02.04 - Aesthetic Considerations in Cranial Neurosurgery PDF

Neurosurg Clin N Am 13 (2002) ixx
Preface
Aesthetic considerations in cranial neurosurgery
Christopher A. Bogaev, MD
Guest Editor
There is no question that the attention of a

neurosurgeon should be focused on the pathologic
ndings at hand when treating intracranial disease.
This includes designing the safest approach that
provides the necessary exposure to treat the pathologic ndings adequately. Although a secondary
consideration is the patients appearance after
having an operation for a life-threatening condition, it is a consideration nonetheless. For many
patients undergoing elective procedures, this is
quite a prominent consideration.
Too many neurosurgeons ignore the cosmetic
aspect of their surgery. This issue is extremely
important, however, because more than ever in
neurosurgery, the quality-of-life issues and morbidity of surgery are prime considerations in
patients discussions regarding open surgical treatment versus alternative treatment, such as radiosurgery, when they have a choice. With modern
drill and instrument technology as well as contemporary imaging techniques, unnecessarily disguring neurosurgical procedures should be a thing of
the past. The goal of this issue of Neurosurgery
Clinics of North America is to discuss the myriad
of contemporary neurosurgical techniques that
exploit the newer drill and instrument technology
to provide the same tumor resection and preservation of critical structures but, at the same time,
have the patient appear as though he or she has
had no operation at all. Included in this issue is
the design of scalp incisions; scalp aps; minimal
hair-shaving techniques; craniotomy ap design

minimizing bone loss and cosmetic deformity;
reconstructive techniques, including newer materials such as hydroxyapatite cement; and craniofacial osteotomies for additional exposure with
the preservation of normal facial contour once
the reconstruction is performed.
As is the case with other areas of neurosurgery, neurosurgeons can gain valuable technical information and expertise from other related
disciplines, such as orthopedic surgery for spinal
instrumentation and otolaryngology for skull base
surgery. In this issue, signicant contributions
are presented by plastic surgeons who are experts in craniofacial, esthetic, and reconstructive
surgery.
Some neurosurgeons are not aware of all
these techniques and their implications in relation
to patient satisfaction after a neurosurgical procedure. A prime example from my personal experience involved two patients, one of whom
had undergone tumor resection using techniques
with an eye toward the esthetic result, where there
was no postoperative cosmetic deformity, and a
second patient who had a similar tumor resected
but whose head was completely shaved and who
had an obvious craniotomy defect in her forehead with atrophy of her temporalis muscle. These
two patients had their follow-up MRI scans on
the same day, and once they realized that they
had almost identical tumors resected by dierent
1042-3680/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.
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C.A. Bogaev / Neurosurg Clin N Am 13 (2002) ixx
surgeons using remarkably dierent techniques,

the second patient was extremely disappointed with
her result, despite the same functional outcome.
Minimally invasive techniques in neurosurgery
are gaining popularity as well as utility. This same
attitude should be carried over to large tumors
requiring large operations, in that the use of the
techniques discussed in this issue can help to reduce the cosmetic deformity resulting from these
procedures and increase patient satisfaction and
quality of life. The more that morbidity is reduced
from a neurosurgical procedure and the quicker
that patients are returned to mainstream daily
living that includes not attracting attention in a
crowd from a cosmetic deformity, the more patient satisfaction will improve. This can be a major factor when patients are weighing treatment
options, such as radiosurgery versus open surgery.
If they know that the tumor can be removed and
that they will look the same as they did before

surgery soon after surgery, the choice for surgery,
if it is indicated, may be easier for them and less
anxiety provoking.
The topic of this issue represents a relatively
overlooked but increasingly important area of
neurosurgery. Hopefully, this issue will bring
this topic to wider attention and spark further
discussion and development of these issues and
techniques.
Division of Neurosurgery
University of Texas Health Science Center
at San Antonio
4410 Medical Drive, Suite 610
San Antonio, TX 78229-3798, USA
E-mail Address: CAB@neuroassocsa.com
Neurosurg Clin N Am 13 (2002) 401403
The cosmetic aspects of neurosurgery

Laligam N. Sekhar, MD*
Mid-Atlantic Brain and Ear and Spine Institutes,
3301 Woodburn Road, Suite 202, Annandale, VA 22003, USA
Advances in neurosurgical operative techniques and instrumentation have resulted in great

improvement in patient outcome after surgery. It
is important, however, for patients to return to
normal life. As explained in this article, recent
modications of neurosurgical techniques have
permitted patients to return to everyday life, and
attention needs to be paid to the cosmetic aspects
of neurosurgery.
Although the advances in neurosurgical operative techniques and instrumentation are achieved
with great improvement in patient outcomes after
surgery, considerable attention needs to be paid to
the cosmetic aspects of neurosurgery. For a neurosurgical patient to return to normal everyday life,
it is important that the patient looks as normal
or as close to normal as possible. Many recent
modications of neurosurgical technique have permitted this.
Skin incisions
Hair shaving
Cranial nerve problems
For most neurosurgical operations nowadays,

we shave just a strip of hair along the line of incision unless it is an area where the operative site is
completely covered by the patients natural hair
(ie, retrosigmoid craniotomy).
The hair in the skin ap that is being reected
can be divided into small locks and taped onto the
patients face or braided and taped. The hair itself
should be prepared in a sterile fashion in the surgical
eld. It is a good idea for the patient to have a good
hair shampoo the night before surgery.
It is important to avoid damaging cranial nerves VII and V (especially corneal numbness).
Obviously, damage to cranial nerves III and VI is
also of great cosmetic disadvantage. Cranial base
osteotomies should be planned in such a way that
the reconstruction is adequate to avoid cosmetic
problems. This is described later in this article.
* 3301 Woodburn Rd., Suite 202, Annandale, VA

22003, USA.
E-mail address: Lsekhar@aol.com (L.N. Sekhar).
Incisions made in the scalp should always be

made behind the hairline. This may represent a
problem in patients with receding hairlines. Additionally, the incision should respect the territory
of major arteries and veins that supply the scalp
(ie, the supercial temporal artery and the occipital
artery) so as to preserve the blood supply. In general, the base of the incision should always be much
wider than the apex to avoid skin necrosis. When
the incision is extended in the preauricular area, a
curve that follows the ear is followed to avoid recognition of the line of incision at a later time. The
human eye discerns a straight line much better than
a curved and broken line, and incisions that are
made in this fashion (curvilinear) are not really
visible. Additionally, incisions should be less than
0.5 cm in front of the tragus of the ear to avoid
damaging the frontalis branch of the facial nerve.
Temporalis muscle
When elevated from the temporal fossa, the temporalis muscle should be elevated as carefully as
possible to avoid damage to its blood supply and
its nerve supply. In most cranial base cases, we prefer to elevate the entire temporalis muscle to avoid
damaging it. If the muscle has to be split, it is split
along the bers so that it is not damaged. Damage
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L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403
to the motor branch of the temporalis muscle may

result in atrophy. A secondary reconstruction is
sometimes necessary after several months.
Craniotomy aps and reconstruction
When a craniotomy is performed, it is important that it be performed adequately without
dural tears, especially because many burr holes
and dural separation are performed as necessary.
When the craniotomy aps are reaxed, however,
we use the combination of titanium mesh and one
of the dierent types of bone cement (eg, Bone
Source cement; Leibinger Company, Freiburg,
Germany) to avoid a cosmetic deformity. Even
over burr hole sites, either burr hole covers or titanium mesh is used to avoid stinging, which is particularly bothersome to the patient. Microplates
should be avoided if possible in the forehead area.
Obviously, all precautions should be taken to avoid
infection of craniotomy aps so that the aps are
not lost.
Cranial base repair
It is important that cranial base operation repair
be performed meticulously using vascularized and
nonvascularized tissue. If the repair is not performed adequately, there is a possibility of epidural or
subdural infection, which may result in prolonged
hospitalization, death, or cosmetic problems.
unacceptable by the patient, subsequent plastic

surgery repair may be indicated.
Frontotemporal craniotomy
During frontotemporal craniotomy, we generally employ a preauricular and frontotemporal
incision, which extends up to or just beyond the
midline depending on the wound ap to be used.
We do not prefer any incisions in the eyebrow or
forehead, because these are quite unsightly in some
patients. When well healed, most frontotemporal
incisions are barley visible or not visible at all
sometimes even to the surgeon.
Orbital osteotomy
We prefer to perform an orbital or orbital zygomatic osteotomy in two pieces. It is easier to perform the osteotomy in this fashion. Additionally,
at least two thirds of the orbital roof and lateral
wall can be removed and replaced such that
endophthalmos can be prevented. If there is excessive loss of orbital bone because of tumor invasion,
secondary reconstruction using titanium mesh is
essential to avoid endophthalmos. In such patients, both eyelids should be sutured shut and
left visible in the operative eld so that they can
be checked at the end of the operation to make
sure that there is no pulsatile endophthalmos or
exophthalmos. When zygomatic osteotomy is performed, it is a good idea to place the plates before
the osteotomy cuts are performed so that they can
be adequately reapproximated.
Specic operative approaches and incisions
Transpetrosal and translabyrinthine approaches
Cervical incision for carotid exposure
During these approaches, which require a petrous bone resection, reconstruction can be performed at the end of the operation in one of two
ways. We currently prefer to remove the outer
mastoid cortical bone as a single piece before the
deeper mastoidectomy. This does carry some risk
of damaging the sigmoid sinus, however. A simple
method of reconstruction is to use titanium mesh,
autologous fat graft, and, if necessary, Bone
Source cement. If such reconstruction is not
employed, the patient subsequently has an
unsightly sinking behind the ear as well as some
displacement of the pinna such that he or she is
unhappy with the results. In such patients, secondary reconstruction needs to be performed.
For carotid exposure in the neck, when it is performed for either proximal control or bypass purposes, we prefer to make an oblique skin crease
incision rather than a vertical incision. When
healed, this is generally barely visible to others.
Forearm and thigh incisions for radial artery
and vein graft extraction
Incisions in the forearm and/or the thigh for
the extraction of radial artery and vein grafts
are presently unavoidable. Although an endoscopic technique for extraction of vein grafts has
been described, we are not comfortable at the
present time in using this technique with the avoidance of injury to the various branches. The incisions should be carefully closed in multiple layers
so as to avoid spreading. If the result is considered
Retrosigmoid approach
We prefer a C-shaped incision for both the
retrosigmoid approach and the extreme lateral
L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403
approach such that the skin ap is located away

from the main dural entry site so as to reduce the
prospect of cerebrospinal uid (CSF) leakage.
The C-shaped incision also allows the elevation
of the muscles from their attachments in layers
rather that cutting through the muscle, which is
an important cause of postoperative headache.
When it is not possible to remove the entire craniotomy and replace it, there is a denite amount
of bone loss, and reconstruction is performed at
the end with titanium mesh and bone cement. This
avoids any cosmetic problems and also the postoperative headache syndrome, which has been
described with the retrosigmoid approach.
Extreme lateral approach
With this approach, the main source of cosmetic problems is damage to the hypoglossal nerve
and spinal accessory nerve. Damage to the spinal
accessory nerve should be carefully avoided during
the early part of the exposure.
Transfacial approaches
We generally do not prefer a transfacial approach, because the incisions are dicult to con-
403
ceal. When a transfacial approach is performed,

it is preferable to use the midface degloving approach, because the incision is located in the sublabial area. In particular, the facial translocation
approach may result in cosmetic deformity as a
result of atrophy of the muscles, frontalis nerve
palsy, and/or trismus with diculty in opening
the jaw. When the transfacial approaches are
performed, the incisions should be made by an
ear, nose, and throat surgeon well trained in facial
plastic techniques.
Summary
The cosmetic aspects of neurosurgery are
important and make a considerable dierence to
the patients quality of life. In general, the saying
is true that at a cocktail party, the patient should
not be recognized as having had neurosurgery, or,
even better, the patients own neurosurgeon
should not be able to detect which side the patient
was operated on when the patient is seen in the
oce 6 months later without looking at the
chart.
Cosmetic considerations in cranial surgery:

plastic surgical perspective
Deepak Narayan, MD, John A. Persing, MD*
Section of Plastic Surgery, 330, Cedar Street, Boardman Building-330,
New Haven, CT 06520, USA
This article is an overview of the recent advances and cosmetic implications of various aspects
of craniofacial surgery from a plastic surgical
viewpoint.
The interaction between plastic surgeons and
neurosurgery colleagues has traditionally been
in the management of problem wounds. More
recently, the arcs of neurosurgery and plastic surgery have intersected in the techniques of craniofacial surgery (eg, congenital anomalies, cranial base
tumors, craniofacial trauma), which has resulted
in a fruitful cross-pollination of ideas that have
beneted both the patients and the specialties.
Integral to this interaction is the concept of a
team, whereby diering perspectives based on clinical experience contribute to the formulation of the
therapeutic plan. The role of communication in
this milieu cannot be overstressed. This includes
communication between the plastic surgeon, the
neurosurgeon, and other members of the team so
as to dene the plan, followed by a thoughtful presentation to the patient. Emphasis on risks as well
as benets results in a more informed patient who
is more likely to contribute to his/her care after
surgery. This approach has assumed greater importance in the information age, where ready
access to some information on virtually any subject is available on the Internet. The teams guidance of the patient and his/her family through
conicting, hyperinated, or occasional misinformation is needed for them to be appropriately
informed.
* Corresponding author.
E-mail address: john.persing@yale.edu
(J.A. Persing).
Scalp
Shaving of the head before intracranial procedures has been a part of neurosurgical custom for
some clinicians. In our practice, when dealing
with most craniofacial patients, we have stopped
shaving hair and have seen no increase in infectious
complications in well over two decades [1]. Clipping
approximately a centimeter on either side of the
incision in patients with long hair can facilitate
wound closure, however. This has the trade-o of
a scalp deformity, which may not be accepted by
young adults. Patient response has been most gratifying when hair is not removed, relieving considerable anxiety about postoperative appearance. This,
we believe, promotes psychologic well-being and a
faster recovery, because the patients have one less
of the operative stigmata to concern them.
Incisions
We remain unconvinced about the superiority
of the electric scalpel [2] compared with standard
scalpel incisions in the scalp. We believe that the
heated scalpel may cause greater thermal injury,
potentially leading to greater incision line alopecia
and infection [3]. Certain principles pertaining to
scalp incisions have stood the test of time, yielding
better cosmetic results. Incisions through hair-bearing areas should be beveled at an angle parallel
to the hair shafts to reduce localized alopecia. In
making an incision where there is hair on one side
and glabrous skin on the other, the incision should
be beveled away from the hair-bearing side so that
the hairless skin can be brought over cut hair
shafts such that when they regrow from the
retained follicles, they grow through the glabrous
skin, thus hiding the incision.
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Scalp defects
Small scalp defects are best treated with local
aps (rotation, transposition, or advancement).
Rotation aps, such as Orticocheas three-ap
and four-ap [4,5] variants, are reserved for those
defects that cannot be closed by simpler techniques
primarily on account of their size. Local aps are
dissected in the subgaleal plane. Galeal scoring
of these aps can produce up to a 20% increase
in coverage area. In a series of publications, Juri
[6,7] has described a number of scalp aps, originally proposed for male pattern baldness, that
can be usefully adapted to provide coverage of the
frontal or frontoparietal region with hair-bearing
skin. The so-called delay phenomenon, a surgical
procedure whereby the outlines of the ap are
incised but not raised in an eort to improve
vascularity by dilatation of the remaining blood
vessels, is a necessary adjunct to the use of these
aps [1]. The physiologic basis of the delay phenomenon is poorly understood. Postulated mechanisms include an increase in the size and number
of vessels and vasodilatation secondary to sympathectomy [8]. Areas of cicatricial alopecia may be
directly excised and closed if tension is suciently
relieved. Large defects can be excised and resurfaced in a staged fashion using tissue expanders.
One must be wary about the eects of prolonged
pressure of tissue expanders on the underlying
skull, however, because secondary deformity may
be produced on the skull surface. These defects
are generally mild, however, and return to normal
on removal of the expander. Scalp tissue can be
re-expanded and readvanced after a previous
expansion. Apparent loss of expanded skin during
advancement by recoil of soft tissue mandates overexpansion by approximately a third in an eort to
compensate for this shrinkage [9].
Pedicled muscle aps play an important role in
the coverage of infected wounds or exposed dura.
The benets of a pedicled myocutaneous ap relate to the bulk of fresh tissue with an independent
blood supply that can be brought into a usually
compromised vascularity without the complexity
of a microvascular anastomosis. This is a distinct
advantage compared with local aps, which may
become compromised by radiation scar or trauma, but is achieved at the cost of a donor site deformity. There are a limited number of pedicled
aps that can be used to cover cranial defects, however. A useful example is the trapezius ap, which
is pedicled on the transverse cervical artery and offers excellent coverage of posterior cranial defects.
Massive scalp losses, such as those resulting

from scalp angiosarcoma extirpation, for example,
are best treated, in our opinion, with free-ap
reconstruction using a at muscle, such as the
latissimus dorsi. The muscular bed is an ideal recipient site for a split-thickness graft, and after
denervation atrophy of the muscle, an excellent,
albeit glabrous, contour is obtained.
Microsurgical replantation of the scalp is the
procedure of choice for total scalp avulsion. This
represents the best possible match in terms of appearance and function, because no other tissue in
the body can substitute for the hair-bearing scalp.
The entire scalp can survive on a single blood vessel, such as the supercial temporal artery. The
procedure, however, demands microsurgical skill
that might not be readily available.
An ischemia time of greater than 30 hours
is considered a contraindication to replantation
[10]. Other indications for microvascular tissue
transfer for scalp wounds are unavailability of
local aps for coverage (eg, the cranial base),
failure of pedicled muscle aps used to treat osteomyelitis of the skull, or radiation damage. The
advantage of free aps is that they can bring in
large volumes of fresh tissue and an independent
blood supply, thereby bypassing the local conditions that interfere with healing. The operative
procedures are time-consuming, require a high
degree of technical skill, leave a donor site defect,
and may, on occasion, demand anticoagulation,
which results in bleeding problems if done in conjunction with intracranial procedures.
Skin substitutes
We make liberal use of allograft skin as a temporizing measure during the excision of scalp
tumors, such as dermatobrosarcomas, where
margins are unreliable on frozen section analysis.
This permits coverage without loss of precious
adjacent native skin and, consequently, a larger
cosmetic defect at the harvest site should a wider
resection be mandated by the permanent section.
We believe that allograft (banked human cadaver
skin) is readily available, more durable, and less
costly than currently available tissue-engineered
skin substitutes.
Planning incisions
Access to the cranium involves consideration
of the triumvirate of speed of access, width of
exposure, and cosmesis. A number of incisions/

approaches are currently at the neurosurgeons
disposal, providing access to regions, particularly
the cranial base, that were previously thought to
be inaccessible. The facial translocation techniques
as popularized by Janecka and his colleagues
[11,12] and the midface degloving technique are
cases in point. In deference to cosmetic concerns,
we have, for instance, eschewed the use of open
sky incisions, eyebrow incisions, and subciliary
incisions for access to the periorbital region or
the oor of the orbit, instead using the transconjunctival or blepharoplasty incision with a crows
foot extension.
Placement of scalp incisions should take
current hair patterns into account. In general, craniotomy incisions should be placed no closer than
3 cm from the glabrous border in the hair-bearing
scalp. Incisions closer to the border are readily
visible and unsightly, but if circumstances dictate
a need for a closer position of the incision line,
it is best to make the incision directly in the interface between the glabrous skin and hair-bearing
scalp.
Such operative ideals may be moot when speed
is paramount, as in cases of severe cerebral trauma. Excessive emphasis on obtaining the perfect
cosmetic result at the cost of signicantly prolonging operative time should be avoided. In most
cases of trauma, however, appreciation of the cosmetic result should be factored into the quality-oflife result.
Soft tissue supplements

The ideal alloplastic material should be
strong, nonallergenic, readily available, noncarcinogenic, nonreactive, pliable, infection resistant,
and moldable, and it should eventually be incorporated into the body. Such a material currently does
not exist, although there are some that possess
a few of these attributes. The popularity of these
products is a result of their ready availability and
lack of donor site morbidity. The introduction of a
foreign body into the soft tissue, however, always
carries with it the risk of local tissue reactivity, migration, and early or late extrusion. Finally, there
is the ever-present problem of infection, either
acute or chronic, resulting from the formation of
a biolm, which may be regarded as consortia of
bacteria organized within an extensive exopolymer
glycocalyx, which confers multiple survival advantages to the component organisms [13].
407
Alloderm
Alloderm (Life Cell, Branchburg, NJ) is a
commercially available form of allogeneic human
dermis that is available in sheets and can be cut
to the required shape and used as a ller. It is currently expensive, and the long-term stability of
this construct remains unclear.
Other adjuncts for soft tissue enhancement are
the use of injectable bovine collagen and autologous and allogeneic human collagen (Autologen
and Dermalogen; Collagenesis, Boston, MA),
both of which are temporary measures usually
requiring reinjection at six monthly intervals to
maintain contour enhancement.
Goretex
Goretex is an alloplastic material composed of
expanded Poly Tetra Fluoro Ethylene (PTFE) and
is available for soft tissue augmentation. It has
been used widely in the face, cheek, lip, and nasal
dorsum for this purpose. Daniel [14,15] is of the
opinion that the widespread use of this material
is potentially hazardous because of its relation to
the long-term risk of infection but that the nasal
dorsum alone may be a privileged site.
Fat injections
Free transplantations of fat date back to the
work of Neuber (1893), Lexer (1910) and Peer in
1950 [16]. Many authors [17,18] have emphasized
the cosmetic advantages of the procedure in that
the same technique can be used to ll soft tissue
defects of the face resulting from trauma, incisions,
and atrophy. The results are heavily dependent on
technique. Multiple injections through separate
ports and overcorrection to account for subsequent
volume loss are the norm. Use of this modality in
heavily scarred or irradiated areas is inadvisable
because of the poor vascularity of the recipient site,
which would not support the persistence of the fat
as a graft.
Bone substitutes
Hydroxyapatite (HA) forms the primary
mineral component of bone. There are two types
of HAs in clinical use: the ceramic type and the
nonceramic type. Until recently, the former was
the only type in clinical use.
Synthetic HA is a homogenous crystalline
solid that is structurally similar to its naturally
occurring bone counterpart and has a chemical
408
composition of Ca10(PO4)6(OH)2. HA acts as a scaffold for the ingrowth of new bone. These are particularly important compounds in view of the fact
that they probably have the most biocompatible
calcium-phosphate stoichiometry [19,20]. Three of
the synthetic HA compounds that we have used
in practice are Bone Source (LeibingerStryker
Howmedica, Kalamazoo, MI), Norian (Cupertino,
CA) and Mimix (Lorenz, Jacksonville, FL). Bone
Source, which is supplied as a powder, is mixed
in an aseptic fashion with water to form a puttylike substance that hardens in approximately 15
minutes. Complete hardening occurs over a period
of 4 to 6 hours, however, which can be a liability
in terms of displacement.
Norian, which is a combination of monocalcium-monohydrate, a-tricalcium phosphate,
calcium carbonate, and sodium phosphate [19,20],
shares a number of common features with Bone
Source but has the purported advantage of solidifying on wet surfaces.
These substances have proved useful in the
treatment of small cranial defects like burr holes
and defects up to 3 cm in diameter.
Computer-aided design/computer-aided machined

production of implants
The availability of three-dimensional representation of CT data has allowed the transformation
of craniofacial images into solid models. Such
models [21] are produced directly from CT data
interfaced with a numerically controlled milling
device either by sculpting a mold into which a resin
is poured to form the anatomic model or by direct
milling of the model in positive [21]. Accuracy in
conformity with actual anatomy to a resolution
of 0.4 mm is available. An additional advantage
is the preplacement of drill holes for xation to
the skeleton. The computer-aided design/computer-aided machined (CAD/CAM) process circumvents the need to contour the implant or the
prosthetic material on the table and may provide
a superior cosmetic result with minimal use of
operating room time. In our unit, we have used
this modality with satisfactory results. Conversely,
designing these constructs is expensive and takes
time. This must be contrasted with methylmethacrylate, which possesses the advantages of ready
availability, strength, predictable shape, and low
cost but requires exposure to fumes, possible cardiac arrhythmias, and results in an exothermic
reaction during the process of setting.
Recent advances: cosmetic implications

Minimally invasive surgery
The reverberations of the laparoscopic revolution have been felt as far aeld as in craniofacial
surgery. Endoscopic techniques have been described for the relief of sagittal synostosis [22], for
the harvest of sural nerves [23] and muscles for
free aps [21], and, more recently, for cranial base
surgery and xation of facial fractures. The common theme is that smaller incisions yield better
cosmesis, shortened recovery times, and, possibly,
fewer wound complications. Balancing these advantages is the downside of increased operative time,
because these procedures have a steep learning
curve. These techniques are not yet universally
accepted nor have their advantages been fully
documented.
Orthotic devices
It may seem strange to include orthotic devices
to shape skulls under the category of recent advances, when the principles underlying these devices have been known for centuries. Nevertheless,
these devices have enjoyed a resurgence in the wake
of the recent increase in children with deformational plagiocephaly that resulted from an American Academy of Pediatrics recommendation of
supine positioning for children so as to reduce the
likelihood of the sudden infant death syndrome
[24]. Application of these devices has helped in remolding the skull. These devices have also been
tried in conjunction with a limited form of cranioplasty (usually linear craniectomies), with the thought
being that the combination of these two modalities
may achieve the same result as the more complete
surgical interventions. This is still being evaluated.
Resorbable plates
The use of resorbable plates in the xation
of the craniofacial skeleton represents a major
advance in the eld, particularly in the pediatric
age group. The advantages are inherent in the
biodegradability of the product in that concerns
about long-term visibility of the plates in thinskinned individuals, malpositioned implants, or
the eects of intracranial migration are mitigated.
The plates are generally thicker than their metal
counterparts and are thus more palpable. In general, the strength of these plates does not allow
them to be used for high-stress sites like the adult
mandible, but that scenario is bound to change
in the coming years.
The rst bioabsorbable xation system for the

craniofacial skeleton approved by the US Food
and Drug Administration was the Lorenz Lactosorb system [25,26]. The material used, Lactosorb,
is a copolymer of L-lactic acid (which is slowly
absorbed, thus providing strength) and glycolic
acid (rapidly absorbed) in a 82:18 ratio. Because
it is substantially amorphous, this material has
marked advantages in terms of long-term stability
and degradation compared with the implants made
out of the pure forms of its component chemicals. Clinical complications, such as pronounced
brous encapsulation, sterile abscess and sinus formation, and bone osteolysis, have been reported
for the homopolymers. One of the few studies
showing a reaction to a copolymer(sinus formation) involved polyglactin 910, a copolymer with
an almost inverse ratio of polylactic acid and
polygalactic acid compared with Lactosorb. In
vivo, the material has been histologically demonstrated to be eliminated by approximately 1 year
[25,26]. Another bioabsorbable product, MacroPore (Macropore Biosurgery, San Diego, CA)
implants are manufactured from medical grade
100% amorphous 70:30 poly(L-lactide-co-D,Llactide). This is produced from a mixture of 70%
L-lactide and 30% DL-lactide, which retains
approximately 70% of its initial strength after 9
months and approximately 50% after 12 months,
converts into carbon dioxide and water by the
process of bulk hydrolysis, and resorbs completely
in approximately 18 to 36 months.
The use of bioabsorbable materials has now
extended to the construction of distraction devices.
We have used resorbable plates for xation of the
pediatric craniofacial skeleton over the last 4 years,
and the results are comparable to those using the
equivalent metal xation devices.
Distraction osteogenesis
Distraction osteogenesis was introduced into
clinical practice by Ilizarov in 1951 [27]. Experimental expansion of the craniofacial skeleton was
demonstrated in a rabbit model by Persing and
colleagues [28,29]. The advantage of this technique
is that bone and soft tissue may be gradually elongated, allowing simpler operative techniques to be
employed. It avoids dead space and decreases the
risk of infection by the reduced rate of change.
The process allows accommodation of soft tissue
to occur.
This feature is desirable, especially in patients
with Ventriculo-Peritoneal (V-P) shunts and those
409
undergoing monoblock midface advancement.

