Facial translocation: A new approach to the cranial base IVO P. JANECKA, MD, CHANDRA N. SEN, MD. LALIGAM N. SEKHAR, MD. and MOÏSES ARRIAGA, MD. Pittsburgh, Pennsylvania
Nasopharynx, clivus, and cavernous sinus are difficult regions of the cranial base in which to perform oncologie surgery. We have developed an approach to this area by using facial soft tissue translocation and craniofacial osteotomies. Surgical field ob tained at the skull base can extend from the contralateral eustachian tube to ipsilateral geniculate ganglion. It includes the nasopharynx, clivus, sphenoid, and cavernous sinus, as well as the entire infratemporal fossa and superior orbital fissure. Our expe rience with this technique in 12 patients is reported. All patients healed primarily, (οτοLARYNGOL HEAD NECK SURG 1990:103:413.)
I he success of surgical oncology is directly related to fornix through the conjuctiva to the lateral canthus, at the technical ease of obtaining clear surgical margins. which point it exits to meet the vertical bicoronal/preauricular incision. The cheek flap is reflected inferiorly This, in turn, is a reflection of a surgical approach. to the level of the hard palate after the elevation of the Direct correlation often exists between the complete maxillary periosteum and the masseteric fascia in a ness of exposure, adequacy of histologie margins, and downward fashion. patient outcome. The frontotemporal scalp flap is reflected toward the This article describes a new approach to the cranial midline after completion of the bicoronal and transtem base, using facial translocation. It offers excellent vi poral incision and an appropriate undermining. Cranio sualization and permits unhindered surgical manipula facial skeleton is exposed from the midline (forehead, tion at the anterior and middle cranial base as well nasion, nasal process of the maxilla, superior, lateral as related structures. The surgical field can extend and inferior orbital rims, maxilla, and the zygomatic from the contralateral eustachian tube to the ipsilat arch). Osteotomies of the orbitomaxillary skeleton eral geniculate ganglion and from the superior orbital fissure /cavernous sinus area to the level of the hard (Fig. 2) are performed to free the anterior face of the maxilla, malar eminence, zygomatic arch, and inferior palate. and lateral orbital rims, as well as the orbitalfloor.This METHOD permits an inferior translocation of the temporalis mus cle after an oblique subperiosteal osteotomy at the base An interiorly based cheek flap is developed on the of the coronoid process. A view available at this point facial and inferior labial vascular pedicles ( Fig. 1, A includes the posterior end of the nasal septum, begin and B). It includes the lateral third of the upper lip, the ning of the contralateral nasopharynx, posterior wall of entire cheek soft tissue (from the maxillary periosteum the maxillary sinus, pterygoid plates and muscles, and to the skin), lower lid, facial nerve, and the parotid the infratemporal fossa (Fig. 3). gland. The lip split incision begins at the vermilion A frontotemporal craniotomy is performed at this border and continues along the nasal ala and the lateral nose. It turns horizontally at the inner canthus, which time, identifying foramina spinosum, ovale, and rotunit transects. It continues at the depth of the inferior lid dum, as well as the superior orbital fissure. If control of the internal carotid artery is required, a decompres sion of the petrous portion of this vessel is performed (Fig. 4). From the Departments of Otolaryngology (Drs. Janecka and Arriaga) The tumor perimeter and its histology guide the threeand Neurosurgery (Drs. Sen and Sekhar), Eye and Ear Institute, dimensional tumor resection, which is well-controlled and the Center for Cranial Base Surgery (Drs. Janecka and Sekhar). because of the excellent visualization. Submitted for publication July 24, 1989; accepted Dec. 16, 1989. The reconstructive phase begins after tumor resection Reprint requests: Ivo P. Janecka, MD, Department of Otolaryngol and margin verification. Dura is repaired either primar ogy, Eye and Ear Institute—Suite 500, 203 Lothrop St., Pitts burgh, PA 15213. ily or with a graft. If orbital exenteration was done in 23/1/18870 conjunction with the superior orbitectomy, a pericranial 413 Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
414 JANECKA et al.
Frontal br. of facial n.
