Reconstruction of the orbital walls in surgery of the skull base for benign neoplasms

Supraorbital Rim and Roof Reconstruction with Vascularized Fascia Lata and Autogenous Rib Graft

OBJECTIVE

Describe a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof.

METHODS

Retrospective chart review and description of surgical technique.

RESULTS

Four patients underwent tumor resection with neurosurgery (2 intraosseous hemangioma, 1 meningioma, and 1 ossifying fibroma), with mean tumor size of 42.6 cubic centimeters on preoperative imaging. All defects involved supraorbital rim and orbital roof. Patients were reconstructed with autogenous osseous rib graft for structure and contour and anterolateral thigh fascia lata (ALTFL) free flap to provide robust vascularity to rib bone and as a barrier between skull base dura and the orbit and/or sinonasal cavities. Two patients underwent resection and reconstruction using minimal access incisions, and two underwent major cranial and skull base resections. All flaps are vascularized via superficial temporal vessels. On postoperative follow-up (mean 33.5 months, range 8-48), all patients report no vision change or diplopia, with excellent contour symmetry to contralateral orbit. Follow-up imaging (mean 29.5 months, range 3-48) demonstrated maintained orbital volume and retention of rib bone graft compared to immediate postoperative imaging. There were no complications related to graft use. Minor complications include 1 patient with cerebrospinal fluid leak managed with lumbar drain placement and 1 patient with mild enophthalmos at 7-month follow-up.

CONCLUSION

We describe a series of patients who underwent a novel technique for reconstruction of complex defects involving supraorbital rim and orbital roof with autogenous osseous rib and vascularized ALTFL-free flap with excellent functional and cosmetic outcomes. This can be accomplished using minimal access techniques to minimize patient morbidity.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:654-658, 2024.

Single-step resection and reconstruction of orbito-fronto-temporal pathologies using a PMMA CAD-implant

BACKGROUND

Resection of bone infiltrating meningiomas of the sphenoid plane and the orbital walls is a highly challenging neurosurgical procedure. In this study, the authors present 11 cases of fronto-orbital and sphenoid wing meningioma which were subjected to tumor resection and cranioplasty using a pre-designed CAD PMMA-implant in one single staged procedure.

METHODS

Eleven cases were prospectively analyzed from January 2011 to December 2018. In all cases preoperative CT scans were performed and evaluated, in order to produce a customized PMMA-implant, fitting the osseous defect left after surgical resection of the predefined tumorous mass. Surgery was performed with standard techniques with the addition of availability of preplanned neuronavigational data as well as a matching template of the implant for intraoperative use. After tumor resection, cranioplasty followed using the predesigned PMMA implant.

RESULTS

Gross total resection was achieved in 82% (9 of 11 cases). Mean time of surgery for the combined procedure resulted in 223min±99min, with a mean blood loss of 427±192cc. Mean hospital stay for the combined procedure resulted in 11.5±3 days. In 18% of the cases (2/11), patients suffered from late onset infection of the implant and needed a surgical removal.

CONCLUSIONS

The presented data show that gross total resection and subsequent single staged bone reconstruction in osseous sphenoid wing and orbital rim meningiomas can be achieved using predesigned PMMA CAD implants with preplanned tumor resection borders with neuronavigational guidance.

Spheno-orbital meningiomas: Is orbit reconstruction mandatory? Long-term outcomes and exophthalmos improvement

Background:

Meningiomas correspond to one-third of all primary central nervous system tumors. Approximately 9% of them are spheno-orbital meningiomas (SOMs), presenting significant clinical symptoms as visual impairment and orbital esthetics. This article aims to evaluate exophthalmos’ improvement in a surgical series without orbital reconstruction.

Methods:

We consecutively included all patients diagnosed with SOM, admitted to a single institution for 10 years. Surgical resection was the standard of care, associated or not with adjuvant radiation therapy. The radiological investigation included preoperative and postoperative head CT or MRI. We quantified proptosis through imaging.

