The Orbitozygomatic Craniotomy and Its Judicious Use : Operative Neurosurgery

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NEUROSURGICAL ATLAS SERIES

The Orbitozygomatic Craniotomy and Its Judicious Use

Cohen-Gadol, Aaron MD, MSc, MBA

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Operative Neurosurgery 18(5):p 559-569, May 2020. | DOI: 10.1093/ons/opz246

Abstract

Erratum

Panels B and C were added to the Model as indicated in the original legend.

DOI:10.1093/ons/opaa169

Operative Neurosurgery. 19(2):218, August 2020.

The orbitozygomatic craniotomy (OZ) (Video) involves an expansion of the pterional approach through osteotomy of various sections of the superior/lateral orbital rim/roof and zygoma. This additional bone removal broadens the subfrontal trajectory and can minimize the need for brain retraction to access the floor of the anterior and middle skull base and the parasellar and interpeduncular spaces.1-6 It also allows for an enhanced inferior-to-superior operative trajectory and working angles with flexible maneuverability and multidirectional degrees of operative freedom. Its judicious and selective or discriminate use is important for justifying the potential risk of cosmetic deformity and additional operative time associated with this skull base osteotomy.

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Multiple variations of the OZ involving different amounts of bone work have been described7-42 and the discussion below is an efficient technique. The most widely used and practical modifications are the “1-piece” and “2-piece” supraorbital osteotomies, which include limited resection of the zygoma. These modified variations involve mobilization of the orbital roof and rim as well as the frontal process of the zygoma.

In the 1-piece osteotomy (Figure 1), the frontotemporal craniotomy and supraorbital osteotomy are completed in 1 bone flap. In the 2-piece osteotomy, a traditional pterional craniotomy is first elevated, and then the supraorbital osteotomy is performed. The 1-piece frontotemporal craniotomy and supraorbital osteotomy (referred to as modified OZ) is the least disruptive and most efficient alternative and provides most of the advantages of all the other OZ variations; this approach, referred to simply as OZ, is the topic of discussion here (Model).

fig1
FIGURE 1.:
Shown are fundamental osteotomy locations for the 1-piece modified OZ. The first osteotomy A cuts across the orbital rim. The second osteotomy B disconnects the frontal process of the zygoma, and the last cut C is made across the roof of the orbit through an expanded keyhole. The “key” location of the keyhole for exposing the orbit and frontal dura is important for planning subsequent osteotomies. These bony cuts lead to disarticulation of the orbital rim, zygoma, and orbital roof. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

MODEL. A
A, The outline of osteotomies for the OZ are shown. The neural structures within the operative corridor are highlighted. The instructions for use of this model are as follows: please use the full-screen function for optimal visualization [by clicking on the arrows on the right lower corner of the model]. To move the model in 3D space, use your mouse\u0027s left-click and drag; to enlarge or decrease the size of the object, use the mouse\u0027s wheel. The right-click and drag function moves the model across the plane. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

MODEL. B
B, The completed osteotomy lines are shown. The neural structures within the operative corridor are highlighted. The instructions for use of this model are as follows: please use the full-screen function for optimal visualization [by clicking on the arrows on the right lower corner of the model]. To move the model in 3D space, use your mouse\u0027s left-click and drag; to enlarge or decrease the size of the object, use the mouse\u0027s wheel. The right-click and drag function moves the model across the plane. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

MODEL. C
C, The osteotomies and extent of exposure for the OZ are shown in 3-dimensional (3D) space. The neural structures within the operative corridor are highlighted. The instructions for use of this model are as follows: please use the full-screen function for optimal visualization [by clicking on the arrows on the right lower corner of the model]. To move the model in 3D space, use your mouse\u0027s left-click and drag; to enlarge or decrease the size of the object, use the mouse\u0027s wheel. The right-click and drag function moves the model across the plane. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

The patient provided written informed consent for the surgery shown in Video and Figures 6 and 9. Institutional review board/ethics committee approval was neither sought nor required for the data presented here.

Indications for the Modified OZ

Modifications of the OZ have been widely used for both vascular and neoplastic lesions within the orbital apex, paraclinoid and parasellar regions, cavernous sinus, and the interpeduncular and upper paraclival territories.1-6 Paramedian cranial base masses with tremendous superior extension can benefit from the expanded inferior-to-superior operative trajectory and from the medial-to-lateral operative working angles afforded by using the OZ pathway; OZ can mitigate the vector of retraction on the frontal lobes.