Infraorbital n.
Masseter transected) ransected frontal brs.of facial n. (tagged)
Mucosa (reflectei
unctiva
B
Transected infraorbital n.
Lower lid
Fig. 1. A, Outline of incisions used in facial translocation approach. B, Cheek and frontotemporal flaps are elevated.
flap is transferred to cover the durai repair. The temporalis muscle is freely mobile from its original position and can be placed over the pericranialflap,covering the anterolateral cranial base, sphenoid sinus, nasopharynx, orbit (if exenterated), space of previous maxillary sinus, and the pterygopalatine, as well as infratemporal fossa
regions. The temporalis muscle, facing the nasal cavity and nasopharynx, may be covered with free grafts of normal mucosa or can be permitted to be "remucosalized" by healing of secondary intention. The orbitomaxillary skeleton, removed during the approach phase, is replaced and affixed (2-0 braided
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base
415
Table 1. Clinical application of facial translocation approach—List of patients and tumors Case no./patient
Histology
Extent
Squamous cell carcinoma
Nasopharynx, infratemporal, pterygopallatine fossae, superior or bital fissure, cavernous sinus Lateral nasopharynx
Squamous cell carcinoma
Maxilla, pterygoids, orbit
Osteogenic sarcoma
Maxilla, orbit, pterygoids
10/KH
Chordoma
Maxilla, orbit, cavernous sinus, an terior/middle cranial fossae, sphenoid sinus
11/BA
Rhabdomyosarcoma
12/HB
Adenocarcinoma
Orbit, infratemporal fossa, sphenoid sinus, middle cranial fossa Maxilla, orbit, pterygoids
1/EM 2/JI 3/RG 4/RB 5/DC 6/CS 7/PS 8/MS 9/JL
Angiofibroma
nylon or mini-plates). A split cranial bone graft can be used to reinforce the orbital floor. Both lacrimai canaliculi and the nasolacrimal duct are stented with the use of silicon tubings (stents with pre-attached wire passers are available). These are left in place for several weeks postoperatively. The medial and lateral canthal ligaments are reapproximated and attached to a previously marked posi tion on the lacrimai bone. The inferior lid segment with orbicularis muscle is repaired, as is the inferior fornix conjuctiva. The frontal branch of the facial nerve is resutured. The infraorbital nerve may also be repaired if not compromised by the tumor. A short nerve graft can be considered here as well. The external soft tis sues, including the skin, are then reapproximated along the preoperative markings. Two horizontal mattress su tures over 5-mtn pieces of rubber band are placed through the upper and lower lid margins, which assist in precise anatomic healing of the lower lid incisions. They can be removed in 10 to 14 days postoperatively. A nasal stent is inserted in the ipsilateral nostril to protect the airway during the healing phase and also to prevent a potential medial bulging of the transferred temporalis muscle. It is removed within 7 to 10 days Postoperatively. RESULTS
Remarks
Both patients had unsuc cessful radiotherapy
Both patients are s/p bilateral retinoblastoma; (no. 9 - JL) final pathology ossifying fibroma
Fig. 2. Craniofaclal osteotomies permitting removal of orbitomaxillary complex.
Twelve patients were operated on using this approach (Table 1); four had squamous cell carcinoma (Fig. 5); This article focuses on the technical aspects of this approach and therefore a short followup (6 months) may two had osteogenic sarcoma, and one each had chor suffice to assess the surgical advantages, disadvantages, doma, rhabdomyosarcoma, and adenocarcinoma, re spectively. Three other patients had extensive angiofiand the degree of primary healing. Of course, no state ments can be made regarding the oncologie followup. bromas (Fig. 6, A through E). Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
416 JANECKA et al.
Turbinâtes o opposite side
Pterygoid p r o c e s s Outfractured coronoid process emporalis
Flg. 3. After transposition of temporalls muscle, Infratemporal fossa content and pterygoid region are seen.