Results:

Forty patients composed this series, 87.5% were female. Proptosis was the most common presentation (90%), followed by decreased visual acuity (65%), motility deficit (20%), and headache (20%). Gross total resection was achieved in 65% of the procedures. In late outcomes, 78% of the patients maintained or improved visual acuity and 85% maintained or improved headache. Proptosis significantly improved after surgery and along with the follow-up (P < 0.001). Ten patients were submitted to adjuvant RT, six of them after a subtotal resection. All patients of this subgroup had proptosis. It was observed a higher frequency of worse in visual acuity in patients submitted to RT (71% vs. 28%, P = 0.038).

Conclusion:

Resection of SOM was sufficient to stop the evolution of visual deficit and allowed the improvement of proptosis. Orbital reconstruction does not seem to be an essential step in reducing enophthalmos.

Surgical Outcomes of Sphenoorbital En Plaque Meningioma: A 10-Year Experience in 57 Consecutive Cases

OBJECTIVE

Sphenoorbital en plaque meningioma is located in a sensitive and complex cranial region. Therefore the therapeutic approach for this type of tumor is of great importance. We aimed to examine the clinical and radiologic outcomes of patients diagnosed with sphenoid wing en plaque meningioma undergoing surgery.

METHODS

In this case series, the results of clinical and functional assessments, as well as appearance before and after surgery, were examined in 57 patients with sphenoorbital en plaque meningioma undergoing surgery with the frontotemporal approach during 2007-2017. Data were entered in the designed forms and statistically analyzed.

RESULTS

Proptosis, headache, and vision impairment were detected in 47 (83%), 33 (58%), and 16 (28%) patients, respectively. Eight (14%) patients complained of diplopia, while 3 (8%) patients complained of ptosis. In all patients, proptosis improved following surgery. Complete treatment of proptosis was reported in 42 cases, and significant improvement was observed in 5 cases. Sixteen patients experienced visual impairment before surgery, 7 of whom showed improvements after surgery, while 1 showed deteriorated visual acuity after surgery. Total tumor resection was achieved in 48 (84%) patients. Tumor relapse was reported in 7 (12.5%) patients during follow-up. One patient had undergone repeated surgery, 1 patient was treated with radiotherapy alone, and 5 patients underwent combined treatment.

CONCLUSIONS

Total tumor resection can be achieved with minimal complications by using microscopic dissection and sufficient bone and orbital wall resection. An important point in the treatment of these patients is the appropriate restoration of the orbital wall.

Orbital Roof Reconstruction Using Nylon Foil Implants

PURPOSE

To describe a surgical technique of orbital roof reconstruction with a thin nylon foil implant.

METHODS

This study is a description of a surgical technique with a retrospective chart review of 3 consecutive patients treated with a nylon foil implant for a complete superior orbital defect after meningioma resection via craniotomy approach.

RESULTS

The nylon foil reconstruction achieved an anatomically stable orbit without globe dystopia, pulsatile proptosis, cerebrospinal fluid leak, or other serious cranio-orbital problems, in all cases. Postoperative visual acuity, pain, extraocular motility, proptosis, and globe position remained stable or improved in each case. There were no complications related to the orbital roof reconstruction.

CONCLUSIONS

Nylon foil implantation was an effective and inexpensive surgical technique for orbital roof reconstruction after tumor resection in this small series.

En Plaque Meningiomas: A Narrative Review

Background  En plaque meningiomas are a rare subtype of meningiomas that are frequently encountered in the spheno-orbital region. Characterized by a hyperostotic and dural invasive architecture, these tumors present unique diagnostic and treatment considerations. Objective  The authors conduct a narrative literature review of clinical reports of en plaque meningiomas to summarize the epidemiology, clinical presentation, diagnostic criteria, and treatment considerations in treating en plaque meningiomas. Additionally, the authors present a case from their own experience to illustrate its complexity and unique features. Methods  A literature search was conducted using the MEDLINE database using the following terminology in various combinations: meningioma , meningeal neoplasms, en plaque , skull base , spheno-orbital, and sphenoid wing . Only literature published in English between 1938 and 2018 was reviewed. All case series were specifically reviewed for sufficient data on treatment outcomes, and all literature was analyzed for reports of misdiagnosed cases. Conclusion  En plaque meningiomas may present with a variety of symptoms according to their location and degree of bone invasion, requiring a careful diagnostic and treatment approach. While early and aggressive surgical resection is generally accepted as the optimal goal of treatment, these lesions require an individualized approach, with further investigation needed regarding the role of new therapies.