The technique also has the advantage of avoiding
donor defects for bone grafts.
A preliminary communication on the application of this technique to distract the mandible
was made in 1992 [30]. The eld has since exploded, with distraction being applied to a variety
of cranial substructures, such as the maxilla, midface, and orbit [31]. Clinical results have ranged
from fair to excellent in terms of the cosmetic
results obtained.
Manipulation of wound healing
The pharmacologic manipulation of wounds
to expedite healing has been a long-sought goal.
There has been progress on this front, with studies
reporting accelerated healing with the use of broblast growth factor (bFGF) [32] and recombinant
platelet-derived growth factor (rPDGF) [33]. The
latter is becoming increasingly popular in the treatment of diabetic wounds of the lower extremities,
and o-label indications, such as use in decubiti,
show promise. Although wounds in the craniofacial region are unlikely to need this supplement,
there may be specic scenarios where this adjunct
may be helpful.
Vacuum-assisted wound closure
A recent addition to the plastic surgeons armamentarium is the vacuum-assisted wound closure
device (VAC; Kinetic Concepts, San Antonio,
TX) [21,34]. The premise of this device is that the
constant application of subatmospheric pressure
applied through the medium of medical-grade polyurethane foam (400600-lm pore size) to chronic
nonhealing wounds results in a substantial wound
contraction and increase in wound pliability, producing wound healing in many recalcitrant cases.
Anecdotally, we have used this device for certain
complex wounds of the torso and lower limb with
good results. It is conceivable that this device
can be applied to carefully chosen complex scalp
wounds to accelerate the healing process.
To summarize, addressing cosmetic concerns
that might initially seem supercial or trivial has
a signicant impact on the functional well-being
of the patient. Coordination of speciality interests
contributes to the nal result.
References
[1] Seitchik MW, Kahn S. The eects of delay on
circulatory eciency of pedicled tissue. Plast
Reconstr Surg 1964;33:16.
410
[2] Farnworth TK, Beals SP, Manwaring KH, et al.

Comparison of skin necrosis in rats using a new
microneedle cautery, standard size needle cautery,
and the Shaw hemostatic scalpel. Ann Plast Surg
1993;31:1647.
[3] Keenan KM, Rodeheaver GT, Kenney JG, Edlich
RF. Surgical cautery revisited. Am J Surg 1984;
147:81821.
[4] Orticochea M. New three ap scalp reconstruction
technique. Br J Plast Surg 1967;20:15971.
[5] Orticochea M. Four ap scalp reconstruction
technique. Br J Plast Surg 1971;24:1848.
[6] Juri J. Use of parieto-occipital aps in the surgical
treatment of baldness. Plast Reconstr Surg 1975;55:
45660.
[7] Juri J, Juri C. Aesthetic aspects of reconstructive
scalp surgery. Clin Plast Surg 1981;8:24354.
[8] Finseth F, Cutting C. An experimental neurovascular island ap for the study of the delay
phenomenon. Plast Reconstr Surg 1978;61:41220.
[9] Argenta L, Watanabe MJ, Grabb CH. The use of
tissue expansion in head and neck reconstruction.
Ann Plast Surg 1982;11:317.
[10] Cheng K, Zhou S, Jiang K, et al. Microsurgical
replantation of the avulsed scalp. Report of 20
cases. Plast Reconstr Surg 1996;97:110916.
[11] Janecka IP. Classication of facial translocation
approach to the skull base. Otolaryngol Head Neck
Surg 1995;112:57985.
[12] Janecka IP, Sen CH, Sekhar LN, et al. Facial
translocation: a new approach to the cranial base.
Otolaryngol Head Neck Surg 1990;103:4139.
[13] Costerton JW, Cheng KJ, Geesy KG, et al. Bacterial
biolms in nature and disease. Ann Rev Microbiol
1987;41:43564.
[14] Daniel RK. (Discussion) The use of Gore-Tex for
nasal augmentation: a retrospective analysis of 106
patients. Plast Reconstr Surg 1994;94:24950.
[15] Daniel RK. The Gore-Texed patient. Plast Reconstr
Surg 1995;95:1336.
[16] Peer LA. Loss of weight and volume in human fat
grafts: with postulation of a cell survival theory.
Plast Reconstr Surg 1950;5:21730.
[17] Guerrerosantos J. Autologous fat grafting for body
contouring. Clin Plast Surg 1996;23:61931.
[18] Toledo S. Syringe liposculpture. Clin Plast Surg
1996;23:68393.
[19] Burgess EA, Mayer MH, Hollinger J. Bone grafting
andsubstitutes.In: AchauerB,EriksonE, GuyuronB,
et al, editors. Plastic surgery. Indications, operations
and outcomes. St. Louis: Mosby; 2000. p. 65771.
[20] Hollinger JO, Brekke J, Gruskin E, et al. The role of

bone substitutes. Clin Orthop 1996;324:5565.
[21] White DN. CT scans, multidimensional reformatting, CAD/CAM produced models in the diagnosis and treatment of craniofacial deformity. In:
Osterhout DK, editor. Aesthetic applications of
craniofacial techniques. Boston: Little Brown &
Company; 1991. p. 95107.
[22] Barone CM, Jimenez DF. Endoscopic craniectomy for early correction of craniosynostosis. Plast
[23] Koh KS, Park S. Endoscopic harvest of sural nerve
graft with balloon dissection. Plast Reconstr Surg
1998;101:8102.
[24] Anonymous. American Academy of Pediatrics
(AAP) task force on infant positioning and SIDS.
Pediatrics 1992;89:11206.
[25] Pietrzak WS, Verstynen ML, Sarver DR. Bioabsorbable xation devices: status for the craniomaxillofacial surgeon. J CranioFac Surg 1997;8:926.
[26] Rubin PJ, Yaremchuk MJ. Complications and
toxicities of implantable biomaterials used in facial
reconstructive and aesthetic surgery. A comprehensive review of the literature. Plast Reconstr Surg
1997;100:133653.
[27] Ilizarov GA. The tension stress eect on the genesis
and growth of tissues. Part 1: the inuence of
stability of xation and soft tissue preservation.
Clin Orthop 1989;238:24981.
[28] Persing JA, Babler WJ, Nagorsky MJ, et al. Skull
expansion in experimental craniosynostosis. Plast
[29] Persing JA, Gamper TJ, Morgan EP, et al. Skull
base expansion: craniofacial eects. Plast Reconstr
Surg 1991;87:102833.
[30] McCarthy JG, Schreiber J, Karp N, et al. Lengthening of the mandible by gradual distraction. Plast
[31] McCarthy JG, editor. Distraction of the craniofacial skeleton1999New York: Springer-Verlag.
[32] Robson MC, Hill DP, Smith PD, et al. Sequential
cytokine therapy for pressure ulcers: clinical and
mechanistic response. Ann Surg 2000;231:60011.
[33] Kallianinen LK, Hirshberg J, Marchant B, Rees RS.
Role of platelet-derived growth factor as an adjunct
to surgery in the management of pressure ulcers. Plast
[34] Morykwas MJ, Argenta LC, Shelton-Brown EI,
McGuirt W. Vacuum-assisted closure: a new method
for wound control and treatment: animal studies and
basic foundation. Ann Plast Surg 1997;38:55362.
Hair sparing techniques and scalp ap design

Joseph C. Camarata, DMD, MD, Peter T.H. Wang, DMD, MD*
Division of Plastic Surgery, University of Texas Health Science Center at San Antonio,
7703 Floyd Curl Drive, Mail Code 7844, San Antonio, TX 78229-3900, USA
There are numerous surgical scalp exposures

to the cranium. Traditional straight-line incisions
often leave visible scars. Recent advances in understanding the scalp physiology and its blood supply
enable the surgeon to design safe scalp aps and
obtain a better cosmetic result.
Scalp anatomy
The scalp is a specialized tissue consisting
of ve layers: skin, subcutaneous tissue, galeal
aponeurosis, loose areolar tissue, and pericranium
(SCALP) (Fig. 1). Vessels and nerves enter the
scalp in a centripetal direction and travel within
the subcutaneous and galeal layers. The main
blood supply to the scalp is from ve arteries
on each side: supratrochlear, supraorbital, supercial temporal, posterior auricular, and occipital.
The supercial temporal artery has anterior and
parietal branches. These vessels are interconnected with some anastomosis across the midline
(Fig. 2). When designing the scalp aps, the major
axial vessels should be incorporated within the
base of the ap. Branches of the rst division of
the trigeminal nerve provide the sensory innervation of the scalp anteriorly. The occipital branches
of the second cervical nerve supply the posterior
scalp. Transection of the nerve during the scalp
incision often results in annoying postoperative
dysesthesia. The frontalis muscle of the galea is innervated by the frontal branch of the facial nerve.
Care must be taken when raising a bicoronal ap in
the temporal region, because the frontal branch
runs on the deep surface of the temporoparietal
fascia (an extension of the galea in the temporal region) as it crosses the zygomatic arch.
E-mail address: wangp@uthscsa.edu (P.T.H. Wang).
Hair
The hair bulb extends into the subcutaneous
plane. There are two groups of stem cells that ultimately are responsible for hair growth [1]. The low
stem cells are located in the bulb of the shaft. The
second group of high stem cells is located in the
sebaceous units, which are often found in the midskin level (Fig. 3). The hair shafts are supplied by
the subcutaneous vascular plexus. The direction
of hair growth is established early in infancy. In
the temporal and occipital region, the hair tends
to fall downward. At the superior scalp, the hair
grows anterior and oblique. The hair retains its
orientation even after the scalp is repositioned.
Bicoronal incision
The bicoronal incision oers an excellent exposure to the entire cranium. The location of the
incision varies depending on the emphasis of the
surgical region [2]. Ideally, the incision is placed
in the middle to posterior to the equator to hide
the incision. If the exposure is for craniofacial surgery, however, the incision may be placed more
anteriorly such that there is less scalp to turn over,
allowing easier access to the facial bones. If necessary, preauricular extensions are performed for
additional facial skeleton exposure. Postauricular
extensions have been reported for better cosmetic
appearance [3].
Straight line versus zigzag
Although a straight-line incision is simple and
fast to incise and close, the resultant linear scar is
often visible, especially in the temporal region.
Not infrequently, as the hair gets wet, such as
when coming out of the swimming pool or shower,
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412
J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
Fig. 1. Layers of the scalp. (From Dingman, Argenta. The surgical repair of traumatic defects of the scalp. Clin Plas
Surg 1982;9:133; with permission.)
the hair in the temporal region parts to either side

of the scar, making it more obvious [4]. The reason
why this happens is because hair in the temporal
region grows directly downward. The straight-line
scar placed parallel to the direction of hair growth
in the temporal region is not hidden by the hair
drape. Furthermore, as the scar widens, the hairbearing scalp moves farther away, increasing the
visibility of the scar (Figs. 4 and 5).
Ideally, the incision should be placed perpendicular to the direction of the fall line of the hair.
The hair provides maximum coverage to the scar,
even if the scar widens in the future. In general,

the direction of hair growth is downward in the
temporal, parietal, and occipital scalp. In the central region, the course of hair growth is more variable, mostly in the anterior direction or sideways.
As a result, in designing the coronal incision, the
zigzag pattern is placed in the temporal region to
decrease the potential scar visibility (Fig. 6) [46].
In the central scalp, the zigzag pattern can be continued between the two temporal fusion lines or
can be modied with a gentle curve (widows peak)
(Fig. 7). Starting above the helical root, the rst
Fig. 2. Vascular supply of the scalp. (From Dingman, Argenta. The surgical repair of traumatic defects of the scalp. Clin
Plas Surg 1982;9:133; with permission.)
413
design [5]. A sinusoidal pattern employing principles similar to those of the zigzag incision, with
rounded transitions between limbs, can also be
used (Fig. 8).
The disadvantage of the zigzag incision is that
it takes longer to make and longer to close at
the end. The zigzag pattern also makes it harder
to retain the Raney clips on the scalp edge. A
postauricular incision has been described as an
extension of the coronal incision. Although this
method can adequately expose the anterior craniofacial skeleton, it is probably more suitable for
the posterior half of the calvaria [3].
Minimizing scar width and scalp elevation
Fig. 3. Hair bulb with low stem cells in the bulb shaft
and high stem cells in the sebaceous units. (From Seery,
GE. Scalp surgery: anatomical and biomedical considerations. Dermatologic Surgery 2001;27(9):82734; with
permission.)
triangle is directed posteriorly. The subsequent triangles moving superiorly can have equal angle
between the limbs and length of the limbs, or
the angle can be sharper inferiorly and gradually
widen superiorly. The sharper angles allow more
horizontal limbs in the zigzag pattern [5]. Creating
the zigzag pattern using a preformed template
has also been described as facilitating the incision
The scar width is a result of alopecia adjacent to

the incision or widening of the incisional scar. To
preserve the maximum number of hair follicles,
the incision is made parallel to the shaft of the hair.
The beveled incision preserves the largest number
of hair roots, which have the ability for future hair
growth (Fig. 9). If one is uncertain of the direction
of the hair shaft, it would be better to incise perpendicular to the scalp rather than risking beveling
in the wrong direction, which can lead to additional hair loss adjacent to the scar. Another consideration is to minimize the thermal damage from
the electrocautery to the hair bulbs that extend
into the subcutaneous plane. Both the bipolar tip
and Colorado needle provide pinpoint cauterization compared with the blade cautery; nonetheless,
Fig. 4. A 14-year-old girl underwent a straight-line bicoronal incision for craniofacial reconstruction. The visible
straight-line vertical scar is dicult to camouage by means of the temporal hair drape.
414
Fig. 5. A male patient had a straight-line hairline incision for a craniotomy to expose massive craniofacial trauma.
Fig. 6. (A) Zigzag design of bicoronal incision in the temporal scalp. (B) The zigzag design continued across the entire
scalp. (C) Postoperative view.
415
Fig. 7. (A) Zigzag design of bicoronal incision in the temporal scalp. (B) The zigzag pattern was changed to a gentle
curve in the central scalp (widows peak). (C) Postoperative view. Note that the zigzag incision pattern is well hidden by
the fall line of the hair in the temporal region.
the high temperature conduction can damage the

nearby hair bulb [4,7]. There are several helpful
methods to control the bleeding scalp. The scalp
can be inltrated with local anesthetic containing
epinephrine before incision, which results in vasoconstriction. Hemostasis can also be achieved by
placing parallel locking sutures to the incision
before making the incision. Raney clips provide
the conventional method of controlling the scalp
bleeding; however, these clips are cumbersome
and frequently dislodge. In addition, prolonged
clamping by Raney clips on the scalp edge, as in a

long operation, may result in ischemia of the hair
follicles and subsequent scar alopecia.
Scalp closure
To minimize the widening of the scar itself, the
scalp ap closure should be performed without
tension. Some surgeons have shown that placement of wide relaxation sutures at 2- to 3-cm intervals with supercial (epidermal) suturing has
416
Fig. 8. A sinusoid pattern is used in this baby for reconstructive exposure for unicoronal synostosis.
resulted in minimal linear scar formation [8]. This

method of relaxation sutures is thought to avoid
tension in the upper stem cell sebaceous units, to
allow hair regeneration within the incision, and,
in some instances, to avoid temporary hair loss.
The strength layer, the galea, must be reapproximated to minimize the tension on the skin closure.
Long-lasting absorbable sutures such as PDS or
Vicryl are generally used. The choice of suture on
the skin layer depends on surgeons preference.
For children, resorbable sutures such as chromic
gut or Monocryl are preferred to avoid the process
of suture removal. Buried long-lasting sutures like
PDS may provide additional internal retention to
the closure. In adults, Prolene suture or even skin
staples can be used for skin closure, followed by
removal in 7 to 10 days. The method of suturing
the skin layer probably makes little dierence if performed without tension. Although running vertical
mattress sutures evert the skin edge, running simple
sutures are much faster and likely to produce the
same cosmetic results. It is probably a good idea
to avoid deep skin sutures so as not to damage
the deep hair follicles. Another method in the prevention and treatment of wide scars is beveling
wedge excision and placement of double relaxation
sutures [8]. The rationale is to allow the preserved
hair root to grow through the incision scar eventually. In summary, by adhering to the principles
of tensionless closure and preservation of hair follicles, scar width and alopecia can be minimized.
To shave or not to shave
Hair shaving has long been a standard practice
in the surgical approach to the cranium. Although
Fig. 9. Beveled incision parallel with hair follicles for

preservation of hair roots. (From Ellis E III, Zide M.
Surgical approaches to the facial skeleton. Lippincott
Williams and Wilkins; 1995 [chapter 6].)
this certainly facilitates preoperative markings and

avoids working within the hair, there is no evidence that shaving prevents wound infections. In
fact, it may lead to higher rates of wound infection
as a result of epidermal injury from shaving [9].
Shaving the scalp before surgery has the benets
of better visualization of underlying cranial defects, facilitation of markings, and avoidance of
the potential annoyance of working within the
hair. One must also take into consideration
the psychologic impact this has on patients and the
potential delay in rehabilitation. From an esthetic
standpoint, sparing the hair with no shaving or
minimal shaving along the incision signicantly
improves the immediate postoperative appearance. There is no typical stigma of baldness from
a neurosurgical procedure; thus, the psychologic
417
aspect is also improved, especially for female

patients. Surgeons are often annoyed by the hair
in the operative eld, however. Hair of moderate
length can be braided into separate bundles
(Fig. 10), whereas shorter hair can be isolated with
towels covering the hair and xed with staples (Fig.
11). In addition, antibiotic ointment or Surgilube
(E. Fougera & Co., Melville, NY) temporarily
parts the hair from the surgical eld, which is helpful during the closure of the scalp incision. A decision to shave the scalp before surgery should be
based on these advantages and not to protect
against wound infection, because shaving the scalp
may lead to a higher risk of postoperative wound
infection.
Temporal hollowing
Temporal hollowing is a not infrequently seen
cosmetic complication after scalp incision in the
temporal region. The reason may be associated
with temporalis muscle atrophy or failure of resuspension of the temporalis muscle. The temporalis
muscle is handled in a couple of ways during the
surgical approach. The muscle can be left with
the scalp ap, and a subperiosteal dissection is
performed. This probably maintains a better
blood supply and minimizes temporal atrophy or
hollowing. Alternatively, the muscle is elevated as
a separate ap from the scalp ap. On closure, it is
important to resuspend the muscle to its original
position or even to advance the muscle ap anterior to the orbital rim. Failure to reattach the
muscle or injury to the blood supply results in
muscle retraction, atrophy, and temporal hollowing. Invariably, some degree of muscle atrophy
Fig. 10. Separate bundles of hair braided with needle

driver and small elastic bands. (From Worthen. Scalp
aps and the rotation forehead ap. In: Strauch B,
Vasconez L, Hall-Findlay EJ, editors. Grabbs Encyclopedia of Flaps. 2nd Edition. Boston: Little, Brown and
Co.; 1990.)
Fig. 11. Only the surgical strip is shaved. The anterior

hair is covered by a surgical towel stapled to the scalp, as
is the posterior scalp.
occurs once the muscle has been elevated. Another

article in this issue discusses temporal hollowing in
further detail.
Local scalp aps and management

of irradiated scalp
Unlike other areas of the skin, the scalp is less
yielding in its elasticity as an advancement ap.
Consequently, small wounds on the scalp require
a larger than expected ap design to obtain tensionless closure. Of the many scalp aps used for
wound coverage, there are a couple of aps that
have a broad ap base and good blood supply.
The rotation ap has been the workhorse for
scalp wound closure. For small- to moderate-sized
wounds, the rotation ap may allow wound coverage and primary closure. Larger wounds may require back-grafting of the donor site with a skin
graft. Ideally, the ap should be based on a major
axial artery (Fig. 12). Larger scalp wounds can be
covered by a bipedicle scalp ap (visor ap), with
back-grafting of the donor site. When back-grafting is anticipated, the periosteum must be left
intact for the skin graft to heal. Alternatively, the
galea or temporoparietal fascia can be dissected
under the subfollicular layer of the scalp. This
layer alone or combined with the periosteum is
elevated as a rotation ap or bipedicle ap to close
small defects, followed by a skin graft. The application of the galeal ap is limited to small wounds
because of its thin fascia, random blood supply,
and tedious dissection. Under elective circumstances, tissue expanders are helpful to recruit and gain
additional scalp tissue.
418
Fig. 12. Scalp advancement ap based on axial blood supply with back-grafting. (From Baker SR, Swanson NA. Local
aps in facial reconstruction. Philadelphia: Mosby Yearbook, Inc.; 1994 [chapter 22].)
Radiation to the scalp after tumor resection

causes local tissue damage, which may lead to
wound breakdown at the incision line. Furthermore, radiation complicates wound healing if
re-resection becomes necessary through the same
incision. If the wound breaks down at the incision
line, it must be excised and covered with a wellvascularized ap under no tension. If a U-shaped
(horseshoe) ap was the original incision, a contralateral rotation ap is a good option for wound
coverage. If a bicoronal incision was used for
exposure, the bipedicle ap with back-grafting
has been described to cover the incision wound
breakdown. Furthermore, it has been suggested
that in the initial preoperative planning, if radiation and reoperation are anticipated, a linear incision (bicoronal ap) rather than the U- shaped
incision should be designed parallel to and not to
sever the major axial artery. A bicoronal incision

oers excellent cranial exposure and is a good option in such a situation. The supercial temporal
artery should be spared in this approach. Ultimately, the design and placement of the incision
should compromise the vascularity and postoperative wound healing to the least extent possible
[10]. Scalp reconstruction for repeated failures
using local aps to repair irradiated wounds requires free tissue transfer.
Summary
Individualizing each patient in deciding on ap
selection, ap design, hair sparing or shaving, and
method of closure ensures proper treatment outcome with the goal of achieving a good cosmetic
result.
References
[1] Inaba Y, Inaba M. Prevention and treatment of
linear scar formation in the scalp: basic principles of
the mechanism of scar formation. Aesthetic Plast
Surg 1995;19:36978.
[2] Akita S, Hirano A. Modied coronal incision: distribution of stress in the scalp and cranium. Cleft
Palate Craniofac J 1993;30:3826.
[3] Posnick JC, Godstein JA, Clokie C. Advantages of
the postauricular coronal incision. Ann Plast Surg
1992;29:1146.
[4] Munro IR, Fearon JA. The coronal incision
revisited. Plas Reconstr Surg 1994;93:1857.
[5] Fisher DM, Goldman BE, Mlakar JM. Template
for a zigzag coronal incision. Plast Reconstr Surg
1995;95:6145.
419
[6] Frodel JL, Mabrie D. Optimal elective scalp incision design. Otolaryngol Head Neck Surg 1999;121:
3747.
[7] Papay FA, Stein J, Luciano M, Zins JE. The microdissection cautery needle versus the cold scalpel in
bicoronal incisions. J Craniofac Surg 1998;9:3447.
[8] Burm JS, Oh SJ. Prevention and treatment of wide
scar and alopecia in the scalp: wedge excision and
double relaxation suture. Plast Reconstr Surg 1999;
103:11439.
[9] Siddique MS, Matai V, Sutclie JC. The preoperative skin shave in neurosurgery: is it justied? Br J
Neurosurg 1998;12:1315.
[10] Nair S, Giannakopoulos G, Granick M, Solomon M,
McCormack T, et al. Surgical management of radiated scalp in patients with recurrent glioma. Neurosurgery 1994;34:1037.
Cosmetic considerations in cranial base surgery