Contents of sup. orbital fissure
ustachian tube o r i f i c e
Fig. 4. Frontotemporal cranlotomy completes superior exposure of the entire nasopharynx and related structures.
All patients healed per primum. Complications in cluded the need for replacement of one horizontal lidmargin suture several days postoperatively. In the same patient, the lacrimai stent came loose from its intranasal attachment and migrated out. As expected, the frontal branch function of the facial nerve has not recovered yet.
DISCUSSION
The facial translocation approach to the anterolateral skull base and related structures provides a direct access to a surgical territory extending from the contralateral eustachian tube along the posterior pharynx, clivus, anterior wall of the sphenoid sinus, through the ipsilateral pterygopalatine and infratemporal fossa, po-
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base 417
Flg. 5. Case 5. Appearance of facial scars 3 months postoperatively (arrows).
tentially up to the geniculate ganglion. The tumor spec imen may therefore contain the anterior wall of the sphenoid, lateral and posterior nasopharynx, pterygopalatine fossa content, pterygoid plates and muscles, and accompanying skull. The superior orbital fissure and the anterior/ inferior portion of the cavernous sinus may be included as well. The entire orbital content, as well as the hard palate, may be easily added to the specimen when necessary. Literature lists a number of approaches to various compartments of this region (e.g., nasopharynx, eli vus, sphenoid, pterygopalatine fossa, infratemporal fossa, etc.),113 but significant limitations in terms of possible complete tumor removal as well as surgical safety exist with all of them. The facial translocation approach we have described here has some disadvantages as well: 1. the need for reconstruction of nasolacrimal system; 2. horizontal scar across the temple; 3. neurorrhaphy of the forehead branch of the facial nerve; and
4. the need for temporary suture of lids postoperatively. The greatest advantage of this approach is in the direct access to a neoplasm in this area, previously accessible to surgery in only limited fashion. The ex cellent visualization and the potential for surgical con trol of important anatomic structures (carotid artery, optic nerve, or the facial nerve), as well as complete visualization of practically all surgical margins (the lat eral aspect of the sphenoid is reached with an osteotome) is the hallmark of this approach. Other advan tages include: 1. cheek soft tissues are pedicled at the level of the hard palate; 2. facial nerve is protected in a cheek flap, except for the frontal branch; 3. there are no visible infraorbital scars; 4. temporalis muscle is completely displaced inferiorly and is used for reconstruction; 5. there is a full access to infratemporal fossa and the petrous segment of internal carotid artery; and 6. the internal maxillary artery is easily controlled laterally before a tumor is manipulated.
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
418 JANECKA et al.
Fig. 6. A, Coronal computer tomography scan (CT) demonstrates involvement of left superior orbital fissure (arrow). B, Axial CT with tumor in left middle cranial fossa and cavernous sinus (arrows). C, Case 2. Resected angloflbroma through facial translocation approach (arrows; 6, 9,12 o'clock— pterygoid plates, orbital, and cavernous sinus tumor extent, respectively). D, Postoperative CT in coronal plane demonstrates an absence of tumor and density of transferred temporalis muscle (arrow). E, Axial CT with tumor-free left middle cranial fossa and cavernous sinus (arrows). Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base 419
SUMMARY
A new direct approach to the nasopharynx, clivus, superior orbitalfissure-cavernoussinus, infratemporal, and pterygopalatine fossae is presented. It permits an excellent access to a complex anatomic region with high degree of surgical control. The adequacy of surgical margins is verifiable in real-time.