Surgical correction in orbitotemporal neurofibromatosis with dystopia

Background

Orbitotemporal neurofibromatosis is a challenging disease for orbital surgeons. Ptosis correction may be needed following correction of orbital dystopia.

Case presentation

A 34-year-old man, who underwent excision of a neurofibroma on the right eyelid in our clinic, returned to our clinic four years later complaining of dystopia and bulkiness of the protruding mass in the right eyelid and eyebrow. Computed tomographic imaging showed dysplasia and deformity in the sphenoid bone and orbit. A large mass was found in the superior portion of the orbit, protruding towards the temporal lobe, which in turn displaced the orbit downwards. A bicoronary incision and transcranial approach were performed, followed by the excision of the superior orbital space and temporal lobe mass by uncovering certain portions of the frontal, temporal, and zygomatic bones. After the excision of the mass, a calvarial bone graft was used to remodel the longitudinal widened orbit to correct the dystopia. While primary surgery was successful in the correction of dystopia, secondary surgery was performed to correct the exacerbated ptosis by levator muscle resection.

Conclusions

Correction of orbitotemporal neurofibromatosis with dystopia involves three steps: removal of the mass in the orbit to eliminate the effect of downward dislocation of the orbit, placement of a bone graft in the orbit floor after repositioning the orbit for suspension and remodeling of the orbit, and following the correction of dystopia, ptosis may be corrected if needed.

Intracranial Meningiomas: A 30-Year Experience and Literature Review

Intracranial meningiomas are tumors arising from the covering cells of the arachnoid layer of the dura mater or from the intraventricular choroid plexus. While mostly benign tumors, they still represent a major challenge to neurosurgeons and other medical disciplines involved in their diagnostic and therapeutic management. Although this review intends to give some state-of-the-art information from the literature, it is mainly based on personal experiences since more than 30 years caring for more than 1500 meningioma patients and point to a few new strategies to further improve on patient outcome.Diagnostics are based on magnetic resonance imaging which shows the relationship between tumor and surrounding intracranial structures, particularly the brain but also the vasculature and to some extent the cranial nerves. Furthermore, it may suggest the grading of the tumor and is very helpful in the postoperative diagnosis of complications and later follow-up course.Surgery still is the main treatment with the aim to completely remove the tumor; also in cases of recurrence, other additional options include radiotherapy and radiosurgery for incompletely removed or recurrent meningiomas. Postoperative chemotherapy has not been shown to provide substantial benefit to the patient especially in highly malignant meningiomas.All therapy options should be intended to provide the patient with the best possible functional outcome. Patients' perspective is not always equivalent to surgeons' perspectives. Neuropsychological evaluation and additional guidance of patients harboring meningiomas have proven to be important in modern neurosurgical intracranial tumor treatment. Their help beyond neurosurgical care facilitates the patients to lead an independent postoperative life.

