Avoiding Facial Incisions: Combined Transcranial-Transfacial Approaches to the Skull Base

Introduction: Combined craniofacial approaches to the midline skull base have traditionally relied on transfacial techniques to expose aspects of the cranial base not accessible by standard craniotomies. These transfacial approaches have typically been performed via facial incisions and superficial soft tissue flaps for supplementary exposure. The introduction of endoscopy and an improved understanding of cranial base anatomy now permit similar approaches to be done without facial incision. We present our experience with the single-stage combined craniofacial technique without any visible facial incisions for select skull base pathology.

Methods: Between 2006 and 2010, a single-stage combined approach was performed in 14 patients for the following indications: esthesioneuroblastoma (2 patients), meningoencephalocele (2 patients), mucocele (3 patients), chordoma (1 patient), gliosarcoma (1 patient), juvenile angiofibroma (1 patient), and CSF leak (4 patients). Cranial approaches utilized consisted of: extended bifrontal craniotomy, subcranial craniotomy, or transorbital approaches (transpalpebral or transconjunctival incisions). Transfacial approaches performed included endoscopic endonasal or midfacial degloving for maxillectomy.

Results: In 13 of 14 patients, surgery was considered successful (gross total resection/negative margins or no CSF leak recurrence); subtotal resection was performed in 1 patient. Wound infection encountered in one patient was an ischemic pericranial graft, but no neurologic or cosmetic complications were noted.

Conclusions: Craniofacial approaches to the midline skull base can now be performed without the need for facial incisions for select pathology not involving superficial structures. Improvements in endoscopy and understanding of cranial base anatomy and the goals of surgery have enhanced access of transfacial approaches while allowing them to become more minimally invasive. In combination with traditional or keyhole craniotomies, circumferential access to the anterior skull base can be obtained. By providing transcranial and transfacial access, combined techniques permit safe dissection and thorough dural and bony reconstruction with a low complication rate.