6. Holliday MJ. Lateral transtemporal-sphenoid approach to the skull base. ENT J 1986;65:153-62. 7. Biller HF, Lawson W. Anterior mandibular-splitting approach to the skull base. ENT J 1986;65:134-41. 8. Jackson IT, Marsh WR, Bite U, Hide TAH. Craniofacial osteo tomies to facilitate skull base tumour resection. Br J Plast Surg 1986;39:153-60. 9. McGuirt WF, Browne JD. An anterolateral approach to the an terior skull base: case report of a malignant schwannoma of the pterygomaxillary space. OTOLARYNGOL HEAD NECK SURG 1986;
REFERENCES
1. Heatly CA. Expanding tumors of the maxillary sinus: value of lateral rhinotomy. NY State J Med 1951;51:2640-4. 2. Krespi YP, Sisson GA. Transmandibular exposure of the skull base. Am J Surg 1984;148:534-8. 3. Obwegeser HL. Temporal approach to the TMJ, the orbit, and the retromaxillary-infracranial region. Head Neck Surgery 1985; 7;185-99. 4. Kennedy DW, Papel ID, Holliday M. Transpalatal approach to the skull base. ENT J 1986;65:125-33. 5. Holliday MJ, Nachlas N, Kennedy DW. Uses and modifications of the infratemporal fossa approach to skull-base tumors. ENT J 1986;65:101-6.
95:87. 10. Sekhar LN, Schrann VL, Jones NF. Subtemporal-preauricular infratemporal fossa appraoch to large lateral and posterior cranial base neoplasms. J Neurosurg 1987;488-99. 11. Sofferman RA. The septal translocation procedure: an alternative to lateral rhinotomy. OTOLARYNGOL HEAD NECK SURG 1988;
98:18-25. 12. Gates GA. The lateral facial approach to the nasopharynx and infratemporal fossa. OTOLARYNGOL HEAD NECK SURG 1988;99:
321-5. 13. Fisch U, Mattox D. Microsurgery of the skull base. New York: Georg Thieme Verlag Stuttgart, Thieme Medical Publishers, Inc., 1988:382-6.
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Nasopharynx, clivus, and cavernous sinus are difficult regions of the cranial base in which to perform oncologie surgery. We have developed an approach to this area by using facial soft tissue translocation and craniofacial osteotomies. Surgical field ob tained at the skull base can extend from the contralateral eustachian tube to ipsilateral geniculate ganglion. It includes the nasopharynx, clivus, sphenoid, and cavernous sinus, as well as the entire infratemporal fossa and superior orbital fissure. Our expe rience with this technique in 12 patients is reported. All patients healed primarily, (οτοLARYNGOL HEAD NECK SURG 1990:103:413.)
I he success of surgical oncology is directly related to fornix through the conjuctiva to the lateral canthus, at the technical ease of obtaining clear surgical margins. which point it exits to meet the vertical bicoronal/preauricular incision. The cheek flap is reflected inferiorly This, in turn, is a reflection of a surgical approach. to the level of the hard palate after the elevation of the Direct correlation often exists between the complete maxillary periosteum and the masseteric fascia in a ness of exposure, adequacy of histologie margins, and downward fashion. patient outcome. The frontotemporal scalp flap is reflected toward the This article describes a new approach to the cranial midline after completion of the bicoronal and transtem base, using facial translocation. It offers excellent vi poral incision and an appropriate undermining. Cranio sualization and permits unhindered surgical manipula facial skeleton is exposed from the midline (forehead, tion at the anterior and middle cranial base as well nasion, nasal process of the maxilla, superior, lateral as related structures. The surgical field can extend and inferior orbital rims, maxilla, and the zygomatic from the contralateral eustachian tube to the ipsilat arch). Osteotomies of the orbitomaxillary skeleton eral geniculate ganglion and from the superior orbital fissure /cavernous sinus area to the level of the hard (Fig. 2) are performed to free the anterior face of the maxilla, malar eminence, zygomatic arch, and inferior palate. and lateral orbital rims, as well as the orbitalfloor.This METHOD permits an inferior translocation of the temporalis mus cle after an oblique subperiosteal osteotomy at the base An interiorly based cheek flap is developed on the of the coronoid process. A view available at this point facial and inferior labial vascular pedicles ( Fig. 1, A includes the posterior end of the nasal septum, begin and B). It includes the