Cranial suture-like gap and bone regeneration after transplantation of cryopreserved MSCs by use of a programmed freezer with magnetic field in rats

Mesenchymal stem cells (MSCs) can be used for regeneration of various organs and tissues. A previous study revealed that cryopreserved MSCs, which were frozen by a programmed freezer with a magnetic field (Cells Alive System: CAS) and cryopreserved for 7 days in a -150°C deep freezer, can maintain high survival and proliferation rates while retaining both adipogenic and osteogenic differentiation abilities. The purpose of this study was to examine MSC viability and tissue regenerative ability after long-term cryopreservation using a CAS freezer. MSCs were isolated from rat femora bone marrow and cryopreserved in a -150°C deep freezer (CAS group) or directly cryopreserved in a deep freezer (Direct group). After 3 years, the cells were thawed and the number of viable cells was counted. Cell proliferation was also examined after 14 days in culture. For histological examination, forty 4-week-old Fischer 344 male rats received bone and sagittal suture defects with a diameter of 6.0mm, and MSCs (CAS or Direct group) cryopreserved for 1 year were grafted with membranes. Non-cryopreserved MSCs (Control group) were transplanted to an additional twenty rats. The rats were sacrificed at 4, 8, 16, and 24 weeks after surgery. The parietal bones, including the sagittal suture, were observed under a light microscope and the extent of bone regeneration was measured. Our results indicate that MSCs survival and proliferation rates were significantly higher in the CAS group than in the Direct group. In the Control and CAS groups, a large amount of new bone formation and a suture-like gap was identified 24 weeks after transplantation, whereas only a small amount of new bone formation was observed in the Direct group. These results suggest that the CAS freezer is amenable to long-term cryopreservation of MSCs, which can be applied to the regeneration of various tissues, including bone tissue with suture-like gap formation.

Application of cranial bone grafts for reconstruction of maxillofacial deformities

This retrospective study evaluated outcomes with the use of calvarial bone grafts (CBGs) in maxillofacial reconstruction as well as donor and recipient site complications. The records of 50 consecutive patients from a private practice were reviewed; there were 34 women and 16 men, with an average age of 32.4 years (range 16 to 66 years). Among the 50 patients, CBGs were placed in 63 sites: the ramus (10), nasal dorsum (14), maxilla/alveolar ridge (12), glenoid fossa/temporal bone (14), mandibular body/symphysis (3), and orbitozygomatic complex (10). The longest follow-up averaged 22.4 months (range 12 to 48 months). An outer-table CBG harvest technique was utilized. All subjects were evaluated for infection, dehiscence, loss of graft, and any other complications. Three complications occurred (5%) at the recipient sites. Two grafts became infected requiring removal, and one nasal dorsal graft was mobile but remained in position. At 50 donor sites, 2 complications (4%) occurred, resulting in dural tears in two patients that were immediately repaired with no untoward consequence. In conclusion, CBGs are an effective bone source for maxillofacial reconstruction with low donor and recipient site complications.

Management of spheno-orbital en plaque meningiomas: clinical outcome in a consecutive series of 40 patients

OBJECTIVE

The clinical results of combined surgical-radiosurgical treatment of the spheno-orbital en plaque meningiomas in a consecutive series of 40 patients are presented. The clinical outcome is evaluated in terms of surgical morbidity, tumour control, visual function and cosmetic result.

METHODS

Forty patients harbouring spheno-orbital en plaque meningiomas were treated. Forty-two surgical procedures were performed through a fronto-temporal craniotomy. The reconstruction of the orbital walls was performed using a titanium mesh. In case of sub-total resection, the patients underwent Gamma-Knife radiosurgery on residual tumour. Visual function was evaluated considering visual acuity tested with a Snellen chart, funduscopy and Goldmann perimetry for visual field defects. Proptosis was quantified on CT scans.

RESULTS

Total or gross-total tumour resection was achieved in 56.1% of cases. Permanent morbidity was recorded in three patients after surgery. Visual acuity and visual field defect both improved in 66.7% of patients; improvement of proptosis was recorded in 92.7% of cases. Eighteen patients were treated with Gamma-Knife radiosurgery for residual tumour after surgery and four patients for tumour relapse at follow-up. The mean follow-up period was 72.6 months.

CONCLUSIONS

Surgical treatment of spheno-orbital en plaque meningiomas is safe and effective: a low morbidity rate was recorded and visual function improved in about two-thirds of patients. Reconstruction of the orbital walls with titanium mesh provides for good functional and cosmetic results. In case of superior orbital fissure and cavernous sinus invasion, the combined surgical-radiosurgical treatment allows to minimise surgical morbidity and to achieve tumour control.