Division of Neurosurgery, University of Texas Health Science Center at San Antonio,
4410 Medical Drive, Suite 610, San Antonio, TX 78229-3798, USA
Recent advances in the surgical techniques for

the resection of cranial base tumors have allowed
for improved degrees of tumor resection, functional outcomes, and esthetic results. If the resection and functional results are not compromised
by procedures providing excellent cosmetic outcomes, there is no reason to ignore or compromise
the aesthetic aspect with regard to technical execution and planning. A thorough assessment of the
patients preoperative decits and tumor anatomy
and a working knowledge of the available cranial
base approaches and their combinations permit
the surgeon to design an approach that allows
for optimal tumor resection with the best possible
cosmetic result. Presented in this article is a discussion of the indications of the various cranial base
approaches available and their combinations, with
an emphasis on the skin incision used and the surgical techniques that facilitate a favorable aesthetic
outcome.
Although a large armamentarium of craniofacial approaches exists to treat cranial base tumors,
progressive emphasis is more recently being
placed on those with superior esthetic outcomes.
Many of the cranial base approaches or combinations of them are successful at providing the necessary exposure for successful tumor resection. No
one would argue that this is the primary goal of these
procedures. Coupled with degree of resection, functional outcome and quality-of-life issues must be
factored into the surgical decision-making process.
As these procedures have evolved, so have the
means to meet these goals of adequate resection
with good functional and cosmetic results. If the
resection and functional preservation are not
E-mail address: CAB@neuroassocsa.com

(C.A. Bogaev).
compromised by procedures providing excellent

esthetic outcomes, there is no reason to ignore or
compromise the cosmetic aspect with regard to
technical execution and planning. The cosmetic
result is an important issue in the patients quality
of life and reintegration into society.
Transfacial versus alternative approaches
to the skull base
Visible scars from facial incisions are a prominent consideration for many patients, particularly
the young ones [1]. This is especially important in
the setting of radiation therapy or other processes that may interfere with wound healing or exacerbate scar formation. Because of the variety
of available craniofacial exposures to the skull
base, a combination of approaches is usually available that can provide the required exposure without a facial incision. If the skin or underlying
soft tissues are involved with tumor, an en bloc
resection, including the skin, may be required [1].
In choosing a surgical approach for a cranial
base tumor, the initial determination is whether
an intradural or extradural approach is needed.
An approach or combination of approaches can
then be selected from one of these sets depending
on the location, extension, and decits caused by
the tumor. Intradural cranial base approaches
include frontal or frontotemporal craniotomy with
orbital or extended orbital osteotomy, frontotemporal craniotomy with orbitozygomatic osteotomy,
presigmoid petrosal approach and its variations,
retrosigmoid approach, and extreme lateral partial
transcondylar approach. Extradural cranial base
approaches include frontotemporal craniotomy
with orbitozygomatic osteotomy, subtemporal/
infratemporal approach, extended subfrontal
transbasal approach, extreme lateral transcondylar
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C.A. Bogaev / Neurosurg Clin N Am 13 (2002) 421441
approach, transsphenoidal approach, and midface

degloving with Le Fort I osteotomy.
Intradural cranial base approaches
Frontotemporal craniotomy with
orbital osteotomy
The increased exposure provided by the addition of an orbital osteotomy to a pterional, frontal,
or frontotemporal craniotomy is most useful for
lesions of the anterior fossa, orbit, orbital apex,
anterior communicating artery complex, parasellar region, retrosellar region, cavernous sinus, tentorial notch, anterior middle fossa, and olfactory
groove [27].
A unilateral question markshaped incision is
most commonly used. The incision is made well
behind the hairline (except at its anterior tip,
which extends to the anterior border of the hairline) so as to preserve hair anterior to the incision and to circumvent the bulk of the temporalis
muscle (Figs. 1 and 2). This prevents cutting the
muscle and facilitates its re-elevation at the time
of closure. Factors thought to contribute to
temporalis atrophy include denervation, devascularization, disuse, or muscle ber injury [8]. Not
Fig. 1. Anterolateral view of question mark incision

used for a frontotemporal craniotomy with an orbital or
orbitozygomatic osteotomy. Note the lower pole of the
incision following the pretragal skin crease.
Fig. 2. Lateral view of question mark incision used for a

frontotemporal craniotomy with an orbital or orbitozygomatic osteotomy. Note the lower pole of the incision
following the pretragal skin crease.
cutting the temporalis muscle, at least through its

thick portion, helps to prevent devascularization
or denervation of the separated portion, and careful elevation of the muscle helps to prevent muscle
ber injury. To eliminate the last risk factor for
atrophy, the temporalis muscle is carefully reattached to its anatomic origin as closely as possible
at the time of wound closure so as to re-establish
its anatomic and functional integrity. One method
of accomplishing this involves leaving a cu of
muscle or fascia attached along the superior temporal line as described by Spetzler and Lee [9],
allowing the muscle to be sutured back to its origin
at the time of wound closure. Another method is to
elevate the temporalis muscle entirely and resecure
it at the time of closure with sutures to multiple
oblique holes drilled along the superior temporal
line. This latter method carries the advantage of
not cutting the temporalis muscle at all. Excellent
results have been attained with both techniques.
Aside from temporalis muscle issues, incisions
are made well behind the hairline (preferably, at
least 3 cm) for optimal cosmetic results. Incisions
just behind the hairline are cosmetically inferior
[10] because of the alteration in hair patterns,
making the incision signicantly more obvious
both short and long term. An incision along the
hairline is signicantly less noticeable than one
just behind it.
423
In patients with a receding hairline or in bald

patients, a bicoronal incision is signicantly less
noticeable than a question mark incision (Figs. 3
and 4). If the hairline is high on the forehead, a
question mark incision may provide inadequate
basal frontal exposure unless the incision is extended onto the forehead, resulting in a suboptimal cosmetic result.
The lower end of many of these incisions is
made in the skin crease just anterior to the tragus
(see Figs. 14). This is more cosmetic, because
the incision is hidden in a normal skin crease. It
also avoids injury to the frontotemporal branch
of the facial nerve and supercial temporal artery
[3,11,12].
Once the best incision has been chosen, the hair
is parted along the planned incision line with a
comb after the head has been placed in pins and is
in the operative position. The hair is easier to part
if it is moistened with saline, alcohol, or antibiotic
ointment. Only 0.5 to 1.0 cm of hair is then shaved
Fig. 4. Frontal view from above of standard bicoronal

incision used for multiple cranial base approaches. Note
that the incision is placed well behind the hairline for
cosmetic reasons as well as to provide a large pericranial
graft. Note the lower pole of the incision following the
pretragal skin crease.
Fig. 3. Anterolateral view of standard bicoronal incision

used for multiple cranial base approaches. Note that the
incision is placed well behind the hairline for cosmetic
reasons as well as to provide a large pericranial graft.
Note the lower pole of the incision following the pretragal skin crease.
on either side of the incision to keep adhesive drapes

in place and facilitate closure. Even if a small strip
of hair is shaved, sucient re-growth of hair stubble occurs after approximately 2 weeks to allow
the area of the incision to be less noticeable and
blend with the surrounding hair. Patients with longer hair can hide the small shaved area along the
incision by combing the surrounding hair over it.
Once the scalp is elevated, an interfascial dissection of the frontotemporal branch of the facial
nerve is performed on the side of the orbital osteotomy, and the temporalis muscle is elevated
completely from its origin for reasons previously
described. This also allows the temporalis muscle
to be retracted laterally, keeping it more out of
the way of the focal point of the exposure. With
bicoronal incisions, the contralateral temporalis
muscle and fascia are left undisturbed. A detailed
description of the craniotomy and osteotomy
techniques is provided in the article in this issue
on osteotomy design and execution.
424
Eyebrow incisions for basal frontal exposure

Signicant controversy exists concerning the
utility, indications, and cosmetic advantages of
the use of eyebrow incisions for frontal or supraorbital craniotomies with or without an orbital
osteotomy. Several case series have been reported
describing the ecacy and excellent cosmetic results for anterior circulation aneurysms and tumors of the anterior cranial fossa and parasellar
region [1315].
For approaches to these regions, bicoronal, pterional, or question mark incisions have
been used traditionally. One of the advantages described for the eyebrow incision is improved basal
frontal exposure with reduced brain retraction,
particularly with the use of an orbital osteotomy.
Few would argue that this basal exposure reduces brain retraction, but the same bone work
can be performed through an incision behind the
hairline. As discussed earlier, if the hairline is
receding or is suciently far posterior that basal
frontal exposure is limited using a unilateral curvilinear or question mark incision, a bicoronal
incision can be used with no limitation to basal
frontal exposure. Therefore, identical bone work
to that described for the eyebrow incision can also
be performed through incisions behind the hairline, making the technical dierences mainly in
the placement of the incision.
Other advantages described for eyebrow incisions are the reduced operative time and the excellent cosmetic results [1315]. This may be a viable
argument because of the reduced length of the
eyebrow incision compared with traditional incisions behind the hairline, particularly a bicoronal
incision. From the cosmetic perspective, some
who use eyebrow incisions place them in the upper
border of the eyebrow but sometimes extend them
into a skin crease or wrinkle in the frontozygomatic area beyond the lateral extent of the eyebrow [13,14]. Furthermore, signicant variability
may exist in the size, thickness, conguration,
and extent of various patients eyebrows, which
may limit exposure unless eyebrow incisions are
extended into neighboring areas of the face. For
this reason, scars may potentially be visible and
are not always hidden by the eyebrow. With regard to the cosmetic signicance of this, John
Diaz Day expressed the sentiments of many critics of the eyebrow incision when he wrote: The
incision that is made completely within the hairline is essentially never seen, in contrast to incisions across any part of the forehead or the lateral
orbit. Even with the most meticulous closure, an

incision line remains that simply is not present
when the incision is made within the hairline
[16]. With regard to the cosmetic results and reduced operative time of the eyebrow incision,
Iver A. Langmen wrote: I have used this approach
on selected patients for years, and my impression
is that neither the cosmetic results nor the operating time are improved as compared with a standard orbitopterional craniotomy [16].
Flexibility is important, because as with other
techniques, cosmetic results can be dependent on
many factors. According to Perneczky et al [14],
a standard skin incision does not exist for this
approach, because the individual anatomy of a
patient should be respected: Important individual
details of the skin, which may greatly determine
the post-operative cosmetic result and the satisfaction of the patient, such as wrinkles, size and shape
of the eyebrows, frontal hairline, or sidewhiskers,
are also visible during the clinical examination
and may inuence the decision-making for an individual approach.
Other disadvantages described for the eyebrow
incision are that it is more dicult to obtain a large
pericranial graft, and one study reported a 6.9%
cerebrospinal uid (CSF) leak rate [15], possibly
because of the increased diculty in repairing
large frontal sinus defects through this incision.
Frontalis weakness has been described as a
temporary sequela to an approach performed
through this incision. Three separate sources
have reported no permanent frontalis weakness,
however [1315]. Perneczky et al [14] attribute
this to the course of the frontotemporal branch
of the facial nerve virtually never crossing this
type of skin incision. The temporary weakness
is usually attributed to retraction.
The average size of a craniotomy performed
through an eyebrow incision has been described
as 25 to 30 mm 15 to 20 mm [14] for endoscopeassisted craniotomies up to an average of 2.5 cm
3.5 cm for the supraorbital microcraniotomy with
an orbital osteotomy [13]. The temporalis muscle is
minimally elevated from the region of the anatomic keyhole, and a single keyhole burr hole is
placed [1315]. If an orbital osteotomy is to be
included, the craniotome has been used to cut
the frontozygomatic process, and the orbital roof
and lateral orbital wall are fractured with osteotomes [13] or a small cutting burr [15]. The craniotomy and orbital osteotomy are removed as a
single piece [13,15]. A detailed discussion of onepiece versus two-piece orbital osteotomies follows
in the article in this issue on osteotomy design and

execution.
In summary, the most signicant dierences
between the eyebrow incision and more traditional
techniques are the cosmetic result, smaller pericranial graft obtainable, more limited exposure, and a
possible reduction in operative time. Supraorbital
craniotomy through an eyebrow incision has been
demonstrated to be a useful approach under the
proper indications, however.
Extended orbital osteotomy
This approach involves a frontal or frontotemporal craniotomy with extension across the
midline, with the orbital osteotomy extending
across the midline to include the glabella. This
greatly enhances midline basal frontal exposure
and combines the advantages of a bifrontal and
pterional craniotomy. This approach is also referred to as a one-and-a-half fronto-orbital approach.
It is most appropriate for large neoplasms of
the anterior cranial fossa with extension across
the midline, such as olfactory groove or planum
sphenoidale meningiomas. A notable feature of this
approach is that the cribriform plate is not manipulated so that olfaction is potentially spared.
A bicoronal incision is used for this approach
to provide the required exposure across the midline. The incision is placed well behind the hairline
not only for cosmetic reasons but to allow for a
large pericranial graft for the repair of any ethmoidal or frontal sinus defects (see Figs. 3 and
4). Minimal hair is shaved along the planned incision line as described earlier. The lower ends of the
incision are placed in the pretragal skin creases
also as described earlier. An interfascial dissection
of the frontotemporal branch of the facial nerve
is performed ipsilaterally, and the temporalis muscle is elevated completely. The craniotomy, osteotomy, and reconstruction are described in detail in
the article in this issue on osteotomy design and
execution.
Frontotemporal craniotomy with
orbitozygomatic osteotomy
The rationale for an orbitozygomatic osteotomy is similar to that for an orbital osteotomy.
The major advantage gained with the orbitozygomatic approach is a signicant increase in subtemporal exposure [17]. If subtemporal exposure is
not needed, an orbital osteotomy alone is likely
to suce. Similarly, a standard orbitozygomatic
425
osteotomy is not performed with a frontal craniotomy but only with a frontotemporal or pterional
craniotomy.
A frontotemporal craniotomy with an orbitozygomatic osteotomy is often used for lesions
of the anterior and middle fossae, upper clivus,
parasellar region, interpeduncular fossa, medial
sphenoid wing, clinoidal region, Meckels cave,
tentorial notch, or cavernous sinus or for basilar
tip aneurysms [12,1823]. A more general indication is for lesions suitable for an orbital osteotomy
with the need for additional basal exposure to the
middle fossa (subtemporal) [17], tentorial notch,
or upper clivus [20].
Either a unilateral question mark (see Figs. 1
and 2) or a bicoronal incision (see Figs. 3 and 4)
can be used, with the incision being placed well
behind the hairline with minimal hair shaved as
described earlier. A bicoronal incision is preferred if the patient has a receding hairline or a sufciently posterior hairline such that inadequate
exposure is provided without extending the incision onto the forehead. Crossing the anterior end
of a question mark incision to the opposite midpupillary line (Fig. 5) is an option [22] but does
not produce the additional exposure provided by
a bicoronal incision and may still provide insucient exposure in patients with a receding hairline.
The added eort of performing a bicoronal incision is more than compensated for by the reduced
eort of performing the orbitozygomatic osteotomy with improved exposure. In either case, the
inferior end of the incision extends into the pretragal skin crease. An interfascial dissection of the
frontotemporal branch of the facial nerve is performed, and the temporalis muscle is completely
elevated as described earlier. A detailed description of the craniotomy, osteotomy, and reconstruction is provided in the article in this issue on
osteotomy design and execution.
Presigmoid petrosal approach
The presigmoid petrosal approach is the most
common approach used for intradural tumors of
the petroclival region. Several variations of this
approach have been developed to optimize exposure along with more clearly dened indications
and limitations.
For the purpose of planning an operative
approach, the clivus can be divided into three
anatomic regions. The upper clivus begins at the
point of crossing of the trigeminal nerve over the
clivus and includes the dorsum sella. The midclivus
426
cisterns to increase brain relaxation, facilitating

the remainder of the dural opening. The temporal
dura is then opened along the inferior temporal
gyrus from the anterior aspect of the craniotomy
to the posterior aspect of the superior petrosal
sinus across from the presigmoid dural opening.
The superior petrosal sinus is suture ligated and
cut at this point. The tentorium is then divided
under direct vision from this location to an area
medially that is just posterior to the entrance of
the fourth nerve into the cavernous sinus or tentorial edge. This dural opening maximizes the transtentorial exposure provided by the presigmoid
petrosal approach.
The retrolabyrinthine variant is specically indicated for small or medium-sized tumors of the
lateral petrous ridge or lateral midclivus with the
presence of useful hearing ipsilaterally [24,25].
This approach is also useful for large tumors of
the lateral petrous ridge or cerebellopontine angle
when useful hearing is present ipsilaterally and the
tumor abuts the inferior surface of the tentorium
or extends through the tentorial notch [24,25].
Fig. 5. Incision for a frontotemporal craniotomy with
an orbitozygomatic osteotomy with additional exposure
provided by extending the incision to the contralateral
midpupillary line. This is an alternative to a bicoronal
incision in patients with a receding hairline.
begins at the inferior aspect of the trigeminal root

and extends inferiorly to the level of the glossopharyngeal root. The lower clivus extends from
the glossopharyngeal root to the foramen magnum
[24,25]. The petrous ridge can be divided into the
medial area (area medial to the internal auditory
canal) and the lateral area (area lateral to the internal auditory canal) [24,25].
Retrolabyrinthine petrosal approach
In this variation, the presigmoid dura is
exposed by a mastoidectomy with skeletonization
of the labyrinth, but no labyrinthectomy is performed. A temporal craniotomy is then performed
that covers the anterior and posterior dimensions
of the tumor with its posterior aspect extending
at least 2 cm posterior to the transverse-sigmoid
junction [24,25]. The presigmoid dura is opened
parallel to the sigmoid sinus from the jugular bulb
to the posterior aspect of the superior petrosal
sinus near its junction with the transverse and
sigmoid sinuses. The presigmoid dura is opened
rst so as to allow CSF drainage from the basal
Partial labyrinthectomy/petrous apicectomy

petrosal approach
The partial labyrinthectomy/petrous apicectomy (PLPA) approach involves a mastoidectomy
similar to a retrolabyrinthine petrosal approach
but with the addition of a partial labyrinthectomy
and a petrous apicectomy. The partial labyrinthectomy involves the removal of the superior and posterior semicircular canals in a controlled fashion
to prevent loss of endolymphatic uid and subsequent hearing loss [6,30,32]. The removal of these
semicircular canals facilitates a petrous apicectomy that involves resection of the bone superior
to a line from the ampulla of the superior semicircular canal to the entrance of the vestibular
aqueduct into the petrous dura [2426]. The superior wall of the internal auditory canal can be skeletonized during the petrous apex removal.
The dural opening is the same as for the retrolabyrinthine variant, but the exposure provided
is greater, because the additional bone removal
allows the dura to be retracted further over the
residual temporal bone, increasing the intradural
exposure.
The PLPA petrosal approach is indicated
for small or medium-sized intradural tumors of
the medial petrous ridge or medial midclivus with
the presence of useful hearing ipsilaterally [24,25].
This approach is also useful for large intradural
midline and paramedian tumors of the upper and
427
midclivus that extend less than 2 cm above the dorsum sella in patients with useful ipsilateral hearing
[24,25].
and the tentorium is divided as previously described, providing the maximum intradural exposure of the midclival and petroclival regions.
Translabyrinthine petrosal approach

A translabyrinthine petrosal approach provides
excellent exposure to the petroclival region when
ipsilateral hearing preservation is not an issue. A
radical mastoidectomy is performed, and the
labyrinthine bone is removed as well as the bone
of the internal auditory canal [24]. A petrous apicectomy can also be performed. When completed,
the translabyrinthine exposure is limited by the
sigmoid sinus posteriorly, the tegmen dura superiorly, the skeletonized facial nerve anteriorly, and
the jugular bulb inferiorly [24]. This is then combined with the temporal craniotomy and division
of the tentorium as described earlier.
The indications for a translabyrinthine petrosal
approach are the same as those for a PLPA petrosal approach, but it is best used in patients with
no useful hearing ipsilaterally. It provides more
exposure to the internal auditory canal than the
PLPA petrosal approach and is generally easier
and quicker to perform [24].
Incision and initial exposure

for the presigmoid petrosal approach
The skin incision and soft tissue dissection are
basically the same for all the variations of the
presigmoid petrosal approach, except for the total
petrosectomy, which requires division of the
external auditory canal. A C-shaped incision is
made along the superior temporal line from near
the hairline anteriorly and is continued posteriorly
and inferiorly into the retroauricular region to the
area just posterior to the asterion, where it is then
extended to join the posterior aspect of an upper
cervical skin crease (Fig. 6). This allows the entire
incision to be hidden within the hairline, except
for its inferior segment, which is hidden within a
skin crease. This incision also allows for an anatomic dissection of the suboccipital musculature.
The hair is parted along the planned incision
line, and minimal hair is shaved only along the
incision line. The scalp, including the pericranium,
is elevated, and the cervical fascia is incised along
the incision line. The posterior aspect of the temporalis muscle is elevated and retracted anteriorly.
A muscle-sparing exposure of the suboccipital musculature is performed to reduce postoperative pain,
to have a multilayered overlapping soft tissue
Total petrosectomy
A total petrosectomy petrosal approach is
complex and time-consuming and has signicant
associated morbidity. For these reasons, it is reserved for giant petroclival intradural tumors with
bilateral extension, extensive encasement of the
vertebrobasilar system, or prior surgery or radiation [24,25]. This approach is also useful for large
medial clival tumors that have no deviation of the
brain stem to either side [24,25].
For this approach, a radical mastoidectomy with
complete labyrinthectomy is performed, and the
facial nerve is exposed along its entire length. The
temporal craniotomy is performed as described
earlier, but it extends farther anteriorly to the
anterior middle fossa. A zygomatic osteotomy incorporating the condylar fossa is performed. The
cochlea is removed, and the petrous carotid artery
is exposed from the posterior cavernous sinus to
the brocartilaginous ring surrounding the carotid
at its entrance into the skull base. This ring is divided, and the petrous carotid artery is transposed
anteriorly. The greater supercial petrosal nerve
and middle meningeal artery are sectioned, and
the facial nerve is transposed posteriorly [24,25,27].
The medial petrous apex and lateral clivus can
then be resected [24,27]. The dura is then opened,
Fig. 6. Incision for a standard presigmoid petrosal

approach. The upper limb of the incision follows the
superior temporal line. The lower end joins an upper
cervical skin crease.
428
closure, and to reduce atrophy of these muscles

from their denervation or devascularization, which
can produce a cosmetically signicant defect. Once
the cervical fascia has been opened, the underlying muscles can be identied by the direction of
their bers. Usually, the sternocleidomastoid muscle is encountered rst. Because part of this muscle inserts into the skin, dissection is performed
posteriorly over the surface of the muscle until
the posterior aspect of the muscle is identied. The
sternocleidomastoid muscle is then elevated anteriorly with the scalp ap. The splenius capitis, semispinalis capitis, and longissimus capitis muscles are
elevated from the occipital bone and reected posteriorly [24,25]. A mastoidectomy is then usually
performed, with the details of the mastoidectomy
dependent on which variation of the presigmoid
petrosal approach is used. The mastoidectomy exposes the sigmoid sinus and the tegmen dura,
making the temporal craniotomy easier and safer
to perform. As mentioned earlier, a temporal craniotomy is made to cover the anterior and posterior dimensions of the tumor, with its posterior
aspect extending at least 2 cm posterior to the
transverse-sigmoid junction [24,25]. As a result of
the exposure of the tegmen dura by the mastoidectomy, the temporal dura can often be stripped
from the overlying bone through this exposure
and the ap turned without the addition of any
burr holes. If a larger temporal craniotomy ap
is planned, a slot can be drilled along the middle
fossa oor with a Midas Rex (Fort Worth, TX)
M8 or equivalent drill bit. A Woodson elevator
can then be used to separate the dura from the
overlying bone, and the ap can be turned using
a Midas Rex B1 footplate or its equivalent. This
minimizes the temporal bony defect, simplifying
the reconstruction and improving the cosmetic
result. The dura is then opened, and the tentorium
is divided as described earlier.
Reconstruction of mastoidectomy defects
during presigmoid petrosal approaches
Reconstruction of mastoidectomy defects has
been advocated for two major reasons: to prevent
cosmetic deformity and to help prevent CSF leak
by using the bone to tamponade the fat graft
against the dura [26,2830]. Defects from extensive
mastoidectomies can be disguring to patients. If
only a fat graft is used for reconstruction, the graft
can atrophy, resulting in an unsightly depression
in the retroauricular region [25,26,28,30]. Larger
defects from more aggressive bone removal may
result in sinking or displacement of the ear.
One method of mastoid reconstruction involves