The judicious use of the 1-piece modified OZ for select lesions within the above-mentioned regions is recommended. A complete zygomatic osteotomy of the temporal portion of the zygomatic arch does not add to the exposure significantly.1,6 Compared to the standard frontotemporal transsylvian approach, previous studies have demonstrated, on average, an increased exposure of 26% to 39% (significant) via the addition of orbital rim osteotomy and an additional 13% to 22% (not statistically significant) via removal of the zygomatic arch.34 In fact, temporal zygomatic osteotomy can be redundant for exposure of most lesions and increases the risk of cosmetic deformity.

I do not routinely use the OZ for lesions that can be exposed through “extended pterional” craniotomy, which requires aggressive drilling of the roof of the orbit and lateral sphenoid wing; these 2 maneuvers expand the reach of the standard subfrontal pterional corridor43; this was just accepted for publication in Operative Neurosurgery).

More judicious and selective use of OZ is indicated for large lesions within the following:

  • the paramedian and midline parasellar regions extending superiorly into the third ventricular space (Figure 2) and
  • orbital lesions within the posterior one-third of the orbit.
fig2
FIGURE 2.:
A and B, This large medial sphenoid wing meningioma was resected via the modified OZ. The significant superior extension of the tumor required a steep inferior-to-superior intradural operative trajectory afforded through the orbital trim osteotomy. C and D, Similarly, this third ventricular craniopharyngioma was removed via the same approach through the lamina terminalis. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

These lesions are directly in line with the expanded operative corridor achieved by supraorbital osteotomy of the OZ. Figure 3 shows the structures in line with the osteotomy through the modified OZ.

fig3
FIGURE 3.:
A, The OZ provides an expanded trajectory toward the anterior sylvian fissure and the M1. B, This corridor remains expanded for the region of the carotid bifurcation and proximal A1. C, However, expansion of the operative trajectory is significantly less effective for lesions anterior to the chiasm because of the bulk of the orbital contents and medial orbital roof. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol, MD.

The softer indications involve giant anterior skull base meningiomas or anterior communicating aneurysms. As there is typically residual bone along the paramedian anterior skull base after completion of the OZ, the effectiveness of OZ for these lesions is diminished. The lesions within the cavernous sinus can potentially benefit from the modified OZ. The list of discriminate uses of OZ is relatively short and selective.

Preoperative Considerations and Pitfalls

Anterior skull base meningiomas can lead to hyperostosis of the roof of the orbit and lateral sphenoid wing; this finding should be evaluated with preoperative imaging. If the modified OZ is performed for the resection of a sphenoid wing and/or orbital meningioma, the osteotomy along the orbital roof should be conducted under direct vision and not blindly. Because of the increased thickness of the orbital roof, uncontrolled fracture of the roof and rim could extend as far as the optic canal and lead to optic nerve injury. Such a fracture can also involve the walls of the sphenoid and ethmoid sinuses and generate postoperative cerebrospinal fluid leakage (Figure 4).

fig4
FIGURE 4.:
Aggressive elevation of the orbitozygomatic or pterional bone flap without completely disconnecting it along the orbital roof or lateral sphenoid wing under direct vision should be avoided. Attempts to blindly fracture the bone flap at its margin at the hyperostotic lateral sphenoid wing in case of sphenoid wing meningioma can lead to an inadvertent extension of the fracture into the optic canal A or ethmoid sinus B and result in an optic nerve injury or unrecognized postoperative cerebrospinal fluid leak, respectively. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

Using a lumbar drain before performing an OZ should be considered, because dural decompression can protect the dura and the brain during OZ osteotomies. In addition, the lateral extent of the frontal sinuses should be studied with preoperative imaging. The risk of entry into the frontal sinus should not compromise adequate exposure. A computed tomography scan is not routinely obtained in expectation of an OZ craniotomy.

MODIFIED ORBITOZYGOMATIC CRANIOTOMY/OSTEOTOMY

The steps for completing an OZ osteotomy are summarized in Figures 5-15. The subfacial technique is applied for protection of the facial nerve branches. The superficial temporalis fascia is incised and reflected along with the fat pad.

