Transfacial approaches to the cranial base

Use of the Smith's Spreader as a Self-Retaining Retractor in the Direct Approach to Clival Tumours - A Technical Note

The traditional Le Fort level 1 osteotomy has proven to be an effective in approaching central skull base lesions. The challenge being - stabilization of the down-fractured maxilla in an amenable position for tumour resection. The authors describe a simple technique to overcome the task of stabilizing the down-fractured maxilla.

Transfacial Exposures of the Anterior Skull Base and Cervical Spine: Straightforward "Line-of-Sight" Algorithm for Selection of Approach

ABSTRACT

Surgical treatment for tumors of the skull base remains gross total resection with microscopic negative margins. Sufficient surgical access is paramount to adequate treatment but must be balanced with patient morbidity and protection of vital neurovascular structures. While endoscopic surgery has made transfacial access less common, there are still indications for open transfacial exposure including tumors that involve facial soft tissues, the palate, anterolateral frontal sinus, dural involvement lateral to the mid-pupillary line, tumor recurrence/repeat resection, and/or lack of access to endoscopic equipment or expertise. The authors present a "line-of-sight" algorithm for selection of approach, discuss pre-operative planning, review selected clinical experiences, and discuss the role of microsurgery and prevention of complications.

Long-Term Surgical Complications in the Oral Cancer Patient: a Comprehensive Review. Part II

OBJECTIVES

Surgery remains the preferred treatment for the majority of oral cancers. The aim of the present article was to provide a comprehensive review of complications associated with surgical treatment of oral cancer including hardware failure; complications associated with choice of reconstruction, donor site morbidity as well as functional and aesthetic issues that impact on the quality of life.

MATERIAL AND METHODS

The available English language literature relevant to complications associated with surgical treatment of oral cancer was reviewed. Complications associated with potential for disfigurement, choice of reconstruction, donor site morbidity as well as functional and aesthetic issues that impact on the quality of life are summarized.

RESULTS

In total 35 literature sources were obtained and reviewed. The topics covered in the second part of this review series include hardware failure, scars and fistula formation; complications associated with choice of reconstruction, donor site morbidity as well as functional and aesthetic issues.

CONCLUSIONS

Cancer resection should be planned around two very important concepts. First and foremost is the eradication of disease. This should be the ultimate goal of the ablative team and all potential complications that may be the result of appropriately executed oncologic resection should be discussed in details with the patient. Adequate reconstruction of the defects with restoration of form and function is the second, but not of less importance, goal for the successful care of the head and neck cancer patient.

Comparison of the Le Fort I maxillary osteotomy with the sublabial transnasal and endonasal approaches to the sphenoid sinus and sella: a cadaveric study

PURPOSE

The purpose of this study is to compare the access afforded by the Le Fort I osteotomy with the more traditional sublabial and endonasal approaches to the pituitary fossa.

PATIENTS AND METHODS

Five fresh cadaveric heads were obtained for this study. Endonasal, sublabial, and Le Fort I osteotomy approaches to the pituitary fossa were performed on each specimen. Retractors were placed in the surgical field to simulate the intraoperative speculum position for each approach. Fluoroscopic images were obtained in 2 views. For each specimen, all images for a given approach were digitally superimposed to compare the magnitude of exposure obtained by each approach. Angular measurements were then compared among the 3 approaches.

RESULTS

In the axial plane the degree of lateral exposure with the Le Fort I approach ranged from 15 degrees to 35 degrees, with a mean of 22.6 degrees. By comparison, minimal or no lateral movement of the speculum was possible with the sublabial and endonasal approaches. In the sagittal plane the degree of vertical exposure with the Le Fort I approach ranged from 13 degrees to 22 degrees, with a mean of 17 degrees. The sublabial approach provided 6 degrees to 17 degrees of vertical exposure, with a mean of 11.4 degrees. Minimal or no vertical movement of the speculum was possible with the endonasal approach.

CONCLUSIONS

The Le Fort I osteotomy is a valuable midline approach for pituitary lesions that require broad exposure. Access in both the axial and sagittal planes is greater than with traditional trans-septal approaches.

Transmaxillary approach to the cranial base: an evaluation of 11 cases

Surgical access to the skull base is always difficult, especially because of the noble anatomic structures present there. Maxillary osteotomy provides direct view to the clivus region and the neck spine, and it also bears less morbidity when compared to the many other accesses described in the literature.

Aim

to assess 11 patients submitted to transmaxillary osteotomy, describing the surgical technique and postoperative results and complications.

Materials and Methods

A retrospective study involving eleven patients submitted to transmaxillary approach to the brainstem. We studied dental occlusion, trans and postoperative bleeding, bone necrosis and soft tissue alterations. All followed the same surgical protocol and were followed up for two years.

Results

after treatment, all the patients improved in their clinical status and had no neurological complication, trans and postoperative hemorrhage or major complications were seen. Among the complications, two patients had incomplete maxilla fracture, two had laceration of their nasal mucosa and one had, as late complication, an oral-sinusal fistula.

Conclusion

Transmaxillary osteotomy provided proper access to the clivus for brainstem decompression with low rate of complications in this series.

Skull Base Tumors: A Comprehensive Review of Transfacial Swing Osteotomy Approaches

Numerous techniques have been proposed for the resection of skull base tumors, each one unique with regard to the region exposed and degree of technical complexity. This study describes the use of transfacial swing osteotomies in accessing lesions located at various levels of the cranial base. Eight patients who underwent transfacial swings for exposure and resection of cranial base lesions between 1996 and 2002 were studied. The mandible was the choice when wide exposure of nasopharyngeal and midline skull base tumors was necessary, especially when they involved the infratemporal fossa. The midfacial swing osteotomy was an option when access to the entire clivus was necessary. An orbital swing approach was used to access large orbital tumors lying inferior to the optic nerve and posterior to the globe, a region that is often difficult to visualize. Gross total tumor excision was possible in all patients. Six patients achieved disease control and two had recurrences. The complications of cerebrospinal fluid leak, infection, hematoma, or cranial nerve damage did not occur. After surgery, some patients experienced temporary symptoms caused by local swelling. The aesthetic result was considered good. Transfacial swing osteotomies provide a wide exposure to tumors that occur in the central skull base area. Excellent knowledge of the detailed anatomy of this region is paramount to the success of this surgery. The team concept is essential; it is built around the craniofacial surgeon and an experienced skull base neurosurgeon.