the fragmentary removal of the mastoid bone with
a rongeur and replacement of these bone fragments into the mastoidectomy defect at the time
of closure [30]. These fragments are mixed with
brin glue and placed over the defect without an
abdominal fat graft [30]. The bone fragments
mixed with brin glue are thought to provide sufcient volume to tamponade the dura and prevent
CSF leak [30]. A potential drawback of this technique is the possibility of infection or mucocele
formation from the presence of retained mucosa
in the bone chips from the mastoid air cells.
An alternative technique described by Couldwell and Fukushima [28] involves undercutting
the outer table of bone of the mastoid with an
oscillating saw. A one-piece temporal and suboccipital bone ap is removed. The outer table of bone
overlying the mastoid is removed with an oscillating saw or a small, high-speed, cutting drill bit [28].
The remainder of the mastoidectomy is completed
in the standard fashion. The outer table of the
mastoid bone is then plated into its original position over a fat graft covering the mastoidectomy
defect. One possible complication of this technique
is sigmoid sinus laceration [30].
A third method of reconstruction and the one
that seems to have gained the most prevalence is
to harvest a split calvarial graft from the inner
table of the temporal craniotomy ap, which is
plated over the mastoidectomy defect (Fig. 7)
[24,25,29]. This bone can be split through the diploe using a reciprocating saw, the Midas Rex C1 or
an equivalent drill bit, or an osteotome. Using the
saw or drill to begin the cut, followed by the osteotome, usually provides a more precise cut than
using the osteotome alone and usually requires
less time than using the reciprocating saw or drill
alone. Once the bone is split, the craniotomy ap
with its intact outer table is plated back into its
original position. The dura is closed with a dural
graft or autologous pericranium, or the fat graft
is placed directly over the dural defect. The remainder of the mastoidectomy defect is packed
with autologous fat, and the entire construct is
augmented with brin glue. The split calvarial
bone graft is then trimmed to the proper size and
plated into its nal position over the mastoidectomy defect.
Once the bony reconstruction is completed,
the temporalis muscle and suboccipital musculature are sutured to their respective lines of origin or
insertion to multiple small holes in the bone. These
holes in the bone are generally made at oblique
429
Fig. 7. Split calvarial reconstruction of a mastoidectomy defect after a presigmoid petrosal approach. The inner table of
the temporal craniotomy is used to reconstruct the defect.
angles using the Midas Rex C1 or an equivalent

drill bit. This re-establishes the anatomic and functional integrity of these muscles. The scalp is then
closed in the usual fashion.
A retrosigmoid approach is indicated for the
resection of selected vestibular schwannomas,
cerebellopontine angle meningiomas, lateral petrous ridge meningiomas, or tumors of the lateral
cerebellar hemisphere; for microvascular decompression of cranial nerves V, VII, or VIII; or for
selected cases of vestibular nerve sectioning.
The patient is placed in the lateral decubitus
or park bench position so as to avoid excessive
turning of the neck, which possibly impairs
venous drainage [31]. From the esthetic standpoint,
having the head turned only slightly more than the
body with the neck laterally exed away from the
side of the operation places tension on the soft
tissues of the neck and improves the exposure
of landmarks useful for the placement of a more
cosmetic skin incision.
A gently curved or C-shaped incision in the
retroauricular region yields an excellent cosmetic
result. The incision begins just superior and posterior to the pinna, continues into the retroauricular
region to the area just posterior to the asterion,
and then is extended to join the posterior aspect
of an upper cervical skin crease (Fig. 8). This
allows the entire incision to be hidden within the
hairline, except for the inferior segment, which is
hidden within a skin crease. This incision also

allows for anatomic dissection of the suboccipital
musculature. A muscle-sparing exposure of the
suboccipital musculature is performed to reduce
muscle atrophy from denervation and devascularization, which can produce a cosmetically signicant defect.
incision line. Once the cervical fascia has been
opened, the underlying muscles can be identied
by the direction of their bers. The sternocleidomastoid muscle is usually encountered rst.
Because part of this muscle inserts into the skin,
dissection is continued posteriorly until the posterior aspect of this muscle is identied. The sternocleidomastoid muscle is then elevated anteriorly
with the scalp ap. The splenius capitis, semispinalis capitis, longissimus capitis, and rectus
capitis muscles are elevated from the occipital
bone and reected posteroinferiorly [24,25,31].
The bony exposure includes the bone of the suboccipital region as well as the base of the mastoid
process [31]. The lip of the foramen magnum can
be exposed if needed.
A craniotomy is preferred to a craniectomy.
This is for cosmetic reasons as well as to reduce
the incidence of postoperative headaches from
adhesions of the muscle forming to the underlying
dura. The craniotomy can be performed by placing
a burr hole inferior and medial to the transversesigmoid junction, separating the underlying dura,
and then turning the ap with the Midas Rex B1
430
Fig. 8. Incision for a retrosigmoid craniotomy. The lower end of the incision joins an upper cervical skin crease. This
incision allows for an anatomic dissection of the suboccipital musculature.
footplate or its equivalent. An alternative and preferred method is to use the Midas Rex M8 or an
equivalent drill bit to make a slot the width of
the bit outlining the craniotomy ap. The advantages of this are that the slot can be made over the
edges of the transverse or sigmoid sinuses, because
direct visualization of the dura in the depths of
the slot is possible as the bone is thinned before
penetration of the bone. This slot is made circumferentially around the planned craniotomy ap,
obviating the need for the Midas Rex B1 footplate
or its equivalent. This is generally a safe method
of performing the craniotomy because of direct
visualization of the dura during the drilling, which
compensates for the irregular contour of the inner
table of bone of the posterior fossa as well as for
some variability in the location of the sinuses.
With the burr hole/footplate method, the ap is
usually located suciently far from the sinuses
for safety reasons so that additional bone removal
is needed for adequate exposure after the ap is
turned. The lip of the foramen magnum can be
included in the craniotomy ap if needed. The size
of the craniotomy is completely dependent on the
pathologic ndings at hand. Sometimes, a craniectomy instead of a craniotomy is necessary in
elderly patients or in patients with extremely

adherent dura.
Once the edges of the transverse and sigmoid
sinuses are exposed, the dura is opened with a
curvilinear incision that parallels the course of
the sigmoid and, subsequently, the transverse sinuses. The inferior aspect of the incision is opened
rst so that CSF can be drained from the cisterna
magna or lateral cerebellomedullary cistern to relax the cerebellum, making the remainder of the
dural opening safer and easier [31]. Small relaxing
incisions can be made in the remaining dura adjacent to the sinuses so that the small dural aps
along the transverse sinus can be retracted superiorly and those along the sigmoid sinus can be
retracted anterolaterally, maximizing intradural
exposure lateral to the cerebellum. The large dural
ap over the cerebellar hemisphere can be left in
place to protect the cerebellum.
Once the dura is closed, the craniotomy ap
is replaced with titanium miniplates. If additional
bone removal is required after the craniotomy ap
is turned, the residual defect present after replacing
the bone ap can be repaired with a small split calvarial graft from the existing bone ap, titanium
mesh, hydroxyapatite cement, or any combination
of these techniques. If a craniectomy is performed

instead of a craniotomy because of the patients
age, adherent dura, or surgeons preference, a cranioplasty is recommended not only for cosmetic
reasons but to reduce the incidence of postoperative headaches from adhesion formation between
the suboccipital musculature and the underlying
dura. The cranioplasty can be performed using
titanium mesh, hydroxyapatite cement, or a combination of the two. The mesh can be used as a
framework or skeleton for the hydroxyapatite.
The muscles are re-elevated to their anatomic
positions and resecured to the superior nuchal line
with sutures to either the plates holding the bone
ap or small oblique holes drilled into the superior
nuchal line using the Midas Rex C1 or an equivalent drill bit. The sternocleidomastoid muscle is
returned to its original position when the scalp ap
is returned to its original position. This not only
produces an overlapping multilayered soft tissue
closure, but re-establishes the normal anatomic
and functional integrity of the muscles, reducing
postoperative muscular pain and subsequent atrophy and improving the esthetic outcome.
Extreme lateral partial transcondylar approach
The extreme lateral transcondylar approach is
indicated for neoplastic or vascular lesions of the
ventral surface of the cervicomedullary junction
or the lower clivus [32]. A retrocondylar approach
can be used for intradural lesions that are lateral
or anterolateral to the cervicomedullary junction,
which simplies the exposure, because no condyle
removal is required [32]. The partial transcondylar approach is indicated for intradural lesions
located anterior to the cervicomedullary junction
[32]. This approach carries the advantage of requiring the removal of only the posterior one third of
the occipital condyle and superior articular facet of
C1, making the need for occipitocervical fusion
unlikely [32]. Removal of this amount of occipital
condyle usually maximizes lateral intradural exposure. Removal of more condyle is usually only
needed if the bone of the clivus has to be exposed
or removed anterior to the ventral dura of the cervicomedullary junction. For this reason, an extreme
lateral complete transcondylar approach is usually required only for extradural lesions of the
lower clivus and generally necessitates an occipitocervical fusion [32].
The patient is usually placed in the lateral decubitus or park bench position with the neck laterally exed away from the side of the surgery. This
431
generally maximizes exposure of the structures in

the suboccipital region and prevents venous compromise by excessive turning of the head [32,33].
A gently curved or C-shaped incision in the retroauricular region yields an excellent cosmetic result
[32,33]. The incision begins just superior and posterior to the pinna, continues into the retroauricular region to the area just posterior to the asterion,
and then extends to join an upper cervical skin
crease. This allows nearly the entire incision to
be hidden within the hairline, except for the inferior segment, which is hidden within a normal
skin crease. This incision also allows for an anatomic dissection of the suboccipital musculature.
This incision is similar to that of the retrosigmoid
approach, except that it is longer and extends
further inferiorly in the cervical skin crease to allow for the additional inferior exposure required
(Fig. 9).
An inverted U-shaped incision or an incision
shaped like the number 7 can be used if an occipitocervical fusion is likely to be needed. The
number 7 incision has its horizontal limb along
the superior nuchal line from the midline, with
its vertical component following the mastoid bone
into a cervical skin crease at its terminus (Fig. 10).
The inverted U-shaped incision follows a similar
course, but its other vertical limb follows the
midline. Both of these incisions allow a midline
exposure to be used for the occipitocervical fusion,
which is usually performed as a second-stage
procedure.
incision line. Again, a muscle-sparing exposure is
performed. Once the cervical fascia has been
opened, the underlying muscles can be identied
by the direction of their bers. Usually, the sternocleidomastoid muscle is encountered rst. Because
part of this muscle inserts into the skin, dissection
is continued posteriorly until the posterior aspect
of this muscle is identied. The sternocleidomastoid muscle is then elevated anteriorly with the
scalp ap.
This is not possible with the 7- or U-shaped
incisions, where the sternocleidomastoid muscle
must be separated from the skin. When the sternocleidomastoid muscle is separated from the scalp
ap, care must be taken to leave sucient thickness of tissue with the skin to prevent necrosis.
The sternocleidomastoid muscle is then usually
reected inferiorly.
The splenius capitis, semispinalis capitis, and
longissimus capitis muscles are elevated from the
432
Fig. 9. Incision for an extreme lateral transcondylar approach. The lower end of the incision joins an upper cervical skin
crease. This incision allows for an anatomic dissection of the suboccipital musculature.
occipital bone and reected posteroinferiorly

[24,25,3133]. At this time, the suboccipital muscles, including the superior and inferior oblique
muscles and the rectus capitis major and minor
muscles, are encountered. The transverse process
of C1 should be palpable as well [33]. The vertebral artery lies in the sulcus arteriosus along the
superior aspect of the C1 lamina in the depths of
the suboccipital triangle (formed by the superior oblique, inferior oblique, and rectus capitis
major muscles). All musculature is detached from
the lateral mass of C1 and reected medially [33].
Note that except for the sternocleidomastoid
muscle, which partially inserts into the skin, all
the musculature is generally reected medially to
keep the soft tissues from obstructing the far lateral exposure.
Because the small muscles of the suboccipital
triangle can be dicult to identify safely during
surgery or it can be too time-consuming to dissect
these muscle distinctly, the larger muscles are reected medially as described earlier, and the remaining deep musculature is dissected free from
the lateral mass of C1 once this structure is palpable. Instead of searching for the vertebral artery
in the suboccipital triangle, it can be located at the
transverse foramen of C1 or C2, or the dorsal
ramus of C2 can be used as a guide to the artery as

it runs between the transverse foramina of C1 and
C2 [33]. The venous plexus surrounding the artery
serves as a warning that the dissection is occurring
directly adjacent to the arterial wall. The transverse foramen of C1 is opened with the combination of a small rongeur and a small diamond drill
bit, and the vertebral artery is dissected and mobilized from the transverse foramen of C2 to its dural
entrance near the foramen magnum. The artery is
then retracted medially with a vessel loop, providing maximal lateral exposure to the occipital
condyle, the atlanto-occipital joint, and the remaining lateral mass of C1. During the mobilization of the vertebral artery, the venous plexus
surrounding the artery can be carefully cauterized with bipolar electrocautery as needed without
aecting the patency of the vertebral artery itself.
A small craniotomy is performed that exposes
the sigmoid sinus and posterior jugular bulb and
extends approximately 3 cm posterior to the sigmoid sinus [32]. This can be a craniectomy if a
craniotomy is contraindicated, but a craniotomy
is preferred for reasons discussed earlier. This
craniotomy also includes the lip of the foramen
magnum [33], but this can be removed separately
or craniectomized if necessary. The craniotomy
433
Fig. 10. Alternate incision for an extreme lateral transcondylar approach for when an occipitocervical fusion is planned
as a second-stage procedure. This spares the midline for the second-stage procedure without compromising the blood
supply to either incision.
can be performed with a circumferential slot using

the Midas Rex M8 or an equivalent drill bit as discussed for the retrosigmoid approach. It can also
be performed with a single burr hole near the sigmoid sinus and the Midas Rex B1 footplate or its
equivalent, also as discussed earlier for the retrosigmoid approach. The slot method is preferred
for cosmetic reasons, because the craniotomy can
be more precisely performed and can be located
closer to or directly over the edge of the sigmoid
sinus without the danger of the footplate lacerating the sinus.
A partial mastoidectomy and complete unroofing of the sigmoid sinus and jugular bulb are
performed next, but in patients in whom these
structures are likely to be adherent, this can be
performed before the craniotomy, making the craniotomy safer. The only drawback to doing the
partial mastoidectomy rst is that it may leave a
larger bone defect than performing a craniotomy
with the slot technique rst. This is a matter of
surgical judgment given the conditions of an
individual case, but safety must obviously take
precedence to cosmetic concerns. In younger patients with nonadherent dura, the slot technique
works well to expose the sigmoid sinus partially.
Minimal bone removal is then necessary to complete the exposure of the sigmoid sinus and jugular
bulb. It is also in these younger patients where
cosmetic concerns are generally more signicant.
For an extreme lateral retrocondylar approach,
the exposure is complete, and no resection of the
occipital condyle is performed [32,33]. This approach is indicated for intradural lesions lateral
or anterolateral to the cervicomedullary junction
[32,33]. Mobilization of the vertebral artery is
usually not needed for this approach. The dura
is opened as described for the retrosigmoid
approach.
For an extreme lateral partial transcondylar
approach, vertebral artery mobilization and transposition, as described earlier, are needed. The atlanto-occipital joint is identied, and its capsule
is opened over its posterior one third. The posterior one third of the occipital condyle and C1
lateral mass are then removed using a drill. The
hypoglossal canal is the anterior limit of the condylar resection [32,33]. This amount of condylar
resection usually does not cause sucient instability to require an occipitocervical fusion [32].
The dura is opened parallel and adjacent to the
sigmoid sinus and inferiorly continues medial to
434
the dural entry point of the vertebral artery [33].

The incision is begun over the basal cisterns, which
are opened and drained of CSF. This relaxes the
brain further and facilitates the remainder of the
dural opening. The dura is opened circumferentially around the vertebral artery at its point of
dural entry. Several relaxing incisions are made
up to the sigmoid sinus, which is retracted laterally, retracting the sinus and maximizing intradural exposure. The vertebral artery can be
further mobilized intradurally by sectioning the
intradural rootlets of C1 and the rst dentate
ligament [33].
Once the dura is closed, the craniotomy ap is
replaced with titanium miniplates. If additional
bone removal is required after the craniotomy ap
is turned, the residual defect present after replacing
the bone ap can be repaired with a small split calvarial graft from the existing bone ap, titanium
mesh, hydroxyapatite cement, or any combination
of these techniques. If a craniectomy is performed
instead of a craniotomy because of the patients
age, adherent dura, or surgeons preference, a cranioplasty is recommended not only for cosmetic
reasons but to reduce the incidence of postoperative headaches from adhesion formation between
the suboccipital musculature and the underlying
dura. The cranioplasty can be performed using
titanium mesh, hydroxyapatite cement, or a combination of the two. The mesh can be used as a
framework for the hydroxyapatite.
The muscles are re-elevated to their anatomic
positions and resecured to the superior nuchal line
with sutures to either the plates holding the bone
ap or small oblique holes drilled into the superior
nuchal line using the Midas Rex C1 or an equivalent drill bit. The sternocleidomastoid muscle is
returned to its original position when the scalp ap
is returned to its original position (when the Cshaped scalp incision is used). This not only produces an overlapping multilayered soft tissue closure,
but re-establishes the normal anatomic and functional integrity of the muscles, reducing postoperative muscular pain and subsequent atrophy and
improving the esthetic outcome.
Extradural cranial base approaches

Frontotemporal craniotomy
with orbitozygomatic osteotomy
A frontotemporal craniotomy with an orbitozygomatic osteotomy is indicated for extradural
lesions of the anterior and middle fossae, medial
sphenoid wing, clinoidal region, Meckels cave,

or anterior or lateral cavernous sinus. The incision
and exposure are the same as for the intradural
approach discussed earlier. A lumbar drain is extremely helpful in facilitating exposure during
extradural approaches by increasing brain relaxation from controlled CSF drainage. Details of
the craniotomy, osteotomy, and reconstruction
are provided in the article in this issue on osteotomy design and execution.
Subtemporal-infratemporal approach
In general, a zygomatic osteotomy is used to
increase the subtemporal exposure provided by a
temporal craniotomy. Indications include extradural lesions of the middle fossa, petrous apex, inferolateral cavernous sinus, or Meckels cave [5,31].
Extradural lesions extending into the middle and
lower clivus or infratemporal fossa may require
a subtemporal-infratemporal approach [35]. A
temporal craniotomy with a zygomatic osteotomy
is the basis of the subtemporal-infratemporal approach. If exposure of the vertical segment of the
petrous internal carotid artery is required, the
zygomatic osteotomy can be extended to include
the condylar (glenoid) fossa.
The patient is generally placed in the supine
position with an ipsilateral shoulder roll, and the
head is turned approximately 70 to the contralateral side. Again, placement of a lumbar drain
is extremely helpful in facilitating extradural exposures through improved brain relaxation. A
bicoronal or question mark incision can be used
depending on the patients hairline and the exposure required. The incision is the same as for a
frontotemporal craniotomy with an orbitozygomatic osteotomy (see Figs. 14). Having the
anterior limb of the incision follow the superior
temporal line instead of extending to the midline
may restrict exposure to the anterior middle
fossa oor and sphenoid wing without extending
the incision anteriorly onto the skin of the forehead. The inferior end of the incision is placed in
the pretragal skin crease and extends to the inferior
edge of the zygomatic root. Placement of the incision in the pretragal skin crease minimizes the
possibility of injury to the frontotemporal branch
of the facial nerve or the superior temporal artery.
If a subtemporal-infratemporal approach is planned, the inferior end of the incision starts near
the root of the earlobe and curves around the
tragus, also in the pretragal skin crease (Fig. 11)
[20,34].
435
assistance of gravity. Placement of a lumbar drain

is nearly essential to increase relaxation of the brain
and reduce the need for frontal lobe retraction.
A bicoronal incision is used, with the lower
ends of the incision extending into the pretragal
skin creases but ending at the superior edges
of the zygomatic roots. As usual, a minimal hair
shave is performed only along the incision line.
The incision is placed fairly far posteriorly (at
least 15 cm above the nasion) [37] to provide for
the long pedicled pericranial graft needed for the
reconstruction. This is several centimeters more
posterior than the bicoronal incision used for the
other approaches discussed (Figs. 12 and 13).
The details of the techniques involved in the
remainder of the soft tissue exposure, craniotomy,
osteotomy, and reconstruction are provided in
execution.
Fig. 11. Incision for a subtemporal-infratemporal approach when the zygomatic osteotomy is to include the
condylar fossa. Note that the incision follows the pretragal skin crease and curves around the tragus.
Extreme lateral complete transcondylar approach

The basic exposure of the extreme lateral transcondylar approach as well as the retrocondylar
The details of the techniques for the remainder

of the exposure, craniotomy, zygomatic osteotomy,
and zygomatic osteotomy, including the condylar
fossa, are provided in the article in this issue on
osteotomy design and execution.
Extended subfrontal transbasal approach
The extended transbasal (extended frontal or
subfrontal transbasal) approach is primarily used
for extradural midline tumors of the anterior,
middle, and posterior cranial fossae [3638]. The
extradural limitations of this approach are the
areas lateral to the optic nerves, anterior clinoid
processes, superior orbital ssures, dorsum sella,
and posterior clinoids; the area lateral to the hypoglossal canals; and the area below the anterior arch
of C1 [36]. Excellent extradural exposure of the
medial cavernous sinuses can also be provided by
this approach.
If olfaction is not present before surgery or the
cribriform plate has been invaded by tumor, the
olfactory nerves are sacriced, and a biorbitofrontoethmoidal osteotomy is performed. If olfaction
is present before surgery and the cribriform plate
is free of tumor, a biorbital osteotomy with a circumferential cribriform osteotomy is performed.
The patient is placed in the supine position with
the head in the midline with slight extension so as
to facilitate elevation of the frontal lobes with the
Fig. 12. Anterolateral view of the incision for an

extended subfrontal transbasal approach. The incision
is further posterior than a standard bicoronal incision to
allow for the long pericranial graft needed for the
reconstruction.
436
placement of a lumbar drain unless contraindicated by tumor mass eect. The reconstruction is
the same as described earlier for the other extreme
lateral approaches. The occipitocervical fusion is
usually performed as a second-stage procedure 1
to 3 days later but can be delayed by 2 to 4 weeks
in the presence of CSF eusion [32]. A cervical
collar is worn the entire period between tumor resection and occipitocervical fusion.
Transsphenoidal approach
Fig. 13. Frontal view from above of the incision for

an extended subfrontal transbasal approach. The incision
is further posterior than a standard bicoronal incision to
allow for the long pericranial graft needed for the
reconstruction.
and partial transcondylar variants was described

earlier in this article. A complete transcondylar
approach is usually only required for extradural
lesions of the lower clivus. This approach usually
results in sucient instability of the craniovertebral junction such that an occipitocervical fusion
is generally performed afterward [32].
The main dierence between this approach and
the intradural approach discussed earlier is that
the entire occipital condyle is removed. After resection of the posterior one third of the condyle
up to the hypoglossal canal is completed, removal
of bone is continued superior and inferior to the
hypoglossal canal, removing most of the jugular
tubercle and the entire occipital condyle. This
results in extradural exposure of the midclival
region [32]. Subsequent removal of the lateral mass
and lateral portion of the anterior arch of C1 provides extradural exposure of the lower clivus and
odontoid process [32].
Because the dura is not opened, signicant additional brain relaxation can be provided by the
The ecacy of the transsphenoidal approach is

well demonstrated for intrasellar lesions. It can
also be used for the biopsy or resection of lesions
in the sphenoid sinus or infrasellar midclivus [39].
Parasellar lesions with extension beyond the anterior genu of the intracavernous internal carotid
artery can be biopsied through this approach,
but poor visualization and exposure of these areas
make resection dicult [39].
A transnasal transseptal approach is less invasive than a sublabial approach yet does not sacrice three-dimensional microscopic vision. It is
well suited for patients with either smaller intrasellar tumors or larger nostrils. This approach generally causes no cosmetic deformity. Conversion to a
sublabial approach is recommended rather than
the use of a relaxing incision from the nostril into
the facial skin from the cosmetic standpoint.
Patients with larger tumors, infrasellar clival
lesions, or small nostrils are usually treated with
a sublabial transseptal transsphenoidal approach
because of the improved exposure provided over
the transnasal approach. The sublabial approach
generally results in no cosmetic deformity but is
more invasive than the transnasal variant and can
produce temporary numbness of the upper teeth
and associated gumline.
An additional indication for a transsphenoidal
approach is as an adjunct to an extended subfrontal transbasal approach. The addition of the
transsphenoidal approach can provide additional
extradural exposure of the dorsum sella posterior
to the sella turcica, which is an area poorly visualized by the transbasal approach because of the
angle of the exposure.
Transoral approach
The transoral-transpharyngeal approach is
another extradural approach that usually results
in no cosmetic deformity. It is generally used for
midline extradural lesions of the craniovertebral
junction or odontoid process. It is usually not
recommended for intradural lesions or for lesions