fig5
FIGURE 5.:
The plane between the galea and the pericranium is developed in case a vascularized pericranial flap is needed at the time of closure. The scalp flap is reflected anteriorly and separated from the temporalis fascia. The belly of the no. 10 scalpel blade can be used to separate the pericranium from the galea. A, The fat pad is exposed. B, The plane between the galea and the pericranium is developed anteriorly until the subgaleal fat pad containing the frontotemporal (frontalis) branches of the facial nerve becomes visible. These branches are located in the superficial fascia of the fat pad, not within the fat pad itself. Therefore, one of two techniques for reflecting the fat pad without injuring these branches can be used: (1) the interfascial technique, in which the superficial temporal fascia is reflected anteriorly along with the fat pad via dissection underneath the fat pad but superficial to the deep temporal fascia; or (2) the subfascial technique, in which the superficial temporal fascia is reflected anteriorly along with the fat pad and the deep temporal fascia, all as one layer (this is my preferred method because it offers maximal protection for the facial nerve branches). This fat pad is usually located 2.5 to 3 cm posterior to the frontal process of the zygoma and the orbital rim. Bovie electrocautery is used to cut the deep temporal fascia and reflect the fat pad in the subfascial manner (see Video). With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig6
FIGURE 6.:
Subfascial technique. A, The 2 layers of the temporal fascia encasing the fat pad are incised to the level of the muscle fibers and parallel to the frontal zygomatic arch. This flap containing the fat pad and the nerve branches (inset) is elevated and reflected anteriorly along with the scalp flap. The pericranium medial to the superior temporal line is cut perpendicular to the superior temporal line. In other words, the cut along the superior temporal line should be made parallel to and in continuity with the cut used to elevate the fat pad, not perpendicular to it, in order to avoid any injury to the branches of the facial nerve. This maneuver reflects the subfascial flap and the pericranial flap medial to the superficial temporal line in 1 layer. B, Subperiosteal exposure of the zygoma is shown C. The deep temporalis fascia is fused along its anterior edge with the periosteum of the frontal zygomatic process. The subfascial dissection is continued anteriorly with subperiosteal dissection over the frontal zygomatic bone to achieve full exposure of the superior orbital rim and frontal zygomatic process. The pericranium over the frontal bone is also reflected anteriorly toward the orbital rim, and subperiosteal dissection is continued until the supraorbital nerve and notch are identified. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol, MD.
fig7
FIGURE 7.:
A, The superiosteal or subpericranial dissection is carried around the orbital rim and underneath the anterior roof of the orbit. Beyond the rim, the periosteum of the zygomatic and frontal bones blends into the periorbita. Blunt dissection is used to free the periorbita from the orbital rim lateral to the supraorbital notch. The periorbita is often adherent at the frontozygomatic suture. This attachment is dissected first, and then a blunt dissector is used to sweep over the periorbita from the inferior orbital fissure toward the supraorbital notch until the subperiosteal plane is well defined. B, The supraorbital nerve is often embedded within its notch but can be mobilized out of its groove with gentle blunt dissection. However, the nerve rarely owns its own foramen. If such a foramen is present, a straight small-caliber side-cutting drill bit is used to cut a halo of the orbital rim around the supraorbital nerve to allow for anterior mobilization of the nerve with its foramen without injury to the nerve (inset). With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig8
FIGURE 8.:
Next, the temporalis muscle is incised along its insertion at the superior temporal line and posteriorly parallel to the scalp-incision line. A, A myofascial cuff is left in place at the superior temporal line to allow for repair of the muscle at the time of closure. The muscle is then elevated in a subperiosteal manner using a periosteal elevator, starting at the zygomatic arch and working toward the superior temporal line. B, Two burr holes are needed to create an orbitozygomatic bone flap. Additional burr holes can be added, if necessary, to preserve the integrity of the dura. The first burr hole is placed immediately caudal to the superior temporal line, close to the posterior margin of the bony exposure. Note the use of fishhooks to maximally mobilize the soft tissues; the temporalis muscle is mobilized inferiorly rather than anteriorly. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig9
FIGURE 9.:
A, It is imperative to place the keyhole at the appropriate location and drill at the correct angle to expose both the periorbital and frontal dura through the expanded burr hole. Accurate creation of the keyhole facilitates execution of the 1-piece orbitozygomatic craniotomy and prevents excessive bone loss in the keyhole region and resultant cosmetic deformity. The keyhole is made approximately 7 mm superior and 5 mm posterior to the frontozygomatic suture (yellow arrow).6 The shaft of the drill is held at a 45-degree angle measured from the plane of the temporal bone. B, The supraposterior half of this burr hole exposes the dura of the anterior fossa, and the anteroinferior part exposes the periorbita (inset). C, The roof of the orbit divides these 2 compartments within the keyhole. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig10
FIGURE 10.:
The craniotome with a footplate attachment is now used for the craniotomy. The first bony cut starts within the supraorbital notch, where the small osteotomy was previously performed to release the nerve. Alternatively, and more commonly, the temporal burr hole can be used as the starting point. This cut stays superior to and follows the contour of the superior temporal line. If the supraorbital notch does not require drilling to release the nerve, the orbital rim osteotomy is conducted lateral to the notch by using a side-cutting drill bit. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig11
FIGURE 11.:
The footplate attachment is also used to create the inferior portion of the craniotomy. A, Starting at the temporal burr hole, the craniotome is directed inferiorly and then anteriorly until the progress of the footplate is stopped by the sphenoid wing. At this point, the drill is “turned around on itself” (steps 1 and 2) to expand the last few millimeters of the bony cut, creating enough space so that the footplate can be removed from the epidural space (step 3). B, Next, the footplate is replaced with a straight side-cutting B1 drill bit and the first orbital osteotomy is performed. This cut involves connecting the orbital portion of the keyhole to the previous exit point of the craniotome via an osteotomy along the lateral wall of the orbit and sphenoid wing. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig12
FIGURE 12.:
A, Next, the same straight side-cutting drill bit is used to cut the zygomatic process approximately 2 cm inferior to the frontozygomatic suture. A spatula protects the intraorbital contents. The last 2 osteotomies disconnect the frontal zygomatic process. B, The periorbita is further dissected away from the lateral orbital wall and the roof in preparation for the next osteotomy. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig13
FIGURE 13.:
A, A thin small osteotome is used to perform the final osteotomy along the orbital roof from the medial-to-lateral direction, starting at the osteotomy that was used to release the supraorbital nerve. The bone of the orbital roof can be very thin, and excessive force while using the mallet should be avoided. B, An alternative and preferred method for completing the orbital roof osteotomy involves the use of a small thin osteotome to cut across the roof of the orbit through the keyhole. Two cotton patties can be used to protect the frontal dura posteriorly and the periorbita inferiorly from the osteotome. It is important that the osteotome is angled toward the exit point of the supraorbital nerve. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig14
FIGURE 14.:
Once the craniotomy and the zygomatic and orbital osteotomies are complete, the 1-piece modified OZ bone flap is free and can be elevated carefully. If the frontal sinus is entered, its mucosa should be thoroughly curetted away/removed and the sinus packed with muscle and bone wax. The vascularized pericranial flap can be used for its coverage during the closure stage. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
fig15
FIGURE 15.:
Once the cranio-orbital bone flap is elevated, additional bone from the anterolateral aspect of the orbital roof is removed, and the lesser sphenoid wing is reduced further; a straight side-cutting B1 drill bit is used for this purpose. The orbital contents are protected. This small piece of orbital roof might not need to be replaced during closure A and B. Additional bony removal along the subfrontal corridor can be tailored on the basis of the location of the target lesion. An extradural clinoidectomy might be necessary for lesions around the proximal internal carotid artery along the skull base. The clinoidectomy provides an early decompression of the optic nerve at its foramen before the adjacent compressive tumor is manipulated. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