lateral third of the upper lip, the ning of the contralateral nasopharynx, posterior wall of entire cheek soft tissue (from the maxillary periosteum the maxillary sinus, pterygoid plates and muscles, and to the skin), lower lid, facial nerve, and the parotid the infratemporal fossa (Fig. 3). gland. The lip split incision begins at the vermilion A frontotemporal craniotomy is performed at this border and continues along the nasal ala and the lateral nose. It turns horizontally at the inner canthus, which time, identifying foramina spinosum, ovale, and rotunit transects. It continues at the depth of the inferior lid dum, as well as the superior orbital fissure. If control of the internal carotid artery is required, a decompres sion of the petrous portion of this vessel is performed (Fig. 4). From the Departments of Otolaryngology (Drs. Janecka and Arriaga) The tumor perimeter and its histology guide the threeand Neurosurgery (Drs. Sen and Sekhar), Eye and Ear Institute, dimensional tumor resection, which is well-controlled and the Center for Cranial Base Surgery (Drs. Janecka and Sekhar). because of the excellent visualization. Submitted for publication July 24, 1989; accepted Dec. 16, 1989. The reconstructive phase begins after tumor resection Reprint requests: Ivo P. Janecka, MD, Department of Otolaryngol and margin verification. Dura is repaired either primar ogy, Eye and Ear Institute—Suite 500, 203 Lothrop St., Pitts burgh, PA 15213. ily or with a graft. If orbital exenteration was done in 23/1/18870 conjunction with the superior orbitectomy, a pericranial 413 Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
414 JANECKA et al.
Frontal br. of facial n.
Infraorbital n.
Masseter transected) ransected frontal brs.of facial n. (tagged)
Mucosa (reflectei
unctiva
B
Transected infraorbital n.
Lower lid
Fig. 1. A, Outline of incisions used in facial translocation approach. B, Cheek and frontotemporal flaps are elevated.
flap is transferred to cover the durai repair. The temporalis muscle is freely mobile from its original position and can be placed over the pericranialflap,covering the anterolateral cranial base, sphenoid sinus, nasopharynx, orbit (if exenterated), space of previous maxillary sinus, and the pterygopalatine, as well as infratemporal fossa
regions. The temporalis muscle, facing the nasal cavity and nasopharynx, may be covered with free grafts of normal mucosa or can be permitted to be "remucosalized" by healing of secondary intention. The orbitomaxillary skeleton, removed during the approach phase, is replaced and affixed (2-0 braided
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base
415
Table 1. Clinical application of facial translocation approach—List of patients and tumors Case no./patient
Histology
Extent
Squamous cell carcinoma
Nasopharynx, infratemporal, pterygopallatine fossae, superior or bital fissure, cavernous sinus Lateral nasopharynx
Squamous cell carcinoma
Maxilla, pterygoids, orbit
Osteogenic sarcoma
Maxilla, orbit, pterygoids
10/KH
Chordoma
Maxilla, orbit, cavernous sinus, an terior/middle cranial fossae, sphenoid sinus
11/BA
Rhabdomyosarcoma
12/HB
Adenocarcinoma
Orbit, infratemporal fossa, sphenoid sinus, middle cranial fossa Maxilla, orbit, pterygoids
1/EM 2/JI 3/RG 4/RB 5/DC 6/CS 7/PS 8/MS 9/JL
Angiofibroma
nylon or mini-plates). A split cranial bone graft can be used to reinforce the orbital floor. Both lacrimai canaliculi and the nasolacrimal duct are stented with the use of silicon tubings (stents with pre-attached wire passers are available). These are left in place for several weeks postoperatively. The medial and lateral canthal ligaments are reapproximated and attached to a previously marked posi tion on the lacrimai bone. The inferior lid segment with orbicularis muscle is repaired, as is the inferior fornix conjuctiva. The frontal branch of the facial nerve is resutured. The infraorbital nerve may also be repaired if not compromised by the tumor. A short nerve graft can be considered here as well. The external soft tis sues, including the skin, are then reapproximated along the preoperative markings. Two horizontal mattress su tures over 5-mtn pieces of rubber band are placed through the upper and lower lid margins, which assist in precise anatomic healing of the lower lid incisions. They can be removed in 10 to 14 days postoperatively. A nasal stent is inserted in the ipsilateral nostril to protect the airway during the healing phase and also to prevent a potential medial bulging of the transferred temporalis muscle. It is removed within 7 to 10 days Postoperatively. RESULTS
