Abstract
The frontal–nasal–orbital craniotomy has been utilized for craniofacial abnormalities and resection of tumors involving the anterior skull base. We describe modifications of this technique to approach extra-axial and intradural midline lesions of the anterior fossa with or without involvement of the skull base. A craniotomy was planned with an endoscope and image guidance. A modified frontal–nasal–orbital craniotomy encompassing the entire frontal sinus complex was performed in conjunction with osteotomies incorporating the bilateral superior orbital ridges and nasal septum. Removal of the posterior wall of the frontal sinus was completed if necessary. Dural repair and final reconstruction are detailed. Our initial experience using this approach in five patients harboring lesions of the anterior skull base resulted in adequate exposure of the targeted pathology. There were no complications of the procedure. Cosmetic results were acceptable. We present a detailed account of this procedure via photographs and a video. The frontal–nasal–orbital craniotomy provides access to the floor of the anterior fossa while avoiding excessive brain retraction associated with facial incisions. In addition, this approach is associated with a lower incidence of complications, such as CSF leak, brain retraction edema, or infection. The frontal–nasal–orbital craniotomy is a useful technique for midline lesions of the anterior skull base, and it should be in the armamentarium of neurological surgeons.
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Federico G. Legnani, Francesco DiMeco, Milan, Italy
In this study, the authors extensively described pro et contra of a modified approach for resecting midline lesions of the anterior cranial fossa with involvement of the skull base. The subcranial approach proposed provides access to the floor of the anterior fossa while avoiding excessive brain retraction and facial incisions. The presence of an intra-operative endonasal endoscope is of aid in tumor resection, especially for the components that extend posteriorly into the sphenoid sinus or inferiorly into the nasopharynx.
We agree with the authors’ attitude advocating aggressive tumor resection. In our Institution, in collaboration with the Istituto Nazionale Tumori, Milan, we probably have the largest mono-institutional series in the world. Our surgical technique is based on a classic transcranial and transfacial combined approach. We perform surgery in close cooperation with a maxillo-facial surgeon, allowing us to perform a standard anterior craniofacial resection as a routine operation lasting usually less than 3 h. We use loupes and microscope without endoscope. We established this final technique after more than 400 cases over 22 years. The choice of a combined approach comes from the need of an “en block” gross total resection that we demonstrated being a relevant variable on patients’ survival.
Even though the modified approach proposed in this study has been performed on a small number of cases, this novel technique should be considered as an option for lesions involving this anatomic region, and it should be included within the armamentarium of skull base surgeons.
The paper is interesting and well written, and clarifies its clinical relevance; therefore, we feel that it can be a great contribution to the literature. A larger case series with a longer follow up is needed to evaluate the role of this modified approach on patients’ survival and quality of life.
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Frontal–nasal–orbital craniotomy. A compilation of video clips from different operative cases demonstrating the various steps of the approach (MOV 136 mb)
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Raza, S.M., Conway, J.E., Li, K.W. et al. A modified frontal–nasal–orbital approach to midline lesions of the anterior cranial fossa and skull base: technical note with case illustrations. Neurosurg Rev 33, 63–70 (2010). https://doi.org/10.1007/s10143-009-0222-4
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DOI: https://doi.org/10.1007/s10143-009-0222-4