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A surgical modification for performing orbitozygomatic osteotomies: technical note

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Abstract

The addition of orbitozygomatic osteotomies to the fronto-temporo-sphenoidal craniotomy minimizes brain retraction required to reach deep seated pathology by allowing additional soft tissue dissection and strategic cranial bone removal. We report a modification of this technique in order to reduce soft tissue and cosmetic morbidity while increasing the efficiency with which this technique is performed. A two piece fronto-temporo-sphenoidal craniotomy combined with orbitozygomatic osteotomies was analyzed via cadaver dissection. The craniotomy and orbitozygomatic osteotomies were performed using the foot plate of the craniotome to facilitate the orbitozygomatic osteotomies. A similar technique was utilized in the operating room to safely create the two piece fronto-temporo-sphenoidal craniotomy and orbitozygomatic osteotomies in a series of patients. The illustrated technique was performed in cadavers and the results were analyzed in a series of 18 consecutive patients with minimum 3-month follow-up. Increased efficiency, good tissue preservation, and minimal soft tissue damage with no orbital injury were noted with a high rate of gross total lesional resection. With the added safety of a cutting instrument separated from the orbital soft tissues by a footplate, tissue trauma was minimized. Orbitozygomatic osteotomies are frequently added to the fronto-temporo-sphenoidal craniotomy in order to reach intracranial pathology that would previously have required excessive brain retraction to address. This manuscript details the use of a single drill system that can be used for both the craniotomy and the safe and efficient generation of orbitozygomatic osteotomies.

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Authors and Affiliations

  1. Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA

    James E. Conway, Shaan M. Raza, Khan Li & Alfredo Quiñones-Hinojosa

  2. The Johns Hopkins Neuro-Oncology Surgical Outcomes Laboratory, The Johns Hopkins University School of Medicine, Baltimore, USA

    James E. Conway, Shaan M. Raza, Khan Li & Alfredo Quiñones-Hinojosa

  3. Department of Neurosurgery, University of California, San Francisco, San Francisco, USA

    Michael W. McDermott

  4. Department of Neurosurgery, Johns Hopkins University, 4940 Eastern Ave/ B 121, Baltimore, MD, 21224, USA

    Alfredo Quiñones-Hinojosa

Authors
  1. James E. Conway
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  2. Shaan M. Raza
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  3. Khan Li
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  4. Michael W. McDermott
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  5. Alfredo Quiñones-Hinojosa
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Correspondence to Alfredo Quiñones-Hinojosa.

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Comments

Rasha Germain, Robert F. Spetzler, Phoenix, Arizona, USA

The authors are to be congratulated on this well-written, organized description of the use of a single drill system for creating a full orbitozygomatic craniotomy. They demonstrate excellent results in terms of cosmesis, efficiency, and surgical outcomes using the drill router/footplate and 5-cut craniotomy. It is well known that the orbitozygomatic approach greatly increases the working area and angle of attack for many lesions of the anterior and middle fossae as well as for the basilar apex.

At our institution, the preference has been to strictly tailor the craniotomy to the working area of interest. Hence, most surgeries are performed using “modified orbitozygomatic” approaches. A primarily “supraorbital variation” is used to access the anterior and middle fossae and proximal sella, and a “subtemporal variation” is occasionally used for greater exposure of the subtemporal middle fossa. Furthermore, we use the reciprocating saw to create narrower gauge cuts in the bone for our orbitozygomatic portion of the craniotomy. The authors’ clear descriptions and illustrative figures and diagrams make this article an excellent addition to the body of literature on skull base approaches.

Bernard George, Paris, France

This is a very nicely illustrated paper on the technique of orbitozygomatic deposition. In spite of a too extensive use by some neurosurgeons, this technique has kept a great interest in some indications. This is not really a mini-invasive procedure but it provides a more anterior and inferior approach to the skull base.

The technique here shown is probably already used by many but has not been described very clearly in the literature yet. The main advantage is not in the number of osteotomies but in the fact that it can be realized by a single drill system (the same footplate as the one used for the first step: the fronto-temporal bone flap). Operative photographs and schematic drawings are very demonstrative and will help a lot the beginner as well as the experienced surgeon to follow and to apply the technique description.

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Conway, J.E., Raza, S.M., Li, K. et al. A surgical modification for performing orbitozygomatic osteotomies: technical note. Neurosurg Rev 33, 491–500 (2010). https://doi.org/10.1007/s10143-010-0274-5

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  • DOI: https://doi.org/10.1007/s10143-010-0274-5

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