extending beyond 2 to 3 cm lateral to midline
[40]. The usual rostrocaudal limits are from the
lower one third of the clivus to the superior aspect
of the third cervical vertebral body [40].
In patients with limited jaw mobility, an adjunctive approach to provide the necessary exposure has been the midline stairstep mandibular
split with or without midline glossotomy [41,42].
This approach requires external incisions through
the lip and chin [41,42]. The bilateral sagittal split
mandibular osteotomy as described by Vishteh
et al [42] is a potentially cosmetically superior
adjunct to a transoral approach in patients with
limited jaw mobility. This procedure provides the
necessary exposure of the craniovertebral junction
and uses only intraoral and mucosal incisions.
Combined approaches
The cosmetically favorable approaches discussed earlier can be combined if a tumor extends
into multiple areas of the skull base. An excellent
example of this is the combination of a subtemporal-infratemporal and basal subfrontal (extended
subfrontal transbasal) approach as described by
Sekhar et al [43]. This combination provides direct
exposure of the ipsilateral petrous and cavernous
internal carotid artery, ethmoid and sphenoid
sinuses, clivus, and infratemporal fossa, and the
entire procedure is performed through a bicoronal
incision [43]. The surgical technique for performing this combined procedure with minimal cosmetic deformity is described in the article in this
issue on osteotomy design and execution.
Other combinations include a combined presigmoid petrosal and retrosigmoid or extreme
lateral partial transcondylar approach for large
intradural tumors of the middle and lower clivus
(performed through a large C-shaped incision
extending more into the upper cervical skin crease
than a standard presigmoid petrosal incision);
a combined extended subfrontal transbasal and
frontotemporal orbitozygomatic approach for extradural tumors of the clivus, ethmoid and sphenoid sinuses, middle fossa, and medial and lateral
cavernous sinus (performed through a bicoronal
incision); a frontotemporal craniotomy with an
orbitozygomatic osteotomy that includes the condylar fossa (when an orbitozygomatic osteotomy
is required as well as exposure of the vertical petrous carotid artery); and a combined presigmoid
petrosal and frontotemporal orbitozygomatic
437
approach for large intradural tumors of the upper and middle clivus extending more than 2 cm
above the dorsum sella.
The surgical techniques of the combined
extended subfrontal transbasal and frontotemporal orbitozygomatic approach (bifrontal and
unilateral temporal craniotomy with biorbital and
unilateral zygomatic osteotomy) are discussed in
execution. A frontotemporal craniotomy with an
orbitozygomatic osteotomy that includes the condylar fossa is performed through the same incision
as a frontotemporal orbitozygomatic approach,
except that the lower end of the incision needs to
curve further around the tragus as with a subtemporal-infratemporal incision.
For a combined presigmoid petrosal and frontotemporal orbitozygomatic approach, a question
mark incision is made from the midline hairline
to the zygomatic root and is bisected posteriorly
by an incision following the posterior aspect of the
superior temporal line that ends in an anterior cervical skin crease (Fig. 14) [24,25]. The suboccipital
musculature is elevated as described earlier for the
presigmoid petrosal approach, an interfascial dissection of the frontotemporal branch of the facial
nerve is performed, and the temporalis muscle is
completely elevated. The mastoidectomy can then
be performed, followed by the frontotemporal
craniotomy and orbitozygomatic osteotomy (with
or without the condylar fossa) and the retrosigmoid craniotomy (if needed) [24].
Occasionally, an extradural and intradural
cranial base approach can be combined for
lesions that are primarily extradural but have
an intradural extension, such as a clival chordoma
[20]. For the most part, however, complications
are best avoided by choosing from the available
intradural approaches for intradural lesions and
from the extradural approaches for extradural
pathologic ndings.
Transfacial approaches
A bicoronal incision is the most versatile and
useful incision for surgery of the anterior cranial
base. According to Posnick et al [44]: For exposure of the craniofacial skeleton above the Le Fort
I level, the most frequently used approach is the
coronal incision. This versatile incision allows for
camouaged access to the anterior and posterior
cranial vault, orbits, nasal dorsum, zygoma, maxilla,
pterygoid fossa, and temporomandibular joints.
438
Fig. 14. Lateral view of the incision used for a combined frontotemporal craniotomy with an orbitozygomatic osteotomy and a presigmoid petrosal approach. The question mark incision extends further posteriorly to allow the incisions
to intersect at a right angle and minimize the length of the posterior ap dependent on the occipital artery.
A Le Fort I osteotomy through an upper buccal

sulcus incision can be used along with the extended
subfrontal transbasal approach and its variations
for more extensive exposure of the cranial base
without facial incisions. Sailer et al [1] describe
the Le Fort I osteotomy as a part of a global
concept of surgical approaches for the resection
of tumors of the midface, skull base, and nasopharynx without facial skin incisions. Tumors of
the anterior cranial base, orbits, or ethmoid or
frontal sinuses can be removed by the subfrontal
transbasal approaches, whereas extension of tumor
into the maxillary sinuses or nasopharynx may
require the addition of a Le Fort I osteotomy [1].
Lawton and his colleagues [17,20,37] describe
a six-level classication scheme of transfacial
approaches to the midline skull base. The level
IV exposure is the transnasomaxillary, which uses
a modied Weber-Ferguson incision. The indications described are for nasopharyngeal lesions or
large clival lesions extending anteriorly, posteriorly, or inferiorly [17,20,37]. The level III exposure
is the transfrontal-nasal-orbital approach, including the supraorbital bar and the medial and
lateral orbital walls, which is performed entirely

through a bicoronal incision. The level V exposure
is the transmaxillary approach, which is performed
through an upper buccal sulcus incision with a Le
Fort I osteotomy. Concerning facial incisions,
Lawton and his colleagues [20,37] observed that
although two of our patients underwent surgery
via a level IV approach, we have learned that combining the level III and level V approaches during
the same operation usually provides the same
degree of surgical exposure and spares the patient
a facial incision. They subsequently concluded:
Facial incisions are seldom needed because of
the wide exposure that is possible with facial
degloving [20,37].
Despite the versatility aorded by the cranial base approaches described in this article, some
cases may require facial incisions, particularly
malignant tumors with invasion of the facial soft
tissues requiring an en bloc resection. In these
cases, a multidisciplinary team that includes an
otolaryngologist or plastic surgeon well versed in
cosmetic facial surgery maximizes the opportunity
for an optimal esthetic result.
Cranial nerve preservation

Functional and cosmetic considerations may
overlap with regard to cranial nerve preservation in cranial base surgery. Facial weakness and
diplopia have obvious functional and cosmetic
implications.
Even in patients with no useful vision in an eye
ipsilateral to a cavernous sinus tumor, a tailored
resection may need to be considered in patients
with preoperative conjugate eye movements.
Despite the absence of diplopia, postoperative
dysconjugate gaze could be considered a cosmetic
problem. Although the primary concerns are
disease control, patient safety, and functional
outcome, cosmetic issues like ophthalmoplegia
in an unseeing eye must factor into the overall
clinical decision-making process. Similarly, if
a cranial nerve is cut during the resection of a
cranial base tumor, repair is performed by direct
anastomosis or interposition graft even if it is a
nerve for ocular motility for an unseeing eye.
Transient cranial nerve decits are expected
after many cranial base procedures, even when
the nerves are anatomically intact. Most patients have transient ophthalmoplegia after cavernous sinus tumor resections. In patients in whom
eventual recovery of ocular motility is expected,
any corrective surgery for ocular misalignment is
usually postponed for at least 6 months after surgery [45]. Noninvasive treatment options while
awaiting eventual recovery include Fresnel prisms,
alternating eye patching, botulinum toxin injections, and ocular exercises for convergence insuciency [45,46].
Summary
Recent advances in the surgical techniques for
the resection of cranial base tumors have allowed
for improved degrees of tumor resection, functional
outcomes, and esthetic results. If the resection and
functional results are not compromised by procedures providing excellent cosmetic outcomes, there
is no reason to ignore or compromise the esthetic
aspect with regard to technical execution and planning. A thorough assessment of the patients preoperative decits and tumor anatomy and a working
knowledge of the available cranial base approaches
and their combinations permit the surgeon to
design an approach that allows for optimal tumor
resection with the best possible cosmetic result. In
a time when alternative treatment options like
439
radiosurgery exist for cranial base tumors, esthetic

outcome is a signicant quality-of-life issue that
patients consider in their decision to choose surgery
versus an alternative treatment.
References
[1] Sailer HF, Haers PE, Gratz KW. The Le Fort I
osteotomy as a surgical approach for removal of
tumours of the midface. J Craniomaxillofac Surg
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Osteotomy design and execution

Division of Neurosurgery, University of Texas Health Science Center at San Antonio,
4410 Medical Drive, Suite 610, San Antonio, TX 78229-3798, USA
Craniofacial osteotomies have become an integral part of contemporary neurosurgery because

of their ability to increase the exposure of deepseated lesions with reduced brain retraction. A
systematic approach to the performance of these
osteotomies coupled with meticulous bone work
capitalizes on their advantages without producing
any signicant cosmetic defects. Presented in this
article are detailed descriptions of the techniques
for performing these osteotomies with an emphasis on their cosmetic implications. Among those
discussed are orbital, extended orbital, orbitozygomatic, biorbital, biorbitofrontoethmoidal, zygomatic, and combined osteotomies.
Craniofacial osteotomies for improved exposure with minimal brain retraction have steadily
evolved, becoming progressively more successful
at reducing functional and cosmetic morbidity.
Principles established by craniofacial surgeon Paul
Tessier [1,2] provided the foundation for the development of facial osteotomies for craniofacial
exposure. His work showed that facial bones,
including the orbits, can survive being osteotomized and replaced and that intra- and extracranial
exposures can be successfully combined with an
acceptable risk of infection.
The evolution of craniofacial osteotomies for
intracranial work has increased the spectrum of
tumors and vascular lesions that are surgically
treatable. As these techniques have evolved, their
execution has become more standardized, increasing their speed and utility while solidifying
their indications. Once the operative team is facile
with these approaches and they can be eciently
E-mail address: CAB@neuroassocsa.com

(C.A. Bogaev).
performed with minimal morbidity, their full

advantages can be utilized. Among the associated
morbidities to be considered are not only functional decits but cosmetic defects.
Fortunately, the development of improved surgical equipment, including high-speed pneumatic
drills and microsagittal and reciprocating saws,
has allowed osteotomy techniques to ourish by
providing maximal exposures with little to no
esthetic side eects. This has provided them with
a permanent place in the neurosurgical armamentarium. Presented in this article is a description
of the indications and techniques for each of the
major types of craniofacial osteotomies, with special emphasis on their cosmetic implications. All
these exposures are designed to avoid facial incisions and are usually performed through incisions
hidden well behind the hairline.
Orbital osteotomy
Background
An isolated orbital osteotomy has become a
common and straightforward adjunct to a standard pterional, frontal, or frontotemporal craniotomy. Several methods have been reported with
increased exposure and cosmetic issues in mind.
The supraorbital approach reported by Jane et al
[3] in 1982, the supraorbital-pterional approach
of Al-Mefty [4] reported in 1987, and the orbitocranial approach reported by Smith et al [5] in 1989
use a single bone ap, including the orbital rim,
and all provide increased exposure to orbital and
cranial base vascular and neoplastic lesions. Cosmetic issues addressed include preservation of
the orbital rim with the bone ap simplifying reconstruction, but drawbacks include only limited
preservation of the orbital roof, the presence of a
PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 3 - 2
444
Fig. 1. Re-elevation of the temporalis muscle to multiple

holes drilled along the superior temporal line. Notice the
elliptical area anteriorly, where the interfascial dissection
of the frontotemporal branch of the facial nerve was
performed.
burr hole in the forehead, and the occasional diculty in passing the Gigli saw required for these
approaches [6].
Although these are excellent methods of
performing orbital osteotomies, alternative techniques have been developed to overcome some
of their minor limitations. Colohan et al [7] and
Persing et al [8] reported on the technique of
cosmetically removing and subsequently replacing
the anterior wall of the frontal sinus to obviate
the need for the forehead burr hole while further
improving basal frontal exposure. Other techniques have used an orbital osteotomy separate
from the craniotomy ap to preserve more of
the orbital roof and lateral orbital wall with the
osteotomy specimen to prevent postoperative pulsatile enophthalmos. Reportedly, preservation of
approximately 2.5 cm or two thirds of the orbital
roof and lateral orbital wall is sucient [9,10]. An
additional reason to perform a separate orbital
Fig. 3. Anterior view of frontotemporal craniotomy

with orbital osteotomy.
osteotomy from the primary craniotomy ap is

that the osteotomy can be left in place and only
the craniotomy ap removed in the event of
postoperative epidural abscess [9,10]. Leaving
the osteotomy in place is possible because the
bone is thin and in close contact with surrounding
vascularized tissue [11]. The main drawback of
the separate orbital osteotomy is that two aps
of bone have to be replaced instead of one during
the reconstruction, which is probably a minor
issue with the current state of craniofacial plating
systems. Both the one-piece and two-piece techniques are employed in multiple state-of-the-art
cranial base and vascular centers across the
world. Because of the lack of burr holes and more
controlled preservation of the orbital roof and
lateral orbital walls, the two-piece technique is described in detail here as the cosmetically superior
method, despite the lack of support in the literature
substantiating this claim.
Indications
Fig. 2. Key dening the graphic representations of the

various bone cuts for all subsequent drawings.
A standard orbital osteotomy substantially

improves exposure to pterional, frontal, and frontotemporal craniotomies. Useful circumstances for
this improved exposure and the associated reduced
445
Fig. 6. One patient 6 months after a right frontotemporal craniotomy and orbital osteotomy for resection of
a planum sphenoidale meningioma.
Fig. 4. Lateral view of frontotemporal craniotomy with

orbital osteotomy.
brain retraction include lesions of the anterior

fossa, orbit, orbital apex, anterior communicating
artery complex, parasellar region, suprasellar
region, retrosellar region, cavernous sinus, tentorial notch, anterior middle fossa, and olfactory
groove [36,10,12].
Technique
Positioning
the head in three-point pin xation. The head is
Fig. 5. View of orbital roof and lateral orbital wall cuts

for an orbital osteotomy. Note their relation to the
superior and inferior orbital ssures.
turned approximately 30 to the contralateral side

to facilitate the opening of the Sylvian ssure. The
head is placed in slight extension to allow gravity
to elevate the frontal lobe. Trendelenburg and
reverse-Trendelenburg maneuvers are generally
used for head depression and elevation during
the procedure to avoid undesired cervical traction
with the head in pins [9,13,14]. Mild hyperventilation (pCO2: 3035) and mannitol (0.51.0 gm/kg)
are commonly used for brain relaxation. A lumbar
drain can be placed in the absence of signicant
tumor mass in the tentorial notch or likely increased intracranial pressure. Slow drainage of
approximately 50 mL of cerebrospinal uid
(CSF) may increase brain relaxation, facilitating
the craniotomy and osteotomy with less chance
of brain contusion or dural tears [9,13].
Incision
Minimal or no hair is clipped to contribute
to the favorable cosmetic outcome and patient
satisfaction. The hair is usually parted along the
planned incision line, and approximately 0.5 to
1.0 cm of hair can be shaved on either side of the
incision to keep adhesive drapes in place and facilitate closure. Even if a small strip of hair is shaved,
sucient regrowth of hair stubble occurs after
approximately 2 weeks to allow the area of the
incision to be less noticeable and blend with the
surrounding hair. Also, patients with longer hair
can hide the area of the incision by combing the
surrounding hair over it.
Either a unilateral question markshaped incision or a bicoronal incision can be used. Incisions
are made well behind the hairline in either case
(except at the most anterior tip of the question
446
mark incision) so as to preserve hair anterior to the

incision and circumvent the bulk of the temporalis
muscle to prevent cutting it as well as to facilitate
its elevation later in the procedure. Incisions just
behind the hairline are cosmetically inferior [15]
because of the alteration in hair pattern, making
the incision signicantly more obvious in the short
term and long term. For this reason, most of these
incisions should be at least 3 cm behind the hairline
for optimal cosmetic results.
Whether a bicoronal or question mark incision
is used is also partially based on cosmetic concerns. In patients with a receding hairline or in
bald patients, a bicoronal incision is signicantly
less noticeable. If the hairline is high on the forehead, a question mark incision may provide inadequate basal frontal exposure unless the incision is
extended onto the forehead, resulting in a suboptimal esthetic result.
The lower end of either of the incisions is made
in the skin crease just anterior to the tragus. This is
more cosmetic, hiding the incision in a normal skin
crease. It also avoids injury to the frontotemporal
branch of the facial nerve and supercial temporal
artery [9,10,13].
Exposure
Once the incision is made, the pericranium and
scalp are usually elevated together, with the pericranium harvested at the end of the procedure if
or when a pericranial ap is needed. Leaving the
pericranium attached to the remainder of the scalp
prevents its desiccation or inadvertent injury
before it is needed [16]. Elevation of the pericranium and scalp is continued leaving the temporalis
fascia intact until only the anterior one fourth of
the temporalis fascia has not been exposed. At this
point, the supercial temporalis fascia divides into
two layers to surround a sickle-shaped layer of fat
[17]. Because the frontotemporal branch of the
facial nerve lies supercial to the supercial temporalis fascia and the subgaleal fat pad [18] and has
occasional twigs entering the intrafascial space
[18], performing an interfascial dissection and elevating this intrafascial fat pad protect the nerve
from injury. To do this, the supercial layer of
the supercial temporalis fascia is incised approximately 2 cm posterior to the zygomatic process of
the frontal bone and is extended from the region of
the anatomic keyhole anteriorly to the root of the
zygoma inferiorly [9,10,13]. Blunt dissection, usually with a periosteal elevator, is then used to elevate the sickle-shaped intrafascial fat pad from
the inner layer of the supercial temporalis fascia.
Fig. 7. Anterior view of extended orbital osteotomy

with the associated craniotomy aps.
Elevation of the fat pad is continued until the lateral orbital rim and superior zygomatic arch are
exposed [9,10,13]. The area of this interfascial
dissection usually correlates to approximately the
anterior one fourth of the temporalis muscle from
the keyhole to the zygomatic root.
Fig. 8. Lateral view of extended orbital osteotomy with

the associated craniotomy aps.
Fig. 9. Surgical view of extended orbital osteotomy with

the associated craniotomy ap. This specimen includes
the zygomatic arch.
Elevation of the scalp and pericranium is then

continued to expose the superior and lateral orbital rim. If a supraorbital foramen is present,
the supraorbital nerve and artery are freed by opening the foramen with a small osteotome [3].
The temporalis muscle is then elevated completely, with the posterior aspect of the scalp incision being undermined so as to elevate the muscle
without cutting it. Factors thought to contribute
to temporalis atrophy include denervation, devascularization, disuse, or muscle ber injury [19].
Not cutting the muscle, at least through the thick
portion, prevents devascularization or denervation of the separated portion. A periosteal elevator
is used to elevate the muscle with avoidance of
monopolar cautery, which is thought to damage
muscle bers and contribute to atrophy [19,20].
Fig. 10. A dierent view of the bone work in Fig. 9

demonstrating the orbital osteotomy from above. Note
the preservation of the orbital roof and lateral orbital
wall with the anterior wall of the frontal sinus incorporated into the orbital osteotomy.
447
Retrograde dissection of the muscle in the subperiosteal plane as described by Oikawa et al [19] and
Zabramski et al [20] is also used to prevent muscle
ber damage. Some alternatives exist to prevent
disuse atrophy, all of which involve completely
reconnecting the muscle to its anatomic origin,
keeping it under stretch, and allowing it to function
normally. One method involves leaving a cu of
muscle and fascia attached along the superior temporal line as described by Spetzler and Lee [21],
allowing the muscle to be sutured back to its origin
at the time of wound closure. Another method is to
elevate the temporalis muscle entirely and resecure
it at the time of closure with sutures to multiple oblique holes drilled along the superior temporal line
(Fig. 1). The second method carries the advantage
of not cutting the temporalis muscle at all. Excellent
results have been obtained with both techniques.
Craniotomy
With the soft tissue work completed, a frontal
or frontotemporal craniotomy is then performed
depending on the exposure requirements of the
procedure. The craniotomy and orbital osteotomy
are performed as separate pieces for reasons
described earlier. When performing a craniotomy
that extends across the sphenoid wing, the number
of burr holes is minimized so as to minimize cosmetic deformity. For example, a frontal burr hole
can be placed at the anatomic keyhole only and the
ap turned with the Midas Rex (Fort Worth, TX)
B1 footplate or an equivalent drill, or a frontotemporal ap can be turned from burr holes at the
keyhole and zygomatic root only. Instead of fracturing the ap across the sphenoid wing and rongeuring the remaining wing and temporal bone, a
slot can be drilled across the root of the sphenoid
wing, around the temporal tip, and along the middle fossa oor using the Midas Rex M8 or a
comparable drill bit. An alternative and preferred
method is to place no burr holes but only to make
the slot with its two ends large enough to accommodate a Woodson elevator for dural separation
and the Midas Rex B1 footplate or its equivalent
[9,13]. The appeal to this method is that the bone
removed is minimal and more precise, and a small
slot in the outer table can be enlarged in the inner
table by angling the drill as the cut is deepened.
This allows a larger area of dural striping, although producing only a small defect in the outer
table.
For a frontal craniotomy, a small slot can be
made only at the keyhole using a similar technique.
If the ap is to cross the superior sagittal sinus or
448
exposing a larger segment of the sinus through a

small supercial defect. The sinus can then be
partially stripped from the overlying bone with
a Woodson elevator.
Fig. 11. Anterior view of frontotemporal craniotomy

with orbitozygomatic osteotomy.
the sinus needs to be exposed, the Midas Rex M8

bit or its equivalent can be used to make a slot
across the sinus in the coronal plane approximately 3 mm wide, which is rarely cosmetically
signicant even if anterior to the hairline. The slot
can be progressively enlarged as it is deepened,
Fig. 12. Lateral view of frontotemporal craniotomy

with orbitozygomatic osteotomy.
Osteotomy
With the craniotomy completed, the periorbita
is separated from the orbital roof and lateral orbital
wall. The periorbita is most densely attached at the
orbital rim, so a freer or the sharp end of a Peneld
number 1 dissector is often used for this. Once the
periorbita of the rim is free, the remainder can be
separated with blunt instruments or cottonoids.
The periorbita is separated approximately 3 cm
from the orbital rim [9,10,13]. The dura is stripped
from the orbital roof and lateral wall intracranially.
The cuts through the orbital rim are made with a
reciprocating saw. Malleable brain retractors or
cottonoids are used to protect the dura and orbital
contents while the cuts are made. The reciprocating
saw allows for ne bone cuts because of its narrow
blade such that there is no signicant loss of bone
along the orbital rim with this technique. The rst
cut through the rim is made from approximately
the supraorbital notch to the medial edge of the
bone ap. The lateral cut is made at the junction
of the orbital rim and the zygomatic arch. Once
the thick bone of the orbital rim has been cut with
the reciprocating saw, the thinner bone of the orbital roof and lateral orbital wall can be cut with a
reciprocating saw, a small osteotome, or the Midas
Rex M8 or an equivalent drill bit [9,10,13]. Using
the Midas Rex M8 bit works well, because less
retraction is frequently required to make the cuts
and the tip of the drill can be watched closely as
the bone becomes transparent before penetration
of the bone. This allows for precise and safe bone
cuts. These posterior orbital cuts are made to preserve at least 2.5 cm or two thirds of the orbital roof
and lateral orbital wall so as to prevent postoperative pulsatile enophthalmos [9,10,13]. The superior
orbital ssure and region of the orbital apex are
avoided when the osteotomy cuts are made. There
is a higher risk of optic nerve injury or injury to
the nerves of the superior orbital ssure with cuts
near the orbital apex or superior orbital ssure
without adding any cosmetic advantage. With the
necessary cuts completed, the osteotomy is then
dislodged with the small osteotome and mallet.
The bone is carefully removed so that residual
adhesions to the periorbita can be separated to prevent tears in the periorbita (Figs. 25).
The remaining posterior orbital roof and lateral
wall are then separated from the surrounding dura
449
Fig. 13. View of orbital roof, lateral orbital wall, and zygomatic arch cuts for an orbitozygomatic osteotomy. Note their
relation to the superior and inferior orbital ssures.
Anterior clinoidectomy
A distinct advantage of an orbital osteotomy is
that it greatly facilitates an anterior clinoidectomy.
Instead of the orbitotomy described by Dolenc
[22], an orbital osteotomy removes the orbital
rim and preserves sucient orbital roof and wall
for cosmetic reconstruction. Once the orbital

osteotomy has been completed, the superior orbital ssure has been decompressed, and the orbital
meningeal artery is divided at the anterolateral
extent of the superior orbital ssure [10], the base
of the anterior clinoid process (ACP) is exposed.
A partial or complete extradural anterior clinoidectomy can then be performed depending on
the needs of the case and the size and conguration of the ACP. The ACP is usually cored using
a small diamond drill bit with copious irrigation
Fig. 14. Surgical view of a right frontotemporal

craniotomy with an orbitozygomatic osteotomy.
Fig. 15. Superior view of an orbitozygomatic osteotomy

at the time of surgery. Note the preservation of the
orbital roof and lateral orbital wall.
and periorbita and removed with a small rongeur.

The superior orbital ssure is widely decompressed
to maximize the exposure provided by the orbital
osteotomy [9,13].
450
Fig. 16. Inferior view of an orbitozygomatic osteotomy

at the time of surgery. Note the preservation of the
orbital roof and lateral orbital wall.
under the guidance of the operating microscope.

