REVIEW Facial

Translocation

No P Janecka,

Chandra

for Cranial N Sen1), Laligam

N Sekhar1)

Base

Surgery

and Daniel W Nuss

Department of Otolaryngology and Neurological Surgery1). University of Pittsburgh,Schoolof Medicine, Pittsburgh, PA, USA (Received for publication on August 8, 1991) Abstract. The complexity of cranial base surgery is a reflection of skull base anatomy as well as technical demands for maximum visualization, control of essential structures, adequate tumor resection and/or reconstruction. Facial translocation has been developed as a new approach to cranial base. It consists of extensive modular facial disassembly which includes displacement of composite facial soft tissue flap and craniofacial skeleton. It creates surgical field with epicenter in nasopharynx and infratemporal fossa allowing easy expansion into sphenoid bone and cranial fossae as well as craniovertebral junction. Recon struction is functional and esthetic. Versatility of this approach permits expansion into neighboring crani ofacial regions. During a 14-month period (11/88-12/89), this facial translocation approach to cranial base was utilized in 20 patients. The approach provided excellent visualization of the involved cranial base permitting oncological as well as reconstructive procedures. All patients healed primarily. Two patients were reoperated on at 4 and 6 months postoperatively; one for a bone graft infection and the other for tumor recurrence. The facial translocation approach offers favorable exposure of the critical zones of cranial base resulting in increased surgical safety and benefit of cranial base surgery. (Keio J Med 40 (4): 215-220, December 1991) Key words:

skull base, craniofacial

skeleton,

tumor

resection,

Materials

Introduction

performed at the basi cranium. 1-6 Adequate visualization of the anatomic landmarks and essential neurovascular structures is a prerequisite for skull base surgery. The deep seated pathology of cranial base is surrounded by normal craniofacial anatomy. Its displacement forms, a foundation of surgical approaches to the cranial base. 7-14

We are presenting our approach to the cranial base which utilizes translocation of facial soft and osseous tissues. It permits direct, wide, and technically advan tageous exposure of nasopharynx, clivus, sphenoid and cavernous sinuses, as well as the middle and anterior cranial fossae. The craniovertebral junction and infra temporal fossa are also within this surgical field.

of Otolaryngology,

and

Methods

We have utilized this approach on twenty patients within a 14-month period (11/88-12/89). Their pathol ogy (Table 1) was primarily neoplastic. Three patients had spontaneous cerebrospinal fluid leak through defects in the middle cranial fossa into a well pneumatized sphenoid sinus (Fig 1). Their ages ranged from 6 to 80 years with median of 32 years. Most of the tumors produced symptoms of a space occupying lesion. The diagnostic work-up included CT and MRI scans. In patients with tumors in the proximity of internal carotid artery (ICA) and cavernous sinus (Table 1: 1-6, 11, 12, 15-17) (Fig 2a-c) an angiography, temporary balloon occlusion test (TBO) and Xenon blood flow studies were performed.15 This was done not only to ascertain the anatomic position of ICA and tumor blood supply but also to determine the importance of the ipsilateral ICA in case it had to be intraoperatively sacrificed, or clamped for a prolonged period of time. The temporary balloon occlusion test permits clinical assessment of a patient with balloon occluded ICA for 15 minutes. Neurosensory

Cranial base represents one of the most complex anatomical regions of human body. Its unique relation ship to the central nervous system as well as facial and cervical regions add additional dimension to surgery

Reprint requests to: Dr No P Janecka, Department treet, Suite 500, Pittsburgh, PA 15213, USA

reconstruction

Center for Cranial Base Surgery

215

, University

of Pittsburgh,

203 Lothrop S

216

Janecka

Table 1 Summary of Translocation Approach

Clinical

Information

on

Patients

Who

Underwent

IP , el al: Facial

Translocation

Facial

Pts-patients CS-cavernous ICA-internal CSF-cerebrospinal

sinus carotid

artery fluid

and higher cortical functions are tested during that time. Xenon blood flow studies are also carried out with ICA occluded. The special CT software permits digital readout of cerebral perfusion in cc/min/100gm of brain tissue in several mirror image zones of anterior, middle and posterior areas of cerebral hemispheres (Fig 3). It has been estimated that with cerebral bolld flow at or

above 35cc/min permanent occlusion of ICA would have only a minimal chance for a significant neurological deficit (5). The facial translocation approach is designed to have three parts. The first part includes the development of a composite facial soft tissue flap (Fig 4a,b) extending from paranasal to pre-or post-auricular area in a hori