Reconstruction techniques in skull base surgery

One of the major challenges of cranial base surgery is reconstruction of basal dural defects. Ineffective reconstruction may result in potentially life-threatening complications such as cerebrospinal fluid leak, meningitis, and tension pneumocephalus. Goals of reconstructive procedures are to repair the dural defect and to separate intracranial contents from bacteria-laden secretion of the mouth, nose, and sinus. Different reconstructive techniques have been reported. Multiple factors may influence the surgical choice of reconstructive technique and its outcome. Regional pedicled flap and vascular free flaps represent the best reconstructive options because vascularized tissues promote fast and complete healing. A variety of endoscopic pedicled mucosal flaps within the nasal cavity have also been described. The different reconstruction techniques are described and discussed in terms of indications, advantages, and drawbacks.

[Sphenoorbital meningiomas]

Sphenoorbital meningiomas account for 20% of all orbital tumors treated by neurosurgeons. Proptosis is the main clinical sign but this can be reduced with accurate surgical management. Complete tumor removal is often difficult considering the frequent extensions of the meningioma to the superior orbital fissure, the cavernous sinus, and the periorbita.

Surgical approaches to cavernous haemangiomas of the orbit

Cavernous haemangiomas are the most common orbital masses and the second most common cause of unilateral proptosis after thyroid ophthalmopathy. We retrospectively analysed 19 patients with retrobulbar cavernous haemangiomas, 9 of whom had lateral orbitotomy to remove retrobulbar cavernous haemangiomas located superior (n=4), inferior (n=2) or lateral (n=3) to the optic nerve. Seven patients had lateral orbitotomy together with an anterior medial approach to gain access to retrobulbar cavernous haemangiomas located medially to the optic nerve in the posterior half of the orbit. An anterior approach was used in 3 patient with an anteriorly located cavernous haemangioma. We describe here the planning of surgical treatment based on the site of the lesion.

Intraorbital plexiform neurofibroma in an NF-1-negative patient

A 52-year-old patient presented with an orbital swelling and exophthalmos that enlarged over a period of about 40 years. The clinical examination showed massive exophthalmos and ptosis of the right eye without diplopia. The radiological investigation (MRI, CT and ultrasound) showed an unclear intraorbital mass with erosion of the orbital floor, infraorbital rim and orbital roof. The lesion was diagnosed histologically as a plexiform neurofibroma. The patient did not present any features of neurofibromatosis type 1 (NF-1) and molecular genetic analysis was unable to uncover a pathogenic sequence alteration in the NF-1 gene. Owing to the absence of clinical and ophthalmologic symptoms and the improbability of complete removal, the patient refused surgical intervention.

Microsurgical technique and results of a series of 63 spheno-orbital meningiomas

OBJECTIVE

For this study, spheno-orbital meningiomas (SOMs) are defined as intraosseus meningiomas at the base of the anterior and middle cranial fossa, involving the sphenoid wing and orbit associated with a carpet-like, soft tissue component. We describe a surgical series of 63 SOMs, including surgical technique, complications, and recurrences.

METHODS

For this retrospective series, patient charts of those who underwent operation for SOM by or under the supervision of the senior author (JS) at two institutions were identified and reviewed. Follow-up data was collected for up to 17 years (median, 4.5 yr).