Usually, 2 to 3 cm of dissection over the periorbita is sufficient in expectation of the osteotomy along the orbital roof. If the periorbita is disrupted, intraorbital fat that herniates through the defect can be shrunken using bipolar electrocautery. Disruption of the periorbita leads to more pronounced postoperative periorbital edema and bruising.

Once the supraorbital nerve is released, it can be easily reflected inferiorly along with the pericranial flap and periorbita. The small osteotomy around the nerve can also be used as the exit point for the footplate of the craniotome at the time of the craniotomy.

This retrograde muscle dissection may permit better preservation of the subperiosteal layer containing the deep temporal arteries and nerves that nourish the muscle, which could minimize postoperative atrophy. The muscle is then retracted inferiorly, not anteriorly, to maximize its mobilization away from the subfrontal working zone.

The closure is conducted using standard cranial plates; the zygomatic arch is plated, and major defects in the bone in the areas anterior to the hairline are filled with cranioplasty material. In cases of intraosseous pathology and significant bone resection, titanium mesh can be used for minimizing the risk of cosmetic deformity. The roof of the orbit is not routinely constructed; we have not observed any incidence of enophthalmos with such a strategy.

Pearls and Pitfalls

  • Selective use of OZ is highly recommended. The modified OZ could be a good fit for high-riding lesions that extend superiorly within the parasellar/third ventricular/interpeduncular spaces and the posterior one-third of the orbit.
  • Accurate placement of the keyhole is important for successfully completing a 1-piece OZ.
  • Indiscriminate and blind fracture of the orbital roof should be avoided during exposure of an anterior skull base meningioma. Because of the resultant hyperostosis of the orbital roof, such a fracture could extend to the level of the optic canal and result in optic nerve injury.

Disclosures

The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.

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Acknowledgments

I appreciate the generous support of the Samerian Foundation for the completion of this work.

Keywords:

Craniotomy; Operative anatomy; Orbitozygomatic; OZ; Virtual reality

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