Keio J Med 40 (4): 215-220,

1991

217

Fig 2a MRI scan demonstrating a superior extension of an angiofibroma to the proximity of internal carotid artery (ICA); (T=tumor; E=Eye). Fig 1 Coronal CT scan (bony algorithm) demonstrating a defect in the right middle cranial fossa (arrow) with communication into the sphenoid sinus(S) with its pterygoid extension(P).

zontal plane and from lower lid margin, suprazygomatic soft tissue to the level of hard palate and craniovertebral junction in a vertical plane. It contains all facial soft tissues including facial nerve and facial muscles. The deep plane of dissection is at the level of maxillary zygomatic periosteum and below the masseteric facia. The main trunk of the facial nerve may be dissected to the bifurcation. If complete dissection of the infra temporal fossa must be performed the upper cervical ICA is dissected free following separation of the deep lobe of the parotid gland, styloid muscles and ligaments. The temporo-mandibular joint (TMJ) can be resected if needed. The raised soft tissue flap protects all facial nerve divisions except for the frontal branch. We elec tively transect this segment just above the zygomatic arch. It is done following identification of all branches (and we have found 3-6 separate nerves in the supra zygomatic region) with EMG controlled electrical simu lation. The infraorbital nerve as well as lacrimal draining

Fig 2b Coronal MR outlining tumor (T) extent (left nasopharynx, cheek, maxillary sinus and temporal fossa).

Fig 2c More posterior coronal cut than 2b with tumor (T) filling the sphenoid (S) and left cavernous sinuses (CS) as well as infra temporal fossa, cheek, and nasopharynx.

Fig 3 Xenon-enhanced CT with digital read out (bottom) of mirror image zones (circles) in both hemispheres.

218

Fig

Janecka

4a

Schematic

composite facial facial translocation

system

outline flap used approach.

of

Fig 4b

Elevated

facial

flap.

in

has to be temporarily

interrupted

Raised

pericranial

flap.

osteotomics approach.

used

as well.

The second phase of the translocation approach involves elective osteotomies (Fig 4c) permitting dis placement of craniofacial skeleton. Further removal of lateral nasal wall and pterygoids as well as inferior displacement of temporalis muscle reveal the content of the infratemporal fossa, nasopharynx, clivus and craniovertebral junction. At this point, surgery can be performed for pathology in these areas as well as the sphenoid and cavernous sinuses. Also, the middle and anterior cranial fossae are accessible with addition of appropriate craniotomies (Fig 4d). The third phase of translocation approach is the reconstruction. It begins with dural repair, either primary suture or with a graft. Pericranial flap and temporalis muscle are the primary soft tissue vascularized flaps utilized for reconstruction. A subperiosteal osteotomy of the coronoid process done initially to increase the exposure of the infratemporal fossa also permits easier muscle rotation (Fig 5a,b). This temporalis muscle can reach the opposite paramedian cranial base structures permitting dural coverage and its separation from nasopharynx. It also fills the space of exenterated maxil lary sinus. Useful mucosal flap from the lateral nasal

Fig 5a

Fig 4c Facial in translocation

Fig 5b Left temporalis muscle being rotated into the surgical defect (M=muscle; LL=lower lid; arrow=LeFort I osteotomy).

IP , et al:

Facial

Translocation

Fig 4d Exposure achieved with facial translocation approach: Anterior and middle cranial fossac, superior and inferior orbital fissures, sphenoid and cavernous sinuses, nasopharynx, clivus, infratemporal fossa, TMJ, and cranio-vertebral junction.