RESULTS

Between 1983 and 2003, 63 patients with a mean age of 51 years underwent operation for SOM. The most common preoperative sign was proptosis (79%), followed by visual acuity deficits (27%). Preoperative symptoms included a visual acuity below 0.8 (47%) and visual field deficits of 32%. Bony resection included the lesser sphenoid wing, the lateral orbital wall, the orbital roof, the optic canal, and the middle fossa base. Periorbital tumor infiltration led to intraorbital resection in 32 cases, and five cases presented a solid intraorbital tumor. After surgery, proptosis improved in 77% of the patients; 64% of the patients had improved visual acuity, and 58% of the patients with preoperative deficits had improved visual fields. Postoperatively, 12 patients showed temporary oculomotor deficits, and eight patients showed permanent oculomotor deficits. Temporary (n = 9) and persisting (n = 2) ptosis was observed. The median follow-up period was 4.5 years. Seventy-six percent of patients had tumor residuals, of which 61% were stable and 39% were progressive. Eleven tumor residuals were operated and four were treated by radiation.

CONCLUSION

Complete surgical resection of SOMs is frequently impossible because the involvement of delicate structures of the orbital cone is common. Although some persisting neurological deficits are possible, proptosis and other visual deficits are often relieved. Two-thirds of tumor rests remained stable during the follow-up period. Consequently, the surgical aim should be the relief of leading symptoms rather than radical resection.

Fibrous dysplasia of the orbital region: current clinical perspectives in ophthalmology and cranio-maxillofacial surgery

PURPOSE

To describe the multidisciplinary diagnosis and treatment of patients with orbital fibrous dysplasia, a slowly progressive disease that may lead to asymmetry, disfigurement, and functional ocular problems.

METHODS

Ten patients with orbital fibrous dysplasia underwent bifrontal craniotomy through a coronal flap, with the removal of the supraorbital arch and dysplastic process involving the anterior and middle base of the skull. Four patients underwent superior orbital fissure and optic nerve canal decompression. Reconstruction was performed by using an autologous bone graft for both the adults and children, in whom a rib graft was preferred. The mean follow-up was 53.2 +/- 18.3 months (range, 14 to 94 months). The patients' preoperative status and postoperative status were compared.

RESULTS

The immediate and long-term morphologic and aesthetic results were good in all cases. All of the patients complained of some degree of diplopia during the immediate postoperative period, but the problem spontaneously resolved within 1 to 6 months in all but one case. No postoperative reduction in visual function was observed in the patients who underwent optic nerve decompression. The only reported complication was the irregular reabsorption of regrafted dysplastic bone in one patient.

CONCLUSIONS

A multidisciplinary approach to orbital fibrous dysplasia is fundamental for treatment planning and execution.

Primary intraosseous hemangiomas of the orbit

INTRODUCTION

Primary intraosseus orbital hemangiomas are rare vascular anomalies, of which only 23 cases have been previously reported in the literature. We here describe a further two cases.

MATERIALS AND METHODS

An anterior approach was used to remove a mass located in the inferior orbital rim in one case, and in the orbital floor in the other.

RESULTS

Good restoration of the orbital walls with no signs of recurrence.

DISCUSSION

Intraosseous hemangiomas of the orbit are usually located anteriorly, and can be removed by anterior surgical approaches. The main surgical problem is due to the removal of the involved areas of the orbital walls because resection without reconstruction may cause functional impairments and secondary deformities that are more damaging for the patient than the tumour itself. In order to avoid defects, the integrity of the orbital walls must be immediately restored by means of autologous bone or alloplastic grafts.

Surgical Strategies for Recurrent Craniofacial Meningiomas

OBJECTIVE:

Recurrent cranial base meningiomas are among the most difficult tumors to treat surgically. Although they are histologically benign, these tumors often invade through the cranial base into the infratemporal and pterygopalatine fossae. We reviewed our experience with these tumors to describe the natural history of these lesions as well as provide a possible treatment paradigm.

METHODS:

Between 2000 and 2004, seven patients with meningiomas recurring through the cranial base into facial structures were treated at the University of Utah. Five patients were treated with transcranial approaches only, and two were treated with a combination of transcranial and transfacial approaches.

RESULTS:

The average age of our patients (6 women, 1 man) was 55 years. The original site of tumor was the sphenoid wing in four patients, the middle fossa in two patients, and the left frontal region in one patient. The average interval between the most recent tumor resection and recurrence into the face was 9.9 years. The mean number of resections a patient underwent before invasion into the face was two. All but one patient had adjunctive therapy (including either radiation or chemotherapy) before recurrence into the face.