Remarks
Both patients had unsuc cessful radiotherapy
Both patients are s/p bilateral retinoblastoma; (no. 9 - JL) final pathology ossifying fibroma
Fig. 2. Craniofaclal osteotomies permitting removal of orbitomaxillary complex.
Twelve patients were operated on using this approach (Table 1); four had squamous cell carcinoma (Fig. 5); This article focuses on the technical aspects of this approach and therefore a short followup (6 months) may two had osteogenic sarcoma, and one each had chor suffice to assess the surgical advantages, disadvantages, doma, rhabdomyosarcoma, and adenocarcinoma, re spectively. Three other patients had extensive angiofiand the degree of primary healing. Of course, no state ments can be made regarding the oncologie followup. bromas (Fig. 6, A through E). Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
416 JANECKA et al.
Turbinâtes o opposite side
Pterygoid p r o c e s s Outfractured coronoid process emporalis
Flg. 3. After transposition of temporalls muscle, Infratemporal fossa content and pterygoid region are seen.
Contents of sup. orbital fissure
ustachian tube o r i f i c e
Fig. 4. Frontotemporal cranlotomy completes superior exposure of the entire nasopharynx and related structures.
All patients healed per primum. Complications in cluded the need for replacement of one horizontal lidmargin suture several days postoperatively. In the same patient, the lacrimai stent came loose from its intranasal attachment and migrated out. As expected, the frontal branch function of the facial nerve has not recovered yet.
DISCUSSION
The facial translocation approach to the anterolateral skull base and related structures provides a direct access to a surgical territory extending from the contralateral eustachian tube along the posterior pharynx, clivus, anterior wall of the sphenoid sinus, through the ipsilateral pterygopalatine and infratemporal fossa, po-
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base 417
Flg. 5. Case 5. Appearance of facial scars 3 months postoperatively (arrows).
tentially up to the geniculate ganglion. The tumor spec imen may therefore contain the anterior wall of the sphenoid, lateral and posterior nasopharynx, pterygopalatine fossa content, pterygoid plates and muscles, and accompanying skull. The superior orbital fissure and the anterior/ inferior portion of the cavernous sinus may be included as well. The entire orbital content, as well as the hard palate, may be easily added to the specimen when necessary. Literature lists a number of approaches to various compartments of this region (e.g., nasopharynx, eli vus, sphenoid, pterygopalatine fossa, infratemporal fossa, etc.),113 but significant limitations in terms of possible complete tumor removal as well as surgical safety exist with all of them. The facial translocation approach we have described here has some disadvantages as well: 1. the need for reconstruction of nasolacrimal system; 2. horizontal scar across the temple; 3. neurorrhaphy of the forehead branch of the facial nerve; and
4. the need for temporary suture of lids postoperatively. The greatest advantage of this approach is in the direct access to a neoplasm in this area, previously accessible to surgery in only limited fashion. The ex cellent visualization and the potential for surgical con trol of important anatomic structures (carotid artery, optic nerve, or the facial nerve), as well as complete visualization of practically all surgical margins (the lat eral aspect of the sphenoid is reached with an osteotome) is the hallmark of this approach. Other advan tages include: 1. cheek soft tissues are pedicled at the level of the hard palate; 2. facial nerve is protected in a cheek flap, except for the frontal branch; 3. there are no visible infraorbital scars; 4. temporalis muscle is completely displaced inferiorly and is used for reconstruction; 5. there is a full access to infratemporal fossa and the petrous segment of internal carotid artery; and 6. the internal maxillary artery is easily controlled laterally before a tumor is manipulated.
