[Transzygomatic pterional approach. Part 2: Surgical experience in the management of skull base pathology]

Esthetics outcomes in patients submitted to pterional craniotomy and its variants: A scoping review

Background:

Highly performed nowadays, the pterional craniotomy (PC) has several widespread variants. However, these procedures are associated with complications such as temporalis muscle atrophy, facial nerve frontal branch damage, and masticatory difficulties. The postoperative cranial aesthetic is, nonetheless, the main setback according to patients. This review aims to map different pterional approaches focusing on final aesthetics.

Methods:

This review follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies were classified through the Oxford method. We searched PubMed/MEDLINE, EMBASE, and Cochrane Library from January 1969 to February 2021 for cohorts and randomized clinical trials that met our inclusion criteria.

Results:

1484 articles were initially retrieved from the databases. 1328 articles did not fit the inclusion criteria. 118 duplicates were found. 38 studies were found eligible for the established criteria. 27 (71.05%) were retrospective cohorts, with low evidence level. Only 5 (13.15%) clinical trials were found eligible to the criteria. The majority of the studies (36/38) had the 2B OXFORD evidence level. A limited number of studies addressed cosmetic outcomes and patient satisfaction. The temporal muscle atrophy or temporal hollowing seems to be the patient’s main complaint. Only 17 (44.73%) studies addressed patient satisfaction regarding the aesthetics, and only 10 (26.31%) of the studies reported the cosmetic outcome as a primary outcome. Nevertheless, minimally invasive approaches appear to overcome most cosmetic complaints and should be performed whenever possible.

Conclusion:

There are several variants of the classic PC. The esthetic outcomes are poorly evaluated. The majority of the studies were low evidence articles.

Endoscopic Endonasal Resection of Meckel's Cave Epidermoid Cysts: Case Discussion and Literature Review

Meckel's cave (MC) epidermoid cysts are relatively uncommon lesions. In cases where surgical excision is indicated, resection is often carried out via a frontosphenotemporal craniotomy from an anterolateral approach or a temporal craniotomy with or without a petrosectomy for a lateral corridor; both of these routes are associated with brain retraction and potential neurovascular injury. The anterior location of MC in the middle cranial fossa makes safe access via posterior fossa-based approaches—such as the retrosigmoid approach—challenging as well. Here, we present the cases of two patients diagnosed with epidermoid cysts in MC who underwent surgical resection via an endoscopic endonasal transpterygoid approach. Near-total resection was achieved in both cases, with only mild transient neurologic disturbances postoperatively. Radiographically, no evidence of residual disease was noted in either patient. We further review the nuances of an extended endoscopic endonasal approach to these lesions.

Combined Extradural and Intradural Pterional Transzygomatic Approach to Large Sphenoid Wing Meningiomas. Operative Technique and Surgical Results

Objectives  Describe a unique and safe surgical procedure for the microsurgical management of large sphenoid wing meningiomas (SWMs) aimed to a radical resection of these tumors. Design  A prospective series of 26 cases with SWMs larger than 3 cm in one of its main diameter is presented. All patients were studied following the same clinical and imaging procedures. The surgical approach was through a pterional transzygomatic craniotomy. The surgical procedure has the following steps: 1. Extradural tumor devascularization and resection of the hyperostotic and/or infiltrated bone and then intradurally; 2. Intradural tumor debunking; 3. Microdissection of vascular branches and perforators from the capsule; 4. Identification of the optic and oculomotor nerves and internal carotid artery; 5. Tumor capsule dissection and resection; 6. Dural resection or cauterization; 7. Dural and bone reconstruction and closing. Results  All lesions were completely removed. Most complications were transient. The most relevant complication was a large middle cerebral artery infarct with permanent hemiplegia despite a decompressive craniotomy. Conclusion  Large SWMs can be considered as a single pathology regarding the surgical approach and intraoperative microsurgical procedure strategies. The pterional transzygomatic approach allows an extradural devascularization of the tumor and an extensive bone resection that facilitates the intradural stage of tumor resection. The proposed approach allows a wide and radical resection of the duramater and bone that increases the Simpson grade. However, surgery does not control other biological or molecular prognostic factors involved in tumor recurrence.

Transzygomatic approach plus mini-peeling of middle fossa for devascularization of sphenoid wing meningiomas. Technical note

Background:

Sphenoid wing meningiomas account for 20% of supratentorial meningiomas. The main supply of these tumors is provided by branches of the middle and accessory meningeal arteries. Surgical resection of meningiomas requires early tumor devascularization. Our objective is to present the role of transzygomatic approach plus mini-peeling of the anterior third of the middle fossa in the extradural identification and coagulation of branches of middle and accessory meningeal arteries involved in tumor supply.

Methods:

Ten formalin-fixed, silicone-injected cadaveric heads were used. On each side a transzygomatic approach plus mini-peeling of the anterior third of the middle fossa was performed. Between 2005 and 2017, the authors applied this technique for the resection of sphenoid wing meningiomas in 28 patients.

Results:

The mean age of patients was 54 years. Thirteen tumors could be classified as medial-third type, 6 as middle-third type, and 4 tumors were lateral-third type. Five tumors represented combined types. Of these, 3 tumors involved the medial and middle-third of the sphenoid wing and 2 involved the entire wing. Surgical resection was classified as Simpson I/II in 24 patients (86%). There were no permanent deficits or postoperative mortality.

Conclusions:

The transzygomatic approach combined with mini-peeling of the anterior third of the middle fossa is effective in allowing early devascularization of sphenoid wing meningiomas. These maneuvers are particularly important during resection of large tumors.