frontal branches of the facial nerve should be identied with a nerve monitor and tagged before their division to allow for reattachment during closure. If a coronal incision is used, the frontal branches of the facial nerve are protected and carried laterally in the ap. The supercial layer of the deep temporal fascia divides over the temporalis

Fig. 14. The zygoma, arch, orbital rim, and mandibular ramus were sectioned to provide for access. Navigation surgery was used to plan the ramus osteotomy to protect the inferior alveolar nerve.

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Fig. 14 (continued )

muscle with an intervening fat plane. Dissection is carried in this fat plane down to the zygomatic arch and zygoma (Fig. 12). With the zygoma and maxilla exposed, the osteotomy is outlined and bone plates applied. The plates are removed and the osteotomy is completed. Depending on the extent and location of the lesion, the osteotomy can include the lateral orbital rim. The lateral canthal ligament, if detached, is tagged for reattachment at the time of closure. The osteotomy can be extended posteriorly to include the entire zygomatic arch and glenoid fossa (Fig. 13); however, a temporal bone ap is elevated rst through a craniotomy and the brain is elevated from the skull base oor rst in this region. Additional access can be gained through condylar and ramus osteotomies (Fig. 14). Navigation surgery is useful to guide the surgeon as he or she plans the osteotomies in relation to the lesion and important structures. After access is obtained and the lesion is removed, reconstruction commences. The temporalis muscle may be rotated to help separate the dura from the nasopharynx and obliterate dead space. Bony segments that have been removed are plated back into position. It is important to reconstruct the glenoid fossa with bone to prevent displacement of the condyle into the middle cranial fossa. Closure proceeds in standard fashion. Paying close attention to detail can minimize postoperative complications. Hemostasis is controlled during surgery to reduce postoperative bleeding. Spinal drainage is initiated if a cerebrospinal uid leak is detected in the postoperative period. If necessary, the patient returns for surgery to close the leak. Transfacial surgical access to the cranial base can provide wide exposure without compromising function or facial esthetics. Preoperative planning, communication between team members, and adherence to sound surgical principles are required for a successful surgical outcome.

References
[1] Donald PJ. editor. Surgery of the skull base. Philadelphia: Lippincott-Raven, 1998 [2] Derome PJ, Visot A, Monteil JP, Maestro JL. Management of cranial chordoma. In: Sekhar LN, Scramm VL, editors. Tumors of the cranial base: diagnosis and treatment. London: Futura, 1987. p. 607622. [3] Fisch U. Infratemporal fossa approach for glomus tumors of the temporal bone. Ann Otorhinolaryngol 1982;91: 474479. [4] Albin RE, ODonnell RS, Hendee RW, Heidman R, Bailey WC, Majure JA. Rhabdomyosarcoma of pterygoid fossa: resection for cure utilizing aninnervated facial ap and craniofacial reconstruction. Cancer 1986;58:163168. [5] Kantrowitz AB, Hall C, Rozycki D, et al. Sublabial bilateral hemi-Le Fort I exposure: a versatile and safe approach to the deep midface. North American Skull Base Society meeting 1990;February:17. [6] Eisig SB, Feghali J, Hall C. The 2-piece Le Fort I osteotomy for cranial base access: an evaluation of 9 patients. J Oral Maxillofac Surg 2000;58:482486.

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[7] James D, Crockard HA. Surgical access to the base of the skull and upper cervical spine by extended maxillotomy. Neurosurgery 1991;29:411416. [8] Anand VK, Harkey HL, Al-Mefty O. Open-door maxillotomy approach for lesions of the clivus. Skull Base Surg 1991;1:217225. [9] Williams WG, Lo L-J, Chen Y-R. The Le fort I palatal split approach for skull base tumors: ecacy, complications, and outcome. Plast Reconstr Surg 1998;102:23102319.