wall allows quick mucosal coverage of exposed muscle in the lateral nasal region. This increases chances for preservation of nasal airway (Fig 6a, b). The temporarily removed craniofacial skeleton (Fig 7) is replaced and affixed. The original osteotomies are done in a key keyhole pattern to increase the postoperative stability as well as precision of bony contours. Orbital floor is reexamined for stability and completeness. A thin bone graft from the lateral wall of the maxillary sinus is useful for reinforcement of the orbital floor if necessary. The preserved infraorbital nerve is passed through a widened infraorbital foramen and sutured to its distal counterpart in the cheek flap (Fig 8). At this point medial canthoplasty is performed as well as lacrimal stenting. The transected orbicularis muscle is reapproximated at the lateral canthus as are the frontalis branches of the facial nerve in the suprazygomatic region. The suture of the conjunc tiva of the inferior fornix, temporary tarsorrhaphy and skin closure complete the reconstructive phase. A free abdominal fat graft can be used to lessen the temporal fossa depression resulting from the transferred temporalis

Fig 6a Endoscopic view of pre served left nasal airway; left lateral wall consists of mucosa covered temporalis muscle (S-nasal septum).

Fig 6b Coronal MR with con trast demonstrating placement of temporalis muscle (M) in the right infratemporal fossa without compromising nasal airway (arrow).

Keio J Med 40 (4): 215-220,

Fig 7

An example

219

1991

of temporarily

removed

craniofacial

skeleton

permitting chordoma resection (K.H.). Tumor involvement necessi tated resection of cavernous sinus, internal carotid artery, left orbital exenteration and subtotal maxillectomy. Malar eminence had an onlay bone graft.

Fig 9 Patient demonstrating neurorrhaphy of left frontal facial

Fig 8

muscle. to protect

Neurorrhaphy

Also

a silicone

nasal

of left infraorbital

nasal

stent

nerve (arrow).

is used

postoperatively

airway. Results

All twenty patients have healed primarily. Two patients required reoperation within 4-6 months post operatively. One for infection of cheek bone graft and the other for what proved to be a tumor recurrence (K.H.). The recovery of frontal branch function appears to require about 8 months. All of our patients have regained frontalis muscle function (Fig 9). The degree of recovery have ranged from 70-100% as compared to the opposite side. The lacrimal drainage remained satisfactory (no subjective complaints of epiphora) in a majority of patients following stent removal. Only 2/20 patients required revision dacryocystorhinostomy. The appearance of facial scars, the lower lid position, and medial and lateral canthus, have been satisfactory. The

translocation

raised branches

eyebrow 9 of the facial

months following nerve used in left

procedure.

nasal airway has remained functional in all patients except one who required release of intranasal scars. This stenosis occurred before we implemented nasal mucosal flap for coverage of the intranasal surface of the trans ferred temporalis muscle. The protective and fine sen sation in the infraorbital nerve distribution has also returned to within one to two cm2 of skin over the infraorbital foramen. Five patients had the infraorbital nerve resected for ontological reason. The masseter muscle function has also returned (measured by external palpation only) in spite of absence of direct suturing of this muscle to the zygomatic arch and maxilla. Careful bony and soft tissue approximation and hematoma prevention, with key placement of vacuum drains, may have helped in the correct muscle reattachment. The fate of the free fat graft in the temporal fossa was directly evaluated in only two patients who were re-explored. The viable fat appeared to be present at 4 and 6 months following the original placement . In the other patients only external appearance of the temporal fossa could be judged. It seemed that at least 50% of the depth of the temporal fossa remained obliterated (? fat;

220

Janecka

? scar) at 14 months. Patients' occlusion following resec tion of TMJ stabilized within several postoperative weeks. First, patients reported malocclusion but with exercises their occlusion returned to pre-surgical pos ition. Five of our patients had TMJ resected and none required night splinting.

Only very early ontological data are available. 3/13 patients with malignant tumors died of their disease within 6, 8, and 21 months postoperatively . 12/13 of these patients had gross total resection, 8/12 patients had primary surgery for their tumor and 4/12 underwent salvage procedure. In all but one patient who underwent primary oncological procedure local control of the disease has been achieved (7/8); one other patient was free of local disease but developed spinal metastasis. In the group where salvage cranial base surgery was performed (4/12), one patient in NED, 2 DOD at 8 and 21 months, and one developed local recurrence at 9 months. The average follow-up for this group of patients has been 13 months. Discussion Selection related

of

to the

a surgical

location

with

the hope

of preserving

and

esthetics

of the

location

of

modular

disassembly

bony

the

tissues.

of the

at the

complimentary.