CONCLUSION:

Meningiomas that recur into facial structures present a unique treatment challenge. These lesions have a high rate of recurrence once they have invaded through the cranial base. Although combined approaches may be necessary to achieve a gross total resection, these lesions can often be reached using standard transcranial techniques.

Management of fronto-orbital sphenoidal and facial osteosarcoma: a case with uncommon localization

Osteogenic sarcomas of the head and neck are rarely seen; approximately 6% to 13% these tumors occur in the head and neck, and less than 2% occur in the cranium. Not only eradication of the tumor but reconstruction to achieve satisfactory esthetic and functional results are the main issues regarding these tumors. In this report, a case of osteogenic sarcoma that invaded the infratemporal area, fronto-orbital region, and sphenoid wing is presented. The surgical results of eradication and reconstruction are also presented.

Spheno-orbital meningiomas: interdisciplinary surgical approach, resectability and long-term results

OBJECTIVE

To describe the interdisciplinary surgical approach in spheno-orbital meningiomas and to evaluate the operative results regarding resectability and functional outcome.

PATIENTS AND METHODS

A series of 16 patients underwent surgical resection of spheno-orbital meningiomas followed by bony reconstruction. Four patients presented with a recurrent meningioma and had undergone surgical resection previously. Radical tumour removal was attempted in all cases, although no aggressive effort was made to remove tumour tissue infiltrating the cavernous sinus or soft tissues deep in the orbit to avoid severe functional disturbances. All patients but one were female (mean age 53 years). Mean follow-up period was 68 months (range 4-155 months).

RESULTS

The leading symptom was proptosis in 14 patients, accompanied in 7 cases by progressive visual impairment. Surgical resection was thought to have been complete in 11 patients (69%) and incomplete in 5 (31%). Residual tumour was deliberately left when there was infiltration of the cavernous sinus (n = 4), the pterygopalatine fossa (n = 2) and/or the deep intraorbital soft tissues (n = 1). Tumour recurrence was observed in 9 patients, among whom were 6 patients with an initially "completely" resected meningioma. Eight patients underwent re-operation. Complete resection was achieved in 3 of these latter patients with an isolated exclusively intraorbital tumour manifestation.

CONCLUSION

By means of combined skull base approaches, spheno-orbital meningiomas are grossly resected totally with a long-term survival free of recurrence and an acceptable quality of life. In some cases, deliberate subtotal tumour resection is useful to avoid severe neurological damage with sufficient tumour control and a valuable progression-free survival.

Craniofacial fibrous dysplasia of the fronto-orbital region: a case series and literature review

PURPOSE

Craniofacial fibrous dysplais (CFD), involving the fronto-orbital region often is challenging to treat because of the proximity of neurovascular and ocular structures. This article presents the surgical experience with 6 patients.

PATIENTS AND METHODS

Six patients ranging in age from 7 to 23 years, who had undergone surgery for CFD of the orbital region, were retrospectively reviewed. All patients had progressive complaints of deformity, pain, paresthesia or visual disturbances. Surgery generally involved extensive tumor excision and immediate orbital reconstruction with autogenous bone grafts. Two patients also were reconstructed with resected and treated autogenous bone, which then was immediately reimplanted, using rigid fixation. Three patients also had intracranial microsurgical optic canal decompression. All patients received perioperative corticosteroids.

RESULTS

Five patients experienced partial relief of their sensory and visual disturbances. These patients also felt that there had been improvement in facial appearance. One patient with very extensive circumferential optic canal involvement, and who underwent 2-wall decompression, suffered visual loss.

CONCLUSION

Early surgery to address progressive sensory disturbances is recommended so as to avoid the hazards of late-stage decompression. The risks of surgery must be weighed against the benefits of achieving a more functional and aesthetic result. Long-term neuro-ophthalmologic monitoring is essential.