When a thin rim of cortical bone remains, it is
removed with ne rongeurs. The optic strut can
be removed after the ACP, and decompression of
the optic canal can be completed. Fracturing the
optic strut before removal of the ACP loosens
the ACP, making it too unstable for drilling. If
the ACP is long or complex, a partial extradural
clinoidectomy can be performed, with the remainder removed intradurally.
Dural incision
With the bone work completed, a curvilinear
dural incision is made near the posterior edge of
the bone ap with the dural ap based anteriorly.
This dural ap is then retracted anteriorly over the
Fig. 17. Anterior view of an orbitozygomatic osteotomy

at the time of surgery. Note the continuity of the orbital
rim with the zygomatic arch.
Fig. 18. Intradural exposure provided by a frontotemporal craniotomy with an orbitozygomatic osteotomy.
orbital osteotomy site, providing more basal exposure by retracting the orbital contents inferiorly.
Reconstruction
The frontal sinus is commonly opened by an
orbital osteotomy. If this is the case, the frontal
sinus is exenterated of mucosa, including the portion of the sinus contained in the orbital osteotomy
specimen. The sinus wall is then drilled thoroughly
with a diamond burr to prevent mucocele formation. The frontonasal duct is packed with rolls of
Surgicel (Johnson and Johnson Medical, Inc.,
Arlington, TX), and autologous abdominal fat
graft is used to obliterate the sinus. A local pericranial ap is harvested on its vascular pedicle using a
combination of sharp and scissors dissection, with
care being taken to preserve the associated galea.
The pericranial graft is placed over the fat graft
and the frontal sinus and sutured to the surrounding dura. When placing the pericranial graft, a
large graft is obtained and placed with signicant
slack to prevent puckering of the forehead, which
can occur with the pericranial ap under tension.
The entire construct can then be reinforced with
brin glue.
The orbital osteotomy and craniotomy aps
are then placed into their original position and
secured with titanium miniplates. With the performance of meticulous bone work during the
exposure, including preservation of at least two
thirds of the orbital roof and lateral orbital wall,
simply replacing the bone aps creates an excellent
cosmetic reconstruction. The temporalis muscle
can be sutured to multiple oblique holes drilled
along the superior temporal line as described earlier. These holes are usually made with the Midas
Rex C1 or an equivalent drill bit, and their oblique
Fig. 19. Surgical view after replacement of craniotomy

ap and orbitozygomatic osteotomy. Note the small
defect left by the slot and the lack of burr holes.
angles facilitate the passage of suture needles.

With the temporalis secured along the entire length
of its origin, atrophy is unlikely because of the
preservation of the muscles anatomic and functional integrity (Fig. 6).
Extended orbital osteotomy

Indications
This exposure is appropriate for large neoplasms of the anterior cranial fossa with extension
across the midline, such as olfactory groove meningiomas. Combined with a frontotemporal craniotomy with extension across the midline, the
advantages of a bifrontal and pterional craniotomy can be combined [9,10]. This approach
has also been referred to as a one-and-a-half
fronto-orbital approach. A notable feature of this
Fig. 20. Surgical view after re-elevation of the temporalis muscle. Note the reapproximation of the supercial
temporalis fascia.
451
Fig. 21. Anterior view of one patient 6 months after a

right frontotemporal craniotomy with an orbitozygomatic osteotomy for resection of an upper clival
meningioma. This patient had a question markshaped
incision.
approach is that the cribriform plate is not manipulated, thus sparing olfaction.
Techniques
Positioning
The patient is placed in a supine position with
turned approximately 20 to the opposite side to
provide a bilateral subfrontal view while allowing
for opening of the Sylvian ssure. The head is
placed in slight extension to allow gravity to aid
in elevating the frontal lobes. Mild hyperventilation (pCO2: 3035) and mannitol (0.51.0 gm/kg)
are commonly used for brain relaxation. As previously mentioned, head depression and elevation
are performed with Trendelenburg and reverseTrendelenburg maneuvers. Firmly securing the
patient to the table with belts, tape, and adequate
padding allows for signicant rotation about the
patients long axis during the procedure [14]. The
lateral thigh or lower abdomen is prepared and
draped for the possible autologous fat graft needed
for reconstruction.
Exposure
A bicoronal skin incision is usually used for this
approach so as to provide the required exposure
across the midline. As discussed earlier in this
article, minimal or no hair is shaved, and the incision is placed well behind the hairline. The lower
end of the incision is again placed in the pretragal
skin crease to protect the frontotemporal branch
of the facial nerve and the supercial temporal
artery.
452
Fig. 22. Lateral view of the patient in Fig. 21. Note

that the lower end of the incision is well hidden in the
The pericranium is elevated with the scalp for

reasons mentioned previously, and the temporalis
fascia is left intact until the anterior one fourth
of the temporalis muscle or the edge of the subgaleal fat pad is encountered. An interfascial dissection of the frontotemporal branch of the
facial nerve is performed as described in the
orbital osteotomy section of this article.
The elevation of the scalp and pericranium is
continued down to the orbital rims bilaterally.
Only the medial orbital rim needs to be exposed
contralaterally. The ipsilateral supraorbital nerve
is freed from its foramen with a small osteotome
[3], and the ipsilateral orbit is exposed from the
superomedial rim to the inferolateral orbital rim
near its junction with the zygomatic arch.
Fig. 23. Anterior view of one patient 1 year after a right

frontotemporal craniotomy with an orbitozygomatic
osteotomy for resection of a large sphenocavernous
meningioma. This patient had a bicoronal incision
because of his receding hairline.
Fig. 24. More lateral view of the patient in Fig. 23. Note
that the lower end of the incision is well hidden in the
The ipsilateral temporalis muscle is then elevated from its entire origin to the zygomatic arch,
with the posterior aspect of the incision undermined to elevate the entire muscle without cutting
it. The muscle is then retracted inferiorly and laterally to maximize exposure of the frontotemporal
region and orbital rim.
Craniotomy
The craniotomy and osteotomy are performed
as separate pieces for reasons discussed earlier. A
frontotemporal craniotomy is made ipsilaterally
extending almost to the midline. This craniotomy
can be initiated with burr holes at the keyhole,
zygomatic root, and just o the midline ipsilaterally along the posteromedial edge of the planned
craniotomy ap. A cosmetically superior alternative is to make a slot with the Midas Rex M8 or
an equivalent drill bit from the anatomic keyhole
to the root of zygoma that passes around the root
of the sphenoid wing, around the temporal tip, and
along the middle fossa oor en route to the zygomatic root (Fig. 8). The slot is slightly enlarged
on either end so as to accommodate the Woodson
elevator for dural stripping and subsequent placement of the Midas Rex B1 footplate or its equivalent. A slot is also made across the superior sagittal
sinus instead of the posterior burr hole being
made. This is a small curvilinear slot approximately 2 cm long and 3 mm wide that passes across
the superior sagittal sinus and exposes dura on
either side. Again, the drill can be angled as the slot
is made to remove more inner table than outer
table of bone, exposing more dura and sinus but
keeping the external bony defect small. The dura
can be stripped with a Woodson elevator with
the sinus under direct vision through the slot. The

frontotemporal craniotomy can then be turned by
placing the Midas Rex B1 footplate or its equivalent into the slot and directed away from the
superior sagittal sinus toward the posterior end
of the other slot at the zygomatic root. The last
cut can be made from the keyhole end of the large
slot to near the midline and then posteriorly to the
smaller slot over the superior sagittal sinus. This
allows the remainder of the superior sagittal sinus
to be stripped completely under direct vision. A
second craniotomy ap can then be turned, extending approximately 2 to 3 cm across the midline
[9,10].
This set of two craniotomy aps is created to
preserve the superior sagittal sinus in cases in
which the dura is adherent. An alternative and
more cosmetic method of performing a bifrontal
craniotomy is described in the biorbital osteotomy
section of this article. The extended orbital osteotomy can be used with either method.
Osteotomy
The ipsilateral periorbita is stripped from the
orbital roof and the medial and lateral orbital
walls. It is not necessary to strip any periorbita
contralaterally. As previously mentioned, the
periorbita is most adherent at the orbital rim, and
the same technique for stripping is used here as
described in the orbital osteotomy section. A notable dierence is that an adherent area is present in
the superomedial orbital wall near the rim. This
represents the trochlea of the superior oblique
muscle. This area is separated from the bone as
well but eventually heals to its original position
with just replacement of the orbital osteotomy at
the end of the procedure [9,10]. Elevation of the
periorbita is continued to approximately 3 cm
from the orbital rim.
The ipsilateral basal frontal dura is separated
from the orbital roof, and the dural elevation is
continued up to the lateral and anterior aspects
of the cribriform plate. The olfactory dural sleeves
are left undisturbed so that olfaction is spared
[9,10]. This is in contrast to the extended transbasal approach, where the olfactory nerves are sacriced or a circumferential cribriform osteotomy is
performed.
The osteotomy cuts are made through the
orbital rim laterally with a reciprocating saw at
approximately the junction of the orbital rim with
the zygomatic arch (Fig. 7,8). The reciprocating
saw is always used for cosmetically signicant cuts
in the facial bones or orbital rim [9,10]. Malleable
453
Fig. 25. Magnied view of the lower end of the incision

in the pretragal skin crease. It is well hidden in this
normal skin crease, despite its being out of the hairline.
brain retractors or cottonoids are used to protect

the dura and orbital contents while the cuts are
made. The second cut through the orbital rim is
made from the superomedial orbital rim to the
contralateral edge of the craniotomy defect. This
allows the glabella to be included with the orbital
osteotomy, which greatly improves basal frontal
exposure in the midline. If a large frontal sinus is
present, this medial cut is made through the orbital
Fig. 26. Anterior view of cosmetic bifrontal craniotomy

with biorbital osteotomy. Note the locations of the slots
and the microsagittal saw cut.
454
Fig. 29. Surgical view of cosmetic bifrontal craniotomy

with biorbitofrontoethmoidal osteotomy.
Fig. 27. Lateral view of cosmetic bifrontal craniotomy

with biorbital osteotomy.
rim and anterior frontal sinus wall only. The

remainder of the frontal sinus can then be cranialized. Posterior orbital cuts are made from the
intracranial side from the posterior aspect of the
medial orbital cut to the posterior aspect of the lateral cut. These cuts can be made with the Midas
Rex M8 or an equivalent drill bit, the reciprocating
saw, or a small osteotome. Again, care is taken to
make these cuts such that 2.5 cm or two thirds of
the orbital roof and lateral orbital wall are preserved to prevent postoperative pulsatile enophthalmos. The superior orbital ssure and orbital
apex are not included in the osteotomy cuts so
Fig. 28. Superior view of bone cuts for a biorbitofrontoethmoidal osteotomy.
as to avoid injury to the optic nerve or nerves of

the superior orbital ssure [9,10]. Once these posterior cuts are completed, the osteotomy is loosened
with a small osteotome and mallet and removed
(Figs. 710).
The superior orbital ssure is then completely
decompressed so as to take full advantage of the
additional exposure provided by the orbital osteotomy. An anterior clinoidectomy can performed if
needed. A description of this technique is provided
in the orbital osteotomy section of this article.
Dural incision
A curvilinear dural incision is made ipsilaterally
circumventing the Sylvian ssure and extending to
the basal midline anteriorly near the base of the
superior sagittal sinus. A contralateral dural incision is made in the basal frontal region only,
extending to the anterior midline at the base of
the superior sagittal sinus directly across from the
other dural incision. The superior sagittal sinus is
then suture ligated at its base and cut, providing
excellent bilateral basal frontal intradural exposure. The ipsilateral dural ap from the frontotemporal region is retracted over the orbital contents,
retracting them further and providing maximal
exposure [9,10]. Early during the intradural dissection, the olfactory tracts are dissected from the
basal frontal lobes to prevent avulsion of the olfactory nerves later in the procedure. The Sylvian
ssure can be opened, providing the maximum
intradural exposure aorded by this approach.
Reconstruction
The dura is closed in a watertight fashion if possible. If not, the dural defect is usually repaired
with an autologous pericranial free graft sewn circumferentially to the defect.
The frontal sinus is almost always opened by

this approach. The mucosa is exenterated, the
walls drilled with a diamond burr, the frontonasal
duct packed with Surgicel, and the residual sinus
obliterated with autologous fat. A pericranial graft
is then harvested based anteriorly on its vascular
pedicle. This ap is dissected from the overlying
galea using a combination of sharp and scissors
dissection. The ap is elevated to as near the orbital rim as possible to allow for a ap with enough
length to cover the frontal sinus defect with absolutely no tension. Tension on the graft after
replacement of the bone aps can produce puckering of the skin of the forehead. If ethmoid or sphenoid defects are present, they too are packed with
fat, and a larger ap is harvested to cover these
defects as well as the frontal sinus. The pericranial
ap is then sutured to surrounding dura to anchor
it in its nal position. The entire construct is then
augmented with brin glue.
The orbital osteotomy ap is replaced with titanium miniplates over the pericranial graft. The
bone aps are then plated back into their original
positions. Any residual defects in the bone can be
repaired with hydroxyapatite cement [9,10]. In
general, the one-piece bifrontal ap with a separate orbital osteotomy is cosmetically superior to
the two-piece craniotomy ap in that there is no
kerf in the forehead. Safety issues, such as patients
at risk for severe dural adhesions, must be considered rst, however.
The temporalis muscle is then re-elevated with
sutures to small holes drilled in the superior temporal line as discussed earlier. The supercial
temporalis fascial incision from the interfascial dissection of the frontotemporal branch of the facial
nerve can also be reapproximated to complete the
reconstitution of normal anatomy.
455
Fig. 30. Surgical view of inferior surface of biorbitofrontoethmoidal osteotomy.
Since Pellerin et al [24] and Hakuba et al

[25] initially reported on the orbitozygomatic
approach, multiple techniques for providing this
exposure have been developed. Although subtle
dierences exist among all the techniques reported, they can generally be placed into three
main categories: craniotomy and orbitozygomatic
osteotomy as one piece [2527], craniotomy and
orbital osteotomy as one piece with separate zygomatic osteotomy [28,29], and craniotomy with separate orbitozygomatic osteotomy [13,20,24,30,31].
As with orbital osteotomies, a single craniotomy/
orbitozygomatic osteotomy unit simplies reconstruction, but limitations include less controlled
Orbitozygomatic osteotomy
Background
The rationale for an orbitozygomatic osteotomy is similar to that for an orbital osteotomy.
The major advantage gained with the orbitozygomatic approach is a signicant increase in subtemporal exposure [23]. If subtemporal exposure is not
needed, an orbital osteotomy alone is likely to sufce. Similarly, a standard orbitozygomatic osteotomy is not performed with a frontal craniotomy
but only with a frontotemporal or pterional craniotomy.
Fig. 31. Surgical exposure provided by an extended

transbasal approach. This photograph was made at the
completion of resection of a clival chordoma. Note the
exposure of both cavernous carotid arteries.
456
cuts through the orbital roof and generally less

preservation of the orbital roof, the need for a
forehead burr hole, and occasional diculty in
passing the Gigli saw commonly used for these
procedures. Although the single frontotemporal
craniotomy/orbitozygomatic osteotomy unit is an
excellent method for this exposure, a craniotomy
with a separate orbitozygomatic osteotomy specimen provides several advantages. A more controlled cut along the orbital roof and lateral
orbital wall is possible, decreasing the likelihood
of postoperative pulsatile enophthalmos. Reportedly, preservation of approximately 2.5 cm
or two thirds of the orbital roof and lateral wall
is sucient [9,10,13,31]. Another advantage is that
the osteotomy can be left in place if the bone
ap has to be removed because of postoperative
epidural abscess [9,10,13,31]. This is possible because the osteotomy ap is composed of thin bone
and is in close contact with surrounding vascularized tissue [11]. As with the orbital osteotomy,
replacing two aps (craniotomy and osteotomy)
instead of one complicates the reconstruction,
but only slightly. Finally, the craniotomy with
a separate orbitozygomatic osteotomy is generally easier to perform than the one-piece technique [31]. Although all these techniques are
currently used in cranial base and vascular centers
across the world, the two-piece technique is presented here as the cosmetic technique of choice
because of the lack of burr holes and more controlled preservation of the orbital roof and lateral
orbital wall.
Indications
A frontotemporal craniotomy with orbitozygomatic osteotomy is often used for lesions of the
anterior and middle fossae, upper clivus, parasellar region, interpeduncular fossa, medial sphenoid
wing, clinoidal region, Meckels cave, tentorial
notch, or cavernous sinus or for basilar tip aneurysms [13,20,2527,30,31]. A more general indication is for lesions suitable for an orbital
osteotomy with a need for additional basal exposure to the middle fossa (subtemporal) [23], tentorial notch, or upper clivus [31].
Technique
Positioning
usually turned 30 to 35 to the contralateral side
to facilitate opening of the Sylvian ssure but

can be rotated up to 60 for lesions primarily
involving the middle fossa [13,20]. The head is
placed in slight extension, with the malar eminence
being the highest point. This facilitates gravitys
role in retracting the brain and maximizes venous
drainage. Again, mild hyperventilation (pCO2: 30
35) and mannitol (0.51.5 gm/kg) are used for
brain relaxation. A lumbar drain can be placed
in the absence of signicant tumor mass in the tentorial notch or in the likelihood of signicantly
increased intracranial pressure. Slow drainage of
approximately 50 mL of CSF may suciently
further relax the brain before dural opening,
preventing brain contusion or dural tears while
performing the craniotomy and osteotomy.
Incision
Minimal or no hair is shaved. Most often, the
hair is usually parted along the planned incision
line, and only 0.5 to 1.0 cm of hair is shaved on
either side of the incision to keep adhesive drapes
in place and to facilitate closure. Either a unilateral
question mark or bicoronal incision can be used,
with the incision being placed well behind the hairline for reasons discussed earlier. The anterior end
of the question mark incision does not cross onto
the forehead for cosmetic reasons. If the patient
has a receding hairline or suciently posterior hairline such that inadequate exposure is provided by a
question mark incision without extending it onto
the forehead, a bicoronal incision is used instead.
Crossing the anterior end of a question mark incision to the opposite midpupillary line [20] is an
option, but this does not produce the additional
exposure provided by a bicoronal incision and
can still provide insucient exposure in patients
with a receding hairline. The added eort of performing a bicoronal incision is more than compensated for by the reduced eort of performing the
orbitozygomatic osteotomy with improved exposure. The inferior end of either incision extends into
the pretragal skin crease so as to protect the frontotemporal branch of the facial nerve and supercial
temporal artery. This pretragal skin incision is continued only to the inferior aspect of the zygomatic
root and no lower for the same reasons.
Exposure
The pericranium is elevated with the scalp as
discussed earlier. The temporalis fascia is left
intact until the anterior one fourth of the temporalis muscle or the edge of the subgaleal fat pad is
457
inserting along the inferior aspect of the zygomatic

arch is freed with a periosteal elevator if possible
but is usually suciently adherent so that its insertion needs to be sharply incised to free the bone
from its soft tissue attachments.
The temporalis muscle is then elevated completely, with the posterior aspect of the incision
undermined so as to elevate the muscle without
cutting it. The muscle is then retracted inferiorly
and laterally to maximize exposure of the frontotemporal region.
Fig. 32. Large vascularized pericranial ap obtained by

undermining the posterior aspect of a posteriorly located
bicoronal incision. This photograph was made during
reconstruction of an extended transbasal approach.
encountered. An interfascial dissection of the frontotemporal branch of the facial nerve is performed
as described in the orbital osteotomy section. Elevation of the scalp and pericranium is then continued to expose the superior and lateral orbital rim.
If a supraorbital foramen is present, the supraorbital nerve and artery are freed by opening the
foramen with a small osteotome [3,9,10,13]. A
periosteal elevator is then used to expose the entire
zygomatic arch from its root to the region of the
zygomaticofacial foramen. The masseter muscle
Craniotomy
The craniotomy and osteotomy are performed
as separate pieces for reasons outlined earlier. A
frontotemporal craniotomy is made ipsilaterally
by the surgeons method of choice. From a cosmetic standpoint, the number of burr holes is
minimized; thus, only one at the keyhole and one
at the zygomatic root are usually required. A cosmetically superior alternative is to make a slot with
the Midas Rex M8 or an equivalent drill bit from
the anatomic keyhole to the root of the zygoma
that passes across the root of the sphenoid wing,
around the temporal tip, and along the middle
fossa oor en route to the zygomatic root. Again,
the slot is slightly enlarged on either end to accommodate the Woodson elevator for dural stripping
and subsequent placement of the Midas Rex B1
Fig. 33. Superior view of the bone cuts for a biorbital osteotomy with a circumferential cribriform osteotomy.
458
Fig. 36. Inferior view of biorbital osteotomy approximated to its associated bifrontal craniotomy ap.
Fig. 34. Bifrontal craniotomy with biorbital osteotomy

and circumferential cribriform osteotomy. The Wshaped biorbital osteotomy is viewed superiorly.
footplate or its equivalent. Although this minimal

placement of burr holes is recommended for cosmetic concerns, the surgeons judgment must take
precedence as to the safety of this technique with
individual patients.
If the slot is performed well, little or subtemporal decompression is needed, because the slot
follows the middle fossa oor. A small lip of bone
usually remains, requiring a small amount of further drilling to make the inferior edge of the craniotomy level with the middle fossa oor.
Osteotomy
The periorbita is stripped from the orbital roof
and lateral orbital wall to at least 3 cm from the
Fig. 35. Inferior view of biorbital osteotomy.
orbital rim. The dura is stripped over these same

areas. The periorbita is further elevated until the
area of the supraorbital notch is freed medially
and the inferior orbital ssure is well visualized
inferolaterally. As before, the cosmetically signicant cuts of the orbital rim and facial bones are
made with a reciprocating saw. Malleable brain
retractors are used to protect the brain and orbital
contents. The rst cut is made through the superomedial orbital rim from the approximate location
of supraorbital notch to the medial edge of the
bone ap. The second cut is the most dicult for
reasons of exposure. It is made beginning intraorbitally with the saw at the inferolateral orbital rim
and the tip of the saw in the inferior orbital ssure.
The cut is then directed toward the approximate
location of the zygomaticofacial foramen, which
serves as a landmark to avoid entrance into the
maxillary sinus. The temporalis muscle is then
retracted medially for the next two cuts. The rst
of these is made from the inferior edge of the zygomatic arch to connect with the posterior end of the
previous cut (making a V on the malar eminence
at the approximate location of the zygomaticofacial foramen) [13]. The last cut is made at the root
of the zygomatic arch mainly in the sagittal plane
so as to provide maximal exposure and produce
a cosmetically less signicant cut. Finally, the posterior cuts are made through the thin portion of
the orbital roof and lateral orbital wall with the
reciprocating saw, the Midas Rex M8 or an
equivalent drill bit, or small osteotomes. The
Midas Rex M8 bit technique is preferred because
less retraction is required and it provides the ability to produce more controlled cuts under direct
vision. The additional loss of bone from the Midas
Rex M8 bit as opposed to the reciprocating saw is
not signicant except at the orbital rims and facial

bones. The posterior cut is made along the orbital
roof from the posterior aspect to the superomedial
orbital rim cut and continued posteriorly approximately 2.5 to 3.0 cm and then laterally along the
lateral orbital wall to the posterior margin of the
extraorbital part of the inferior orbital ssure.
Preserving approximately 2.5 cm or two thirds
of the orbital roof and lateral orbital wall is sucient to prevent postoperative pulsatile enophthalmos [9,10,13,31]. Once all these cuts are
completed, the orbitozygomatic osteotomy is loosened with the small osteotome and mallet and
carefully removed (Figs. 1117). The condylar
fossa can be included with the orbitozygomatic
osteotomy and is discussed later in this article.
The remaining posterior orbital roof and lateral
wall are then separated from the surrounding dura
and periorbita and removed with a small rongeur.
The superior orbital ssure is widely decompressed
to maximize the exposure provided by the orbitozygomatic osteotomy. An anterior clinoidectomy
can be performed if needed as described in the orbital osteotomy section.
Dural incision
With the bone work completed, a curvilinear
dural incision is made near the posterior edge of
the bone ap with the dural ap based anteriorly.
This dural ap is then retracted anteriorly over
the orbital soft tissues, providing more basal
exposure by retracting the orbital contents inferiorly (Fig. 18).
Reconstruction
The dura is closed in a watertight fashion if
possible. If not, the dural defect is usually repaired
with an autologous free pericranial graft sewn circumferentially to the defect.
The frontal sinus is almost always opened by
this approach. The mucosa is exenterated, the
walls drilled with a diamond burr, the frontonasal
duct packed with Surgicel, and the sinus itself obliterated with autologous fat. A pericranial ap is
then harvested based anteriorly on its vascular
pedicle. This ap is dissected from the overlying
galea with a combination of sharp and scissors
dissection. The ap is elevated to as near the orbital rim as possible to allow for a ap with enough
length to cover the frontal sinus defect without
tension. Tension on this graft after replacement
of the bone aps can produce a puckering of the
skin of the forehead. If ethmoid or sphenoid defects are present, they too are packed with fat,
459
Fig. 37. Anterior view of biorbital osteotomy approximated to its associated bifrontal craniotomy ap.
and a larger ap is harvested to cover these defects

as well as the frontal sinus. The pericranial ap is
then secured to the surrounding dura to anchor
it in its nal position. The entire construct is augmented with brin glue.
The orbital osteotomy and craniotomy aps
are then replaced with titanium miniplates with
no additional bony reconstruction needed. As previously mentioned, the performance of meticulous
bone work during the exposure is the largest factor
in producing a simple and cosmetic reconstruction
(Fig. 19).
The temporalis muscle is then re-elevated with
sutures to small holes drilled in the superior
temporal line as discussed earlier. The supercial
temporalis fascial incision from the interfascial
dissection of the frontotemporal branch of the facial nerve is also reapproximated so as to prevent
Fig. 38. Surgical view of circumferential cribriform

osteotomy specimen attached to the inferior frontal
dura. The instruments are holding the sleeves of superior
nasal mucosa open.
460
any temporal hollowing (Fig. 20). The scalp is then

closed in the usual two layers (Figs. 2125).
Biorbital osteotomy
Background
The biorbital osteotomy has a history of exibility for use in both intra- and extradural cranial base approaches. Its uses for intradural
work predominantly consist of its being used in
conjunction with a bifrontal craniotomy so as
to provide increased bilateral basal frontal exposure [3234]. Modications of this technique have
been used to approach extradural midline cranial
base tumors of the anterior, middle, and posterior fossae [11,16,32,3436]. This extradural
approach has led to the development of a
biorbitofrontoethmoidal osteotomy if olfaction
is to be sacriced [11,16,35,36] or a circumferential cribriform osteotomy if olfaction is to be
spared [16,35,37,38].
The evolution of these extradural approaches
has steadily progressed with regard to increased
exposure with improved functional and esthetic
outcomes. The transbasal approach for removal
of sphenoethmoidal lesions extradurally through
a bifrontal craniotomy as described by Derome
et al [39], was followed by the extended transbasal
approach, which added an orbital osteotomy to
the bifrontal craniotomy as described by Bejjani
et al [35] and Cophignon et al [40]. Sekhar et al
[11] developed this extended transbasal approach
further with a biorbitofrontoethmoidal osteotomy, resulting in a cosmetic method of removing
extradural tumors from the clivus and medial
cavernous sinuses without facial incisions. Spetzler
and his colleagues [3234] subsequently added the
nasal bone and medial orbital wall complex to the
supraorbital bar (level II transfacial approach) and
further added the lateral orbital walls to this complex (level III transfacial approach). Spetzler and
his colleagues [3234,37] also described the circumferential cribriform osteotomy to make these
approaches possible while preserving olfaction.
The specics of the biorbital osteotomy, biorbitofrontoethmoidal osteotomy, and circumferential
cribriform osteotomy are described in this section
but not the integration of the nasal bones and
medial orbital walls for the following relatively
minor reasons. A supraorbital bar through the
region of the frontonasal suture leaves the nasolacrimal ducts relatively undisturbed, does not
require the manipulation of the upper lateral nasal
Fig. 39. Another surgical view of the olfactory mucosa

attached to the cribriform plate after a circumferential
cribriform osteotomy has been performed.
cartilages with the associated possibility of saddle

nose deformity [32], and does not require detachment and subsequent reattachment of the medial
canthal ligaments. Furthermore, the reected scalp
ap is often more in the line of sight than the inferior aspect of the nasal bones, making the added bone removal and mobilization of the nasal
cartilages only marginally useful. For this reason,
Fig. 40. Bony reconstruction after a cosmetic extended

transbasal approach.
461
only the extended transbasal approach with and

without circumferential cribriform osteotomy is
described in detail because of the excellent exposure obtained, ease of performance, and lesser possibility of cosmetically signicant complications.
Biorbital osteotomy for intradural lesions