It is true

skull that

canthus with

elective nerve

more

frontal

the

impact

ical

preservation

The

requires

branches

frontal

of

the

nerve of

does

a permanent described

these

guarantee does

translocation

occur

the

for return

in

frontalis there approach

10.

gain with

11. 12.

of frontalis

neurorraphies nerve

9.

facial

at the skull

in patients

transection.

not

of The

of the

However,

branches

8.

pro

procedures.

facial

7.

is, however,

manipulation

loss

control

interruption This

multiple

6.

approach

branches

Potential

5.

and

surgical

especially

of the

3.

reconstruction

apparatus.

through

2.

for

soft

permits

orbito-maxillary

problems.

function

the

tion;

which

approach

important

demands

unhindered

of surgical

1.

anatomic

translocation

to be a disadvantage.

life-threatening

approaches10

the

sequential

of the

and ease far

muscle

the and

deep

of

further

lessens

Even

anatom

other

surgical

muscle

func

as well. also

permits

Translocation

References

directly

pathology

craniofacial

The

medial

appears are

of

and lacrimal

most

in visibility base

this

be

the function

The

heightens

exposure

base.

transection

field.

normal

structures

is then

true

of goal

cedure

medial

base

thorough

essential

should of patient's

or re-establishing

operative

skull The

is to achieve

approach

Facial

further surgical expansion medially and laterally as well as superiorly and inferiorly. This adds to the versatility of this approach. Our follow-up is, of course, too short for assessment of oncological benefits of this approach. At this time the significantly increased visualization and relative ease of control of vital structures at the cranial base, in a single surgical field, are the main advantages of this approach. It is anticipated that this will be eventu ally reflected in increased incidence of oncologically clear surgical margins and thus an improved disease free statistics for our patients.

4.

and nature

IP , et al:

13. 14. 15.

Smith RR, Klopp CT, Williams JM: Surgical treatment of cancer of the frontal sinus and adjacent areas. Cancer 7: 991-994, 1954 Ketcham AS, Wilkins RH, Van Buren IM, Smith RR: A com bined intracranial facial approach to the paranasal sinuses. Am J Surg 106: 698-703, 1963 Shah JP, Sundaresan N, Galicich J, Strong EW: Craniofacial resections for tumors involving the base of the skull. Am J Surg 154: 352-358, 1987 Jackson IT, Somers P, March WR: Esthesioneuroblastoma: Treatment of skull base recurrence. Plast Reconstr Surg 76: 195-201, 1985 Sekhar LN, Moller AR: Operative management of tumors involving the cavernous sinus. J Neurosurg 64: 879-889, 1986 Janecka IP, Sekhar LN: Surgical management of cranial base tumors: A report on 91 patients. Oncology (Williston Park) 3: 69-74, 1989 Fisch U, Pillsbury HC: Infratcmporal fossa approach to lesions in the temporal bone and base of the skull. Arch Otolaryngol 105: 99-107, 1979 Sekhar LN, Schramm VL, Jones NF, Yonas H, Horton J, Latchaw RE, Curtin H: Operative exposure and management of the petrous and upper cervical internal carotid artery. Neurosurgery 19: 967-982, 1986 Derome PJ: Transbasal approach to tumors invading the base of the skull. In: Operative Neurosurgical Techniques, Schmidek HH, Sweet WH, cds, Grune and Stratton, San Diego, 1982, 357 Sekhar LN, Janecka IP, Jones NF: Subtemporal-infratemporal and basal subfrontal approach to extensive cranial base tumors. Acta Neurochir 92: 83-92, 1988 Casson PR, Bonanno PC, Converse JM: The midface degloving procedure. Plast Reconstr Surg 53: 102-103, 1974 Jackson IT, Marsh WR, Bite U, Hide TA: Craniofacial oste otomies to facilitate skull base tumour resection. Br J Plast Surg 39: 153-160, 1986 Lauritzen C, Vallfors B, Lilja J: Facial disassembly for tumor resection. Scand J Plast Reconstr Surg 20: 201-206, 1986 Krespi YP, Sisson GA: Transmandibular exposure of the skull base. Am J Surg 148:534-538, 1984 de Vries EJ, Sekhar LN, Horton JA, Eibling DE, Janecka IP, Schramm VL Jr, Yonas H: A new method to predict safe resection of the internal carotid artery. Laryngoscope 100: 85-88, 1990