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
OtolaryngologyHead and Neck Surgery
418 JANECKA et al.
Fig. 6. A, Coronal computer tomography scan (CT) demonstrates involvement of left superior orbital fissure (arrow). B, Axial CT with tumor in left middle cranial fossa and cavernous sinus (arrows). C, Case 2. Resected angloflbroma through facial translocation approach (arrows; 6, 9,12 o'clock— pterygoid plates, orbital, and cavernous sinus tumor extent, respectively). D, Postoperative CT in coronal plane demonstrates an absence of tumor and density of transferred temporalis muscle (arrow). E, Axial CT with tumor-free left middle cranial fossa and cavernous sinus (arrows). Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
Volume 103 Number 3 September 1990
Facial translocation: New approach to cranial base 419
SUMMARY
A new direct approach to the nasopharynx, clivus, superior orbitalfissure-cavernoussinus, infratemporal, and pterygopalatine fossae is presented. It permits an excellent access to a complex anatomic region with high degree of surgical control. The adequacy of surgical margins is verifiable in real-time.
6. Holliday MJ. Lateral transtemporal-sphenoid approach to the skull base. ENT J 1986;65:153-62. 7. Biller HF, Lawson W. Anterior mandibular-splitting approach to the skull base. ENT J 1986;65:134-41. 8. Jackson IT, Marsh WR, Bite U, Hide TAH. Craniofacial osteo tomies to facilitate skull base tumour resection. Br J Plast Surg 1986;39:153-60. 9. McGuirt WF, Browne JD. An anterolateral approach to the an terior skull base: case report of a malignant schwannoma of the pterygomaxillary space. OTOLARYNGOL HEAD NECK SURG 1986;
REFERENCES
1. Heatly CA. Expanding tumors of the maxillary sinus: value of lateral rhinotomy. NY State J Med 1951;51:2640-4. 2. Krespi YP, Sisson GA. Transmandibular exposure of the skull base. Am J Surg 1984;148:534-8. 3. Obwegeser HL. Temporal approach to the TMJ, the orbit, and the retromaxillary-infracranial region. Head Neck Surgery 1985; 7;185-99. 4. Kennedy DW, Papel ID, Holliday M. Transpalatal approach to the skull base. ENT J 1986;65:125-33. 5. Holliday MJ, Nachlas N, Kennedy DW. Uses and modifications of the infratemporal fossa approach to skull-base tumors. ENT J 1986;65:101-6.
95:87. 10. Sekhar LN, Schrann VL, Jones NF. Subtemporal-preauricular infratemporal fossa appraoch to large lateral and posterior cranial base neoplasms. J Neurosurg 1987;488-99. 11. Sofferman RA. The septal translocation procedure: an alternative to lateral rhinotomy. OTOLARYNGOL HEAD NECK SURG 1988;
98:18-25. 12. Gates GA. The lateral facial approach to the nasopharynx and infratemporal fossa. OTOLARYNGOL HEAD NECK SURG 1988;99:
321-5. 13. Fisch U, Mattox D. Microsurgery of the skull base. New York: Georg Thieme Verlag Stuttgart, Thieme Medical Publishers, Inc., 1988:382-6.
Downloaded from oto.sagepub.com at DALHOUSIE UNIV on June 5, 2016