Indications
A biorbital osteotomy is most useful for an
intradural approach as an adjunct to a bifrontal
craniotomy for approaching a bilateral intradural
lesion of the base of the anterior cranial fossa. This
osteotomy avoids the cribriform plate so as to
spare olfaction.
Technique
Positioning
generally placed in the midline for a bilateral anterior fossa lesion. The head is placed in slight extension to facilitate elevation of the frontal lobes.
Mild hyperventilation (pCO2: 3035) and mannitol
(0.51.0 gm/kg) are used for brain relaxation. A
lumbar drain can be used for further relaxation,
with slow drainage of approximately 50 mL of
CSF in the absence of signicant tumor mass in
the tentorial notch or likely increased intracranial
pressure. This additional brain relaxation greatly
facilitates the posterior orbital roof cuts by reducing the need for brain retraction.
Fig. 41. Temporal craniotomy with zygomatic osteotomy, excluding the condylar fossa.
only minimally elevated and the lateral orbital

rims are not exposed, there is no need for an interfascial dissection of the frontotemporal branch of
the facial nerve on either side. The temporalis
muscles are elevated only 1.0 to 1.5 cm at the
anatomic keyhole bilaterally. These small aps of
muscle are retracted laterally to provide exposure
for a cosmetic bifrontal craniotomy ap.
Incision
A bicoronal incision is used. As previously
addressed, only minimal hair is shaved along the
incision, and the incision is placed well behind
the hairline. An added benet of such a posteriorly
located incision is that a large pericranial graft can
be harvested for reconstruction of the anterior
fossa oor. As usual, the lower ends of the incision
extend into the pretragal skin creases, but they do
not extend below the superior edges of the zygomatic roots.
Exposure
The pericranium and scalp are elevated
together for reasons discussed earlier. The temporalis fascia is left intact. The elevation of the scalp
and pericranium is continued to the orbital rims
bilaterally as well as to the frontonasal suture in
the midline. Because the temporalis muscles are
Fig. 42. Simple zygomatic osteotomy for smaller lesions

or in cases in which the zygomatic arch is removed to
increase mobilization of the temporalis muscle.
462
Bifrontal craniotomy
Several methods exist for a bifrontal craniotomy. When the Midas Rex B1 footplate or its
equivalent is used for the basal frontal cut, the
dura can easily be torn, the bone along the frontal
sinus may be too wide for the footplate, or the cut
may not be suciently close to the base to facilitate the intracranial cuts along the orbital roof.
One method to avoid these problems is to use a
template of the frontal sinus to remove the anterior
wall of the frontal sinus, providing a low craniotomy ap with no signicant cosmetic defect
[7,8]. An alternative and easier method is to use
the microsagittal saw with a narrow (3 mm) blade
for the basal frontal cut. A small burr hole or slot
is placed at each keyhole before the basal frontal
cut. These holes or slots are made near the oor
of the anterior fossa, and the drill is angled as previously described such that the inner table bony
defect is larger than the outer table defect. The
basal frontal dura deep to the planned basal frontal bone cut is then stripped, and a 0.5 in 3 in cottonoid is placed over the dura to protect it. Brain
relaxation, including the use of the lumbar drain,
greatly facilitates this step. The microsagittal saw
is then used to make a cut through the anterior
wall of the frontal sinus that follows the contour
of the anterior fossa oor. The cut is continued laterally where the frontal sinus ends, but the underlying dura is protected by the cottonoids. This cut
can be dicult to make, because the microsagittal saw is somewhat dicult to control. A narrow
blade not only makes the saw more controllable
but allows for a more precise cut with sucient
curves to follow the anterior fossa oor closely.
The posterior frontal sinus wall is then usually
scored using the microsagittal saw when the
remainder of the cut has been completed. This
facilitates fracturing of the posterior wall of the
frontal sinus when the ap is elevated. The greatest
feature of the microsagittal saw for this basal cut is
its extremely narrow width with a resultant minimal loss of bone.
To complete the craniotomy, a small slot is
made along the posterior midline of the planned
craniotomy ap across the superior sagittal sinus.
This slot is made with a Midas Rex M8 or equivalent bit as described earlier. The slot is only approximately 3 mm wide supercially, but the drill
is angled as the deeper bone is drilled so as to
expose a larger area of the inner table. This
exposes the sinus as well as the dura to either side.
This dura is then stripped with a Woodson elevator, and the Midas Rex B1 footplate or its
Fig. 43. Temporal craniotomy with zygomatic osteotomy, including the condylar fossa.
equivalent can be placed at either end of the slot

to connect the slot with the keyhole burr holes.
These last cuts are continued laterally to beyond
the superior temporal line before directing them
inferiorly. This places most of the bone kerf out
of the forehead. Once the nal cuts are made, the
ap is carefully elevated, fracturing the posterior
wall of the frontal sinus. The frontal sinus is then
cranialized by removing the remainder of the
posterior wall with a large rongeur.
Fig. 44. Zygomatic osteotomy, including the condylar

fossa for more posteriorly located lesions.
Olfactory-sparing biorbital osteotomy

The basal frontal dura is elevated from the
orbital roofs and the periorbita along each orbital
rim, and the roof is elevated to approximately 3 cm
from the orbital rims. The brain and orbital contents are protected with malleable brain retractors.
The reciprocating saw is used to cut through each
superolateral orbital rim until the thin bone of the
orbital roof is encountered. A cut is then made just
inferior to the frontonasal suture bilaterally but
only deep enough to pass through the thick bone
of the nasion and into the posteroinferior oor
of the frontal sinus. If the cut is made any deeper,
the nasal septum or olfactory mucosa may be
injured. Finally, the thin bone of the orbital roof
is cut beginning at the posterior aspect of the
superolateral orbital rim and continued posteriorly until approximately 2.5 cm or two thirds of
the orbital roof has been preserved. Again, the
superior orbital ssure is avoided for reasons of
safety. The cut is continued medially near the
posterolateral aspect of the cribriform plate and
then anteriorly to the posteromedial oor of the
frontal sinus. This procedure is performed bilaterally, and a nal cut is made along the anterior aspect of the cribriform plate. Overall, this produces
a W-shaped cut that circumvents the cribriform
plate and spares olfaction. It removes the orbital
rims and nasion as well, providing maximal intradural exposure (Figs. 26 and 27).
463
Fig. 45. Superior view of V-shaped cut spanning the

condylar fossa. Note that the apex of the cut is at the
foramen spinosumz.
cribriform region and cover both sides of the

defect. The entire construct is augmented with
brin glue.
The biorbital osteotomy is replaced after the
pericranial graft is placed. This allows for a vascularized tissue plane to be placed between the
osteotomy specimen and the paranasal sinuses
and nasal cavity. The osteotomy segment is then
Dural incision
Bilateral dural incisions are usually made inferiorly and anteriorly near the frontal poles. They
are extended to near the base of the superior sagittal sinus. The sinus is then suture ligated and cut
near its base. This provides a wide basal frontal
opening without unnecessarily exposing the brain.
Small dural aps are retracted over the orbital contents to optimize exposure.
Reconstruction
The dura is closed in a watertight fashion if possible. If not, the dural defect is usually repaired
with an autologous free pericranial graft sewn circumferentially to the defect.
The frontal sinus is exenterated of mucosa,
and its walls are thoroughly drilled with a diamond burr. The frontonasal ducts are packed
with rolls of Surgicel, and the sinus itself is obliterated with autologous fat graft. A pericranial
ap is placed over the frontal sinus defects and
secured to surrounding dura. A long pericranial
graft is often slit longitudinally to straddle the
Fig. 46. Anterior view of biorbital with unilateral

zygomatic osteotomy.
464
secured with titanium miniplates. Finally, the

bifrontal ap is also replaced with miniplates.
Because of the meticulous bone work invested in
the exposure, the reconstruction is substantially
simplied, with an excellent cosmetic outcome.
Extended transbasal approach

Indications
The extended transbasal (extended frontal
transbasal) approach is primarily used for extradural midline tumors of the anterior, middle, and
posterior cranial fossae [11,16,36]. The extradural
limitations of this approach are the areas lateral
to the optic nerves, anterior clinoids, superior orbital ssures, dorsum sellae, and posterior clinoids;
the area lateral to the hypoglossal canals; and the
area below the anterior arch of C1 [16].
If olfaction is not present before surgery or the
cribriform plate has been invaded by tumor, the
olfactory nerves are sacriced, and a biorbitofrontoethmoidal osteotomy is performed. If olfaction
is present before surgery and the cribriform plate
is free of tumor, a biorbital osteotomy with a circumferential cribriform osteotomy is performed.
Technique
Positioning
The patient is placed is a supine position with
usually placed in the midline with slight extension
so as to facilitate elevation of the frontal lobes.
Mild hyperventilation (pCO2: 3035) and mannitol
(0.51.0 gm/kg) are used for brain relaxation. A
lumbar drain is extremely helpful in this approach
and is used unless contraindicated by tumor mass
eect or suspected elevated intracranial pressure.
Small amounts of CSF are intermittently drained
throughout the exposure and resection phases of
the procedure so as to minimize the need for brain
retraction.
Incision
A bicoronal incision is used, with the lower
ends of the incision extending into the pretragal
skin creases but ending at the superior edges of
the zygomatic roots. Further inferior extension
of the incision is not necessary and only increases
the likelihood of injury to the frontotemporal
branch of the facial nerve. As usual, minimal hair
shaving is performed only along the incision line.
The incision is placed fairly far posteriorly (at

least 15 cm above the nasion) [36] so as to provide
for the long pedicled pericranial graft needed for
the reconstruction. Further length of pericranium
is obtained by incising the galea without cutting
the underlying pericranium. The posterior edge
of the scalp can then be undermined to harvest
additional pericranium, lengthening the graft by
3 to 4 cm [16,36]. The remainder of the pericranium is not harvested until the reconstruction
phase so as to prevent its desiccation or injury.
Once the pericranium is elevated posterior to the
incision, the anterior scalp and pericranium are
elevated together.
Exposure
The scalp and pericranium are elevated to the
orbital rims, and the superior orbital rims are
exposed bilaterally along with the nasion and frontonasal suture. The galea is dissected from the
underlying temporalis fascia bilaterally. The temporalis muscles are elevated only 1.0 to 1.5 cm at
the keyholes bilaterally. No interfascial dissection
of the frontotemporal branch of the facial nerve
is needed on either side. If a supraorbital foramen
is present on either or both sides, the supraorbital
nerves and arteries are freed with a small osteotome as described earlier.
Bifrontal craniotomy
A cosmetic bifrontal craniotomy is begun with
slots at the keyholes and across the superior sagittal sinus at the posterior margin of the planned
bone ap. Cottonoids are placed in the keyhole
slots to protect the basal frontal dura, and the
microsagittal saw is used for the basal frontal
cut. The slots are then connected with the Midas
Rex B1 footplate or its equivalent. This technique
is discussed in more detail in the previous section.
Once the bifrontal ap has been elevated, the frontal sinus is cranialized by removing the posterior
wall with a large rongeur.
Biorbitofrontoethmoidal osteotomy
The olfactory bers with their associated dural
sleeve are sectioned with a number 11 blade as
closely as possible to the cribriform plate. Drilling
away the crista galli or removing it with a small
rongeur provides additional exposure to these
dural sleeves, allowing them to be sectioned as distally as possible [8,11]. The dura is then closed with
two parallel running nonabsorbable suture lines
incorporating all the openings from the olfactory
bers [8]. Any areas of apparent CSF leakage are
repaired with additional interrupted sutures.
Fig. 47. Lateral view of biorbital with unilateral

zygomatic osteotomy.
The dura is then elevated from the planum

sphenoidale and orbital roofs. The periorbita is
elevated from the superior orbital rims to approximately 3 cm posteriorly. A reciprocating saw is
used for the thick bones of the orbital rims and
face. The rst cuts are made at the superolateral
orbital rims. Posterior cuts are made from the
posterior ends of the rst cuts in the thin part of
the orbital roof to approximately 2.5 to 3.0 cm
posteriorly, where they are continued medially
465
across the anterior aspect of the planum. Only

the anterior aspect of the planum is cut so as to
prevent optic nerve injury, which is possible with
cuts placed more posteriorly. These cuts are made
bilaterally and are then connected in the midline at
the planum.
The anterior ethmoidal arteries are located,
cauterized, and divided intraorbitally. The anterior ethmoidal foramina act as landmarks for the
horizontal osteotomy through the nasal and ethmoid bones just inferior to the frontonasal suture.
These two cuts are made in the horizontal plane
with the tip of the reciprocating saw in the anterior ethmoidal foramina. They are made to meet
in the midline, cutting the nasal septum. These cuts
are made last because they commonly elicit brisk
bleeding from the residual anterior ethmoidal
arteries. The osteotomy is then loosened with a
small osteotome and mallet and carefully removed
(Figs. 2630). The nasal and ethmoidal mucosa as
well as the bleeding ethmoidal arteries can now be
thoroughly cauterized.
The residual ethmoidal air cells are removed,
increasing the width of the subcranial exposure
[36]. The anterior and lateral walls of the sphenoid
sinus are removed, as are the planum sphenoidale
and tuberculum. The sella and entire bilateral
medial cavernous sinus walls are exposed by the
sphenoid removal. The cavernous carotids can be
followed back to the petrous apex. Rotating the
operating table improves the view of the contralateral medial cavernous sinus [36]. The optic canals
Fig. 48. View at the time of surgery of bifrontal and right temporal craniotomy with biorbitofrontoethmoidal/zygomatic
osteotomy.
466
can be exposed, but unless they are involved with

tumor, a thin translucent sleeve of bone can be
left around them for added protection. The optic
struts and medial aspects of the ACPs can also
be removed by this approach. The bone of the
clivus can be progressively removed superiorly to
inferiorly as it is viewed end on by this approach
[36]. The entire middle and lower two thirds of
the clivus limited by the cavernous carotids and
hypoglossal canals can be removed by this route
[16,36]. The inferior limit of the exposure is the
inferior aspect of the foramen magnum (Fig. 31)
[11,36].
Reconstruction
Dural defects are closed primarily or with free
pericranial or fascia lata grafts sewn circumferentially around the defect when primary closure is
not possible. Watertight dural closure may be
dicult or impossible for lower clival defects.
The long pedicled pericranial ap is carefully
harvested from the overlying galea with a combination of sharp and scissors dissection. This graft
is harvested as closely as possible to the orbital
rims to maximize length and is left attached anteriorly to its vascular pedicles (bilateral supraorbital and supratrochlear arteries) (Fig. 32). This
vascularized ap is then placed over the exposed
clival dura and cavernous sinuses. If sucient
length is available, the ap is folded onto itself
with the fold at the distal end. This creates a
pocket of vascularized tissue that can be lled
with autologous fat. The pericranial ap is then
secured to the surrounding dura with sutures. Any
residual dead space on the intracranial side of
the pericranial ap can be obliterated with autologous fat. The entire construct is reinforced with
brin glue.
The biorbitofrontoethmoidal osteotomy is
replaced only after the pericranial ap is placed
in its nal position to allow the osteotomy, bone
ap, and intracranial contents to be separated
from the paranasal sinuses and nasal cavity by vascularized autologous tissue [11,16,36]. The osteotomy and bone aps are replaced with titanium
miniplates. The small areas of temporalis elevation
are resecured with sutures to small oblique holes
drilled in the associated superior temporal line.
The scalp is closed in the usual two layers.
The lumbar drain can be left in place for 3 to 5
days after surgery, with regular controlled drainage to minimize the chances of a postoperative
CSF leak.
Biorbital osteotomy with circumferential

cribriform osteotomy
Although this technique provides an attempt
to preserve olfaction, the exact rate of olfactory
preservation is controversial. Because of the importance of olfaction on the quality of life, attempts
are made to preserve olfaction whenever possible. The bifrontal craniotomy is performed as
described previously. A W-shaped biorbital osteotomy circumventing the cribriform plate is also
performed as described in the previous section. All
this exposure facilitates the nal cut across the posterior cribriform plate. No matter how successfully
the brain is relaxed, some retraction of the planum
dura is required for this maneuver. The original
report by Spetzler et al [37] recommends performing this posterior cut with a reciprocating saw. The
Midas Rex M8 bit can also be used, because a
more controlled cut can be made with slightly less
retraction of the planum dura. The Midas Rex M8
bit is used on one side and subsequently the other,
with malleable brain retractors protecting the
dura. The two posterior cuts are then joined in
the midline (Figs. 3337).
To maximize the chances of successful olfactory preservation, as much olfactory epithelium
must be preserved as possible, because olfactory
nerve endings have been identied up to 20 mm
below the cribriform plate in anatomic studies
[41]. The nal bone cut is made through the nasal
septum. This is most easily accomplished with a
pair of curved Mayo scissors placed as low as
possible on the nasal septum below the cribriform
plate. This releases the last bony attachment of the
cribriform complex, which is now tethered only by
two sleeves of superior nasal mucosa, including the
olfactory epithelium. If gentle traction is placed on
the cribriform complex, these mucosal sleeves are
stretched, allowing them to be cut with a number
15 blade or Metzenbaum scissors as low in the
nose as possible. This completely frees the entire
cribriform/olfactory complex, leaving a generous
cu of mucosa attached bilaterally (Figs. 38
and 39).
This complex has a signicant keel because of
the aggressive preservation of the nasal septum
with the elevated cribriform plate. To prevent this
complex from obstructing the view of this approach, the entire structure sometimes has to be
turned on its side until the reconstruction begins.
Reconstruction
The olfactory epithelium has to be exposed to
the nasal cavity to work properly. For this reason,
467
Fig. 49. Superior view of biorbitofrontoethmoidal/zygomatic osteotomy.
the large pericranial graft is harvested as described

in the previous section, but a longitudinal linear
cut is made approximately 3 cm long where it
meets the cribriform in its nal position. The lateral edges of the mucosa are then sewn to the edges
of this pericranial incision, ensuring that the mucosa maintains access to the nasal cavity. Once
the pericranial ap is secured, the area around
the cribriform between the pericranial graft and
the dura is packed with autologous abdominal
fat graft to obliterate the dead space. The whole
construct is augmented with brin glue.
Because of brain relaxation, particularly in

older patients, it is dicult to replace the cribriform complex completely in its original position
and to wire it to surrounding bone as originally
described [32,37]. A simpler method is to secure
it to the pericranium as described previously and
to replace the orbital osteotomy and bone ap
with titanium miniplates (Fig. 40). After surgery,
the cribriform complex gradually returns to its
original position aided by gravity and normal
brain re-expansion.
Zygomatic osteotomy
Background
In 1985, Fujitsu and Kuwabara [42] originally
described detachment of the zygomatic arch for
lesions in the interpeduncular cistern. The zygomatic osteotomy has gained signicant popularity since then because of its versatility and low
complexity. Both osteoplastic [43] and free [15]
zygomatic osteotomies have been reported with
excellent results.
The temporal craniotomy with zygomatic
osteotomy facilitated the development of the subtemporal-infratemporal approach by Sekhar et al
[44,45], including the incorporation of the condylar fossa in the zygomatic osteotomy.
Indications
Fig. 50. Inferior view at the time of surgery of craniotomy ap and biorbitofrontoethmoidal/zygomatic
osteotomy reapposed.
In general, a zygomatic osteotomy is used

to increase subtemporal exposure. Indications
468
Fig. 51. Anterior view at the time of surgery of craniotomy ap and biorbitofrontoethmoidal/zygomatic osteotomy
reapposed.
include extradural lesions of the middle fossa,

petrous apex, and infratemporal fossa. It is also useful for intradural lesions of the inferolateral cavernous sinus, Meckels cave, and tentorial notch
[45,46]. Extradural lesions extending into the middle and lower clivus or infratemporal fossa may
require a subtemporal-infratemporal approach [45,
46]. Vascular lesions of the upper cervical or petrous internal carotid artery (ICA) may also require
a subtemporal-infratemporal approach [46]. A temporal craniotomy with a zygomatic osteotomy is
the basis of the subtemporal-infratemporal approach. If exposure of the vertical segment of the
petrous ICA is required, the zygomatic osteotomy
can be extended to include the condylar fossa.
Technique
Positioning
the head in three-point pin xation. A large roll is
placed under the ipsilateral shoulder, and the head
is turned approximately 70 to the contralateral
side [46]. Mild hyperventilation (pCO2: 3035)
and mannitol (0.51.0 gm/kg) are used for brain
relaxation. A lumbar drain is extremely helpful
for an extradural approach and is used unless contraindicated by tumor mass eect in the tentorial
notch or suspected elevated intracranial pressure.
Small amounts of CSF can be drained intermittently during the procedure to maximize brain
relaxation.
Incision
A bicoronal or question mark skin incision can
be used depending on the patients hairline and the
exposure required. As usual, minimal hair shaving
is performed only along the incision line. The inferior edge of the incision is placed in the pretragal
skin crease and extends to the inferior edge of
the zygomatic root. Placement of the incision in
the pretragal crease minimizes the possibility of
injury to the frontotemporal branch of the facial
nerve or the supercial temporal artery. If a subtemporal-infratemporal approach is planned, the
inferior end of the incision starts near the root of
the earlobe and curves around the tragus as well
as in the pretragal skin crease [45,46].
Exposure
The scalp and pericranium are elevated
together, and an interfascial dissection of the
frontotemporal branch of the facial nerve is performed as described earlier. The temporalis muscle
is completely elevated from its origin and retracted
laterally and inferiorly. The zygomatic arch is
freed of soft tissue attachments, including the
masseter muscle, which often has to be sharply
dissected from the inferior surface of the zygomatic arch.
Craniotomy
A temporal craniotomy is performed by either
placing burr holes at the keyhole and zygomatic
root or, preferably, by making a slot from the
Fig. 52. Surgical view of reconstruction of the patient in

