A Modification to the Transfacial Approach for Large Middle Cranial Base Tumors: A Technical Report

Background and Objective Extensive tumors of the clivus, anterior skull base or anterior brainstem are technically challenging to skull base surgeons. Numerous open approaches have been described to resect extra or intra-dural lesions but some provide limited exposure or cause functional dysfunctions. We present a technical report on a new transfacial approach to the midline cranial base that provides exposure from the rostral frontal sinus to the inferior clivus. This new approach is a modification from the classic Weber-Fergusson incision with maxillary swing. It allows an optimal exposure for tumor resection without the morbidity associated with a maxillectomy. A small case series of patients in whom this approach was used will be reviewed. Surgical Technique Bilateral subciliary incisions are joined on the glabela and a midline nasal incision is drawn down to the lip. The lip is split to expose the maxillary alveolar process. The nasal cavity is entered lateral to the quadrangular cartilage, between the alar cartilages. The nasal bones and maxilla are exposed with limited soft tissue dissection through the subciliairy incisions. Both frontal process of the maxillary and alveolar process are osteotomized to create a rectangle opening on the anterior wall of both maxillary sinuses. The lateral limit of the osteotomies is the infra-obital nerve. The nasal septum and vomer are detached from the maxillary crest. This allows the anterior wall of the maxillary with the attached half-nose to be swung laterally up to the infra-orbital nerve. The resulting exposure is a bilaterally widened pyriform aperture with direct exposure to the ethmoids, maxillary sinuses, nasopharynx and clivus. After tumor resection and skull base reconstruction, the anterior maxillary wall and nose are swung back medially. Because no soft tissue dissection was performed, the periostum remains attached to the maxilla. Osteotomies are approximated with the closure of the facial soft tissues without the need of plates and screws. Results: This technique was used to approach a large clival chordoma in a 56 year old woman. Endoscopic approaches combined to radiotherapy had previously failed. The exposure allowed for total removal of the clival tumor under microscopic vision. A pericranial flap was used to reconstruct the skull base. The post operative period was noticeable for a CSF leak that was surgically occluded. Patient was discharged home and remains free of gross residual disease 8 months later. A unilateral modification of this approach was used during a craniofacial resection in a 21 year old male with an extensive sarcoma involving the maxillary, ethmoid and anterior cranial base. The orbit was preserved and the patient had a complete functional recovery after the procedure. Conclusion: This trans-facial approach allows for very large exposure to the ethmoids, maxillaries, nasopharynx and clivus. It compares favorably to other open approaches in functional and aesthetic morbidity. The dissection can be performed uni or bilaterally depending on the involved tissues. It has the benefit of providing better exposure for en-block resection with a wide bilateral trans-facial view.

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