Figs. 48 through 51.
keyhole that passes across the root of the sphenoid

wing, around the temporal tip, and along the middle fossa oor en route to the zygomatic root
(Fig. 41). The Midas Rex B1 footplate or its
equivalent is used to complete the bone ap. If a
zygomatic osteotomy, including the condylar
fossa, is planned, the slot along the middle fossa
oor is continued posteriorly to just above the
external ear canal, and the corresponding craniotomy ap is made more posteriorly as well
(Fig. 43). Any residual bone along the inferior edge
of the craniotomy can then be drilled to make the
craniotomy level with the middle fossa oor.
Zygomatic osteotomy, excluding
the condylar fossa
The temporalis muscle is usually retracted
medially, whereas the zygomatic osteotomy cuts
are made with the reciprocating saw. Anteriorly,
a V-shaped cut is made just posterior to the
zygomaticomaxillary suture, including part of
the lateral orbital rim (Fig. 41) [45,46]. The
posterior cut is made across the root of the
zygoma nearly in the sagittal plane so as to maximize exposure. A smaller and simpler zygomatic
osteotomy can be performed only through the
thinner parts of the zygoma for smaller lesions
or in cases in which the zygomatic arch is removed
to increase mobilization of the temporalis muscle
(Fig. 42).
Middle fossa dissection
The dura of the oor of the middle fossa is
elevated laterally to medially and posteriorly to
anteriorly [46]. Dissection in this direction allows
the tegmen tympani and arcuate eminence and,
469
Fig. 53. Surgical view of a bifrontal and right temporal

craniotomy with a biorbital and unilateral zygomatic
osteotomy with a circumferential cribriform osteotomy.
Note the frontal basal microsagittal saw cut.
subsequently, the hiatus of the greater supercial

petrosal nerve (GSPN) to be located. The middle
meningeal artery can then be found by tracing its
branches proximally [46], and it is cauterized and
cut at the foramen spinosum. V3 and V2 are
located next at the foramen ovale and rotundum,
respectively. These nerves can be exposed further
distally by drilling the adjacent middle fossa oor.
The region of Meckels cave can be exposed with
further dural dissection.
Exposure of the horizontal segment

of the petrous internal carotid artery
The petrous ICA is located posterior and
medial to V3 and directly inferior to the GSPN
[46]. The horizontal petrous ICA is usually only
partially covered by bone, and its periosteal sheath
can usually be visualized through a bony hiatus in
the middle fossa oor [13,45,46]. If this bony hiatus is not present, the bone overlying the horizontal petrous ICA is quite thin and can be exposed
with careful drilling using the GSPN and V3 as
landmarks. A diamond burr is usually chosen for
this task.
The horizontal petrous ICA is further exposed
with a diamond burr to the genu of the artery.
Drilling is not performed posterior to the petrous
carotid genu because this may result in damage
to the basal turn of the cochlea. Exposure of the
petrous ICA proximal to the genu (the vertical
segment) is greatly facilitated by including the
condylar fossa in the zygomatic osteotomy [13,
45,46].
470
Fig. 56. Three-month postoperative view of the patient

in Figs. 53 through 55.
Fig. 54. Superior view of the osteotomy of the patient in
Fig. 53.
Zygomatic osteotomy, including

the condylar fossa
The temporalis muscle is usually retracted
medially while the osteotomy cuts are made with
the reciprocating saw. Anteriorly, a V-shaped cut
is made just posterior to the zygomaticomaxillary
suture, including part of the lateral orbital rim
(Fig. 43) [45,46]. The temporomandibular joint
capsule is separated from the condylar fossa with
a small periosteal elevator. The middle fossa dura
is elevated until the middle meningeal artery is
visualized, which is subsequently cauterized and
cut. Another V-shaped cut that spans the condylar
fossa and encompasses the zygomatic root is made
with the reciprocating saw [9,35,37]. The apex of
the V-shaped cut should be no further medial than
Fig. 55. Operative view of the patient in Fig. 53 after the

craniotomy and osteotomy. Note the cribriform plate
attached to the frontal dura. Also note the exposure of
the horizontal petrous internal carotid artery marked by
the instrument.
the foramen spinosum so as to avoid damaging

the petrous ICA (Figs. 44,45) [13,45,46]. Using a
beroptic light source or endoscope is helpful by
transilluminating the condylar fossa from below,
more precisely delineating its exact limits on the
middle fossa oor [13,46]. The zygomatic osteotomy fragment is then freed from its remaining soft
tissue attachments and removed.
Exposure of the vertical segment
of the petrous internal carotid artery
The middle fossa dissection and exposure of the
horizontal segment of the petrous ICA is performed as described previously. The temporomandibular joint capsule and mandibular condyle are
rmly retracted inferiorly. The tensor tympani
muscle and eustachian tube cross the vertical petrous ICA and are exposed with further drilling of
the middle fossa oor. The tensor tympani muscle
is divided, and the osseous eustachian tube is
followed anteriorly with further drilling. The eustachian tube is then divided in its cartilaginous
portion, with its anterior end packed with fat or
Surgicel and oversewn, and its posterior end is
handled similarly [13,46]. The vertical petrous
carotid is followed further inferiorly with progressive drilling until the dense brocartilaginous
ring at the entrance of the carotid canal is encountered [13,46]. This ring can then be separated from
the periosteal sheath of the artery so that the ring
can be opened and excised. This exposes the entire
petrous ICA from the cervical carotid to the cavernous sinus.
Reconstruction
Dead space is obliterated with autologous
abdominal fat. The zygomatic osteotomy and
Fig. 57. Anterior view of a biorbital and unilateral

zygomatic osteotomy with a circumferential cribriform
osteotomy in a dierent patient.
craniotomy ap are then replaced with titanium

miniplates. The temporalis muscle is re-elevated
with sutures to small oblique holes drilled in the
superior temporal line as described earlier. The
scalp is closed in the usual two layers.
Combined osteotomies
With a working knowledge of the available
osteotomy techniques and their indications, combined osteotomies are possible. The advantages
of combined osteotomies are complimentary when
properly performed, and they can be performed
with excellent cosmetic results. Some of the more
common combinations are the orbitozygomatic
osteotomy, including the condylar fossa; the biorbital with unilateral zygomatic osteotomy; and
Fig. 58. Lateral view of the patient in Fig. 57.
471
Fig. 59. Inferior view of the patient in Fig. 57.
the biorbital with unilateral zygomatic osteotomy,

including the condylar fossa.
Orbitozygomatic osteotomy, including
the condylar fossa
When an orbitozygomatic osteotomy is required as well as exposure of the vertical segment
of the petrous ICA, the orbitozygomatic osteotomy can include the condylar fossa [13,31,47].
The craniotomy and osteotomy are performed as
usual, with the exception of the cut across the
zygomatic root. The temporomandibular joint
capsule is dissected free from the condylar fossa,
the middle meningeal artery is cauterized and
cut, and V-shaped cuts are made around the condylar fossa as described previously.
Biorbital with unilateral zygomatic osteotomy
Some extensive extradural lesions meet the
indications for an extended transbasal approach
as well as a subtemporal-infratemporal approach.
This results in a combined anterior and lateral
clival extradural approach [48].
A bifrontal and unilateral temporal craniotomy can be performed as a single piece. A slot is
made from the keyhole to the zygomatic root as
described earlier, with additional slots at the contralateral keyhole and across the superior sagittal
sinus at the posterior margin of the craniotomy
ap. The microsagittal saw is used to make the
bifrontal basal cut across the brow line. The slots
are connected with the Midas Rex B1 footplate
or its equivalent. The large ap is carefully elevated, fracturing the posterior wall of the frontal
sinus in the process. The remainder of the frontal
sinus is cranialized.
472
Fig. 60. Reconstruction of the patient in Figs. 57

through 59.
If olfaction is not present or the cribriform

plate is involved by tumor, a circumferential
cribriform osteotomy is not performed. The biorbitofrontoethmoidal/zygomatic osteotomy is performed as a single piece. The cuts described for
the orbitozygomatic osteotomy are performed,
except for the superomedial orbital rim cut.
Instead, a cut is made at the contralateral superolateral orbital rim as described for the biorbitofrontoethmoidal osteotomy, and the posterior
orbital roof cuts are made 2.5 to 3.0 cm from the
orbital rims crossing the anterior planum sphenoidale. These cuts are then continued inferolaterally
on the ipsilateral side to meet the posterior aspect
of the inferior orbital ssure. Finally, the cuts are
made just inferior to the frontonasal suture bilaterally with the tips of the saw blade in the anterior
ethmoidal foramina. This produces a large osteotomy, including both orbits, the cribriform plate,
Fig. 61. Lateral view of the reconstruction of the patient

in Figs. 57 through 60. Note the minimal loss of bone
from the use of slots.
Fig. 62. More magnied view of the slots used in the

patient in Figs. 57 through 61. Note the way the inferior
aspect of the slot closely follows the middle fossa oor.
and the ipsilateral zygomatic arch (Figs. 4651).

The reconstruction is performed using a large pericranial graft with autologous fat as described for
the extended transbasal approach (Fig. 52).
If olfaction is to be preserved, a circumferential cribriform osteotomy is performed. The cuts
described for an orbitozygomatic osteotomy are
made, except for the ipsilateral superomedial orbital rim cut. Instead, a contralateral superolateral
orbital rim cut is made, followed by the W-shaped
bilateral orbital roof cuts circumventing the cribriform plate. These cuts are continued inferolaterally on the ipsilateral side to meet the posterior
aspect of the inferior orbital ssure. Finally, the
cuts are made just inferior to the frontonasal
suture bilaterally with the tip of the saw blade only
deep enough to reach the anterior cribriform plate
so as to prevent damage to the olfactory epithelium. Both orbits and the ipsilateral zygomatic
arch can then be dislodged as a single piece with
a small osteotome and mallet (Figs. 5362). The
cribriform mobilization is then completed, and
the subsequent reconstruction is performed as
described in the section on circumferential cribriform osteotomy.
If vertical petrous carotid artery exposure is
needed for the combined approach, the condylar
fossa can be added to the zygomatic osteotomy.
All cuts are performed as described previously,
except at the zygomatic root. The temporomandibular joint capsule is dissected from the condylar
fossa, the middle meningeal artery is cauterized
and cut, and the V-shaped cuts are made around
the condylar fossa as previously described. This
allows the orbits, ipsilateral zygomatic arch, and
condylar fossa to be elevated as a single piece
Fig. 63. A combination of many osteotomies. This

patient had a recurrent clival chordoma whose initial
surgery employed a left frontotemporal craniotomy with
an orbitozygomatic osteotomy. For this operation, the
original bone work was converted into a bifrontal
and left temporal craniotomy with a biorbital and left
zygomatic osteotomy, including the condylar fossa, with
a circumferential cribriform osteotomy.
(Fig. 63). This greatly simplies the reconstruction

and produces an excellent cosmetic result.
Summary
Craniofacial osteotomies are an integral part of
contemporary neurosurgery because of their ability
to provide substantially more exposure to deepseated lesions with reduced brain retraction. A
systematic approach to the performance of these
osteotomies coupled with meticulous bone work
capitalizes on their advantages without producing
any signicant cosmetic defects. As their indications are progressively more clearly dened and
familiarity and facility are gained by the surgeons
performing them, operative time and morbidity
should decrease. Lowering operative time and morbidity with excellent esthetic results is likely to be
increasingly important when considering operative
versus nonoperative management, particularly as
nonsurgical modalities continue to develop.
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Cosmetic concerns in posterior fossa

skull base surgery
Gavin Wayne Britz, MDa, Marcelo D. Vilela, MDa,
Neal Futran, MDb, Robert Rostomily, MDa,*
a
Department of Neurological Surgery, University of Washington, 1959 NE Pacic Street, Seattle, WA 98195, USA
b
Department of Otolaryngology, Head and Neck Surgery, University of Washington, 1959 NE Pacic Street,
Seattle, WA 98195, USA
This chapter provides an overview of surgical

techniques and principles, that when applied to
specic posterior fossa approaches, improve cosmetic outcome. Techniques that employ anatomic
planes for exposure also allow the best anatomic
integrity at closure, reduce the risks of complications that impact wound healing, and thus produce
a good cosmetic outcome.
Although cosmetic defects produced by posterior fossa surgery are not as obvious as those
resulting from anterior or middle fossa procedures, patients nevertheless inspect their surgical
sites after posterior fossa surgery and are acutely
aware of the cosmetic result. As in other neurosurgical procedures, a poor cosmetic result can
overshadow an otherwise successful operation.
This article provides an overview of surgical techniques and principles that improve cosmetic outcome when applied to specic posterior fossa
approaches. It is the contention of these authors
that all things being equal (relative to surgical
access), approaches that use anatomic planes for
exposure also allow the best anatomic integrity
at closure, reduce the risks of complications that
aect wound healing, and thus produce a good
cosmetic outcome. This article briey reviews general surgical principles with implications for cosmesis and examples of these techniques applied
to specic posterior fossa surgical approaches as

well as reconstructive procedures.
* Corresponding author. Department of Neurological Surgery, University of Washington, 1959 NE Pacic

Street, Room RR-744, Seattle, WA 98195, USA.
E-mail address: rosto@u.washington.edu
(R. Rostomily).
Cosmetic aspects of surgical exposure and repair
Basic principles of wound healing

It is beyond the scope of this article to address
the basic biology of wound healing, but it is worth
mentioning briey the variables that aect wound
healing and subsequent cosmetic results. Nutritional state, preexisting illnesses like cancer,
exposure to radiation therapy, smoking, and metabolic diseases like diabetes can all aect wound
healing [1,2]. Correctable systemic factors should
be aggressively managed before surgery. Local
factors that aect wound healing include oxygen
tension, tissue edema, and infection. Low oxygen
tension can be prevented by preservation of the
local blood supply; thus, knowledge of the vascular anatomy in relation to the skin and soft tissue
incisions is vital. The vascular anatomy of the skin
and soft tissues of the posterior fossa is illustrated
in Fig. 1. Although most standard neurosurgical
approaches to the posterior fossa do not critically
impair the robust collateral blood supply in this
region, it must be considered when performing
multiple approaches or in the setting of reoperation after infection as well as in the debilitated or
previously irradiated patient.
Posterior fossa surgical approaches require violation and repair of skin, muscle, bone, and dura.
The technique used to handle these tissue layers
PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 8 - 1
476
G.W. Britz et al / Neurosurg Clin N Am 13 (2002) 475489
Fig. 1. The major arteries from the external carotid artery form collateral connections that provide robust blood supply
to the scalp of the posterior fossa.
during each phase of a surgical procedure either

directly or indirectly has an impact on the eventual
cosmetic result. The general surgical principles
with relevance to cosmetic results during exposure
and repair of posterior fossa approaches are briey
reviewed here.
Scalp, muscle, and soft tissue
dissection and repair
The cosmetic aspects of the techniques of skin
incision (electrocautery versus scalpel) and closure
(suture versus staples) are reviewed in more detail
elsewhere in this issue. For posterior fossa approaches, incisions that extend into the cervical
region should be made in a natural skin crease. For
closure, sutures may be preferable to staples when
there is concern about cerebrospinal uid (CSF)
leakage. The possible cosmetic dierences attributable to the dierent techniques for skin incision
and closure are likely marginal compared with
the cosmetic impact of tissue injury that can be
produced through poor surgical technique [3,4].
The use of muscle-splitting techniques that respect
fascial planes and detach muscles from their anatomic bony attachments rather than muscle transection preserves muscle bulk, facilitates anatomic
repair, minimizes swelling and ischemia that can
lead to deep infection or seroma formation, and
reduces postoperative pain. The utilization of the
ne-tipped electrocautery or Hoan dissector is

useful for performing these dissections. Appropriate repair of soft tissue should provide hemostasis
without compromise of blood supply, eliminate
dead space to prevent uid accumulations and a
potential nidus for infection, and reapproximate
muscles into their anatomic position under tension
to preserve muscle bulk.
Bone removal and repair
During posterior fossa surgery, bone removal is
accomplished with a craniotomy, craniectomy
with cranioplasty repair, or craniectomy alone.
Reconstituting the native skull contour with the
former two options is preferred for cosmetic purposes, but a craniectomy is indicated for emergency decompressive procedures or in situations
where postoperative swelling is a concern. The reconstitution of the bony contour provides additional benets of acting as a support to help seal
dural closures, thus preventing pseudomeningocele formation. Aside from cosmetic issues, the
use of craniotomy or cranioplasty versus craniectomy has been advocated in the acoustic neuroma patient undergoing a suboccipital craniotomy
(SOC), because it may prevent postoperative headaches [58]. The validity of this contention remains
controversial. The increasing number of new materials available for cranioplasty has produced a
myriad of techniques suitable for repair of bony

defects. Current choices for repair of bony defects
include native split-bone grafts; soft tissue grafts,
such as fat, bone extenders, or cements; traditional
methylmethacrylate cranioplasty material; bioabsorbable or titanium mesh for structural support;
and customized or preformed implants. One must
carefully consider the goal of the repair as well as
the costs and advantages of each approach or
material before proceeding. There is no literature
to guide decision making, and each surgeon must
use the technique and materials that are believed
to be the most cost-eective and appropriate for
a particular application. A summary of available
477
materials for cranial reconstruction and their

potential advantages and disadvantages is provided in Table 1. The specic techniques that we
employ for various procedures are outlined here.
Dural opening and closure
Dural opening and repair can directly aect
cosmesis through pseudomeningocele formation
or can indirectly aect cosmesis when CSF stulae
promote wound breakdown and infections that
require additional wound repair and debridement
or bone ap removal. The goal of dural repair
is to achieve a watertight closure if possible. The
Table 1
Summary of materials available for cranial reconstruction
Materials
Advantages
Disadvantages
Autogenous grafts:
craniotomy plate,
split-thickness
bone graft
Tantalum
Inexpensive, less susceptible to

infection
Possibility of reabsorption over

time, may have limited supply
to cover the defect, dicult
to conform to the defect
Expensive, higher risk of infection,
radiopaque with artifacts
on both CT and MRI, heavy,
has a risk of erosion through
the scalp, thermoconductive
Higher infection risk, has a
risk of erosion through the
scalp, minor artifact on CT,
susceptible to fracture
with trauma
Polymethylmethacrylate
Titanium mesh
Bioabsorbable mesh
Custom surgical
Implants (eg,
Medpor;
Porex Surgical, GA)
Hydroxyapatite cement
Bone graft extenders,

(eg, Novabone;
Porex Surgical)
No reabsorption, no limitation of
supply, can be molded to conform
to the defect, good tensile strength
Relatively inexpensive, no
reabsorption, unlimited supply, can
mould to conform to the defect,
medium strength, inert with minimal
tissue reaction, adheres tightly to
bone, not thermoconductive, no
paramagnetic artifacts on MRI
Well tolerated by soft tissues and
bone, easily contoured to t defect
Provides structural support, easily

contoured to t defect
Customized to t defect, open pore
structure allows for tissue ingrowth,
easily further customized with
scissors or scalpel, immediate good
structural and cosmetic support
Extremely biocompatible with no
inammation or foreign body
reaction, osteoconductive and
allows for ingrowth of new bone,
unlimited supply, may be used to
augment autogenous grafts
Used to augment autogenous bone
grafts with limited supply, easily
placed around preferred site
No reabsorption, higher infection

risk, often has to be used in
conjunction with polymethylmethacrylate to provide adequate
strength, artifacts on MRI or CT
although minor, expensive
Bioabsorbable and therefore limited
long-term support, minimal strength
Higher risk of infection, expensive,
needs to be ordered before surgery
Initial brittleness that limits its

use for larger defects, dicult
to conform to defect, expensive
Expensive, cannot be used exclusively
478
use of a continuous linear dural incision and

avoidance of cauterization helps to preserve the
native dura for primary watertight closure. If a primary repair is not possible, dural patch grafts with
autologous tissue (pericranium, fascia lata, and
temporalis fascia), allograft, or articial dural substitutes can be secured with a running suture and
brin glue to obtain a watertight closure [920].
The use of transient lumbar drainage can further
facilitate the sealing of this and other tenuous
dural closures. In rare cases, tissue transfer with
a pedicled or free ap may be required to prevent
CSF leaks (see below).
Cosmetic issues in specic posterior fossa
approaches
Surgical approaches to the posterior fossa
The surgical approaches that provide access to
the posterior fossa include midline approaches,
lateral approaches (paramedian and retrosigmoid), far lateral approaches, and the petrosal or
combined presigmoid transtentorial approaches
[21]. Needless to say, a variety of lesions can be
addressed by these approaches. From a cosmetic
perspective, the choice of approach should be
matched to the pathologic ndings such that
adequate exposure and repair are achieved without unnecessary tissue dissection or bony removal.
Specic techniques that can be used to improve
cosmesis for the retrosigmoid (RSA), far lateral,
and petrosal approaches are emphasized. Lastly,
the cosmetic issues for more radical reconstructive
techniques are reviewed.
Midline posterior fossa approaches
Cosmetic concerns for the midline approaches
are generally restricted to bony removal, muscle
repair, and skin incision. The latter two factors
have already been reviewed, and adherence to the
general principles of tissue and skin edge handling, muscle dissection in the avascular midline,
and avoidance of excessive monopolar cautery that
can damage muscle tissue should optimize the cosmetic outcome for these factors. The muscles that
insert superiorly along the nuchal midline include
the trapezius, splenius capitis, and semispinalis
capitis. The anatomy of the supercial musculature encountered in the basic posterior fossa
approaches is shown in Fig. 2. These above-mentioned muscles are taken down as a unit in a
subperiosteal fashion and should be reattached
in proximity to the nuchal line with the suture
Fig. 2. Anatomic diagram showing the relation between

the muscular layers of the posterior fossa.
anchored to a cu of tissue or to plates or holes

drilled into the bone. We prefer the latter choices
because they do not require division of the muscle
at its insertion and the anchoring is more secure.
Atrophy or retraction of muscle at the nuchal
line can produce a noticeable defect, particularly
in patients with short hair or in those who have
undergone a craniectomy. As mentioned previously, the decision to perform a craniotomy, craniectomy with cranioplasty, or craniectomy alone
must be based on the clinical situation, the surgeons preference, and the available cranioplasty
materials. Any method of bony reconstruction
that securely reconstitutes the normal bony and
soft tissue contour of the posterior fossa has the
same positive cosmetic outcome. Delayed cranioplasty can also be performed, but the cosmetic
result can be compromised by any intervening
muscular atrophy that must be accounted for
when contouring the cranioplasty. In cases of
Arnold-Chiari type I malformations, one performs a craniectomy to expand the posterior
fossa. Although modest bony removal is essential
to treat the underlying pathophysiology, excessive
bony removal not only creates a potentially poor
cosmetic result but can produce symptoms
caused by cerebellar sag.
Lesions in the lateral cerebellar hemisphere and
or cerebellopontine angle (CPA) generally require
a lateral approach. Variations of the commonly

employed RSA can be modied to address lesions
in either location and thus serve to demonstrate
surgical techniques and issues that aect cosmetic
outcome for treatment of lesions in both locations
[2226]. The type of incision one uses for the RSA
can dictate the muscle dissection employed to
access the suboccipital bone and, ultimately, the
cosmetic outcome from surgery. Three dierent
incisions commonly used for the RSA are shown
schematically in Fig. 3.
The vertical incision employs a muscle-splitting
technique that allows rapid access to the suboccipital bone, but the division of muscles may
increase postoperative pain and local inammation, impair muscle healing, and enhance atrophy.
In addition to the potential loss of muscle bulk,
this approach is more likely to divide the lesser
occipital nerve as it courses between the sternocleidomastoid muscle (SCM) and splenius capitis
muscle to produce numbness in the postauricular
region or neuroma formation. The absence of a
layered wound may increase the CSF leak and subsequent infection risk, which can compromise the
cosmetic result.
Fig. 3. Illustration of three common skin incisions

applied to the retrosigmoid approach to the posterior
fossa: the vertical or straight incision, a retroauricular
C-shaped incision, and a U-shaped incision.
479
An inverted U-shaped ap involves a midline

incision that traverses horizontally above the
nuchal line and then inferiorly along the mastoid
parallel to the midline incision. The subcutaneous
tissues and muscles are elevated as a unit and
detached from their anatomic insertions, thus
allowing preservation of muscle bulk and the lesser
occipital nerve. During closure, the muscles can be
anchored under tension at their nuchal insertion
using one of the techniques described previously
to prevent atrophy. This approach is relatively fast
but has the disadvantage of having muscle bulk at
the inferior aspect of the wound, which can limit
exposure, and a nonlayered closure with the lateral
limb of the incision overlying the dural opening,
which may be more prone to CSF leak.
We prefer the C-shaped retroauricular incision
for the RSA (see Fig. 3). The steps in this approach
are demonstrated in Fig. 4. Briey, the apex of
the incision approximates the medial border of the
SCM to facilitate the elevation of a myocutaneous
ap that incorporates the SCM. The medial extent
and superior and inferior extension of the incision
are modied according to the lesion size and location. For large lesions requiring exposure to the
foramen magnum, the incision can be extended
below the level of the mastoid tip and hairline in
the normal cervical skin creases so as to provide
a more cosmetic result. The inferior border of the
SCM is elevated if possible, but it can be split
along its bers for smaller exposure. By extending
the ap inferiorly, the muscle can generally be
elevated forward without division to provide
generous access to the suboccipital region.
After the elevation of the myocutaneous ap, the
splenius capitis and deeper suboccipital muscles
are encountered. These can be detached as a unit
or dissected sequentially with preservation of the
lesser occipital nerve between the SCM and splenius and the occipital artery in its course between
the splenius capitis and suboccipital muscles.
These muscles are retracted inferomedially to allow generous exposure of the suboccipital region.
A craniotomy is fashioned by drilling a narrow trough over the inferior and medial edges of
the transverse and sigmoid sinuses, respectively,
and completing the bone cut with a craniotome
or high-speed drill. This allows elevation of a more
generous bone ap that does not require augmentation at closure to cover the defect. The mastoid
emissary vein is directly visualized under the ap
and can be coagulated and divided to free the ap
without producing a tear at its point of entry into
the sigmoid sinus. In cases in which there is
480
Fig. 4. Intraoperative photographs of a right-sided retroauricular C-shaped incision and muscle-splitting retrosigmoid
craniotomy. (A) Skin incision with the course of the transverse and sigmoid sinus and mastoid marked. (B) Myocutaneous
scalp ap with the sternocleidomastoid muscle elevated and the splenius capitis muscle exposed. Note the course of the
preserved lesser occipital nerve (arrow). (C ) The splenius capitis muscle elevated as a separate layer. (D) The splenius
capitis and suboccipital muscles elevated from the nuchal line to provide exposure of the suboccipital bone. (E ) The bone
ap created by drilling over the medial edge of the sigmoid sinus and inferior edge of the transverse sinus gives full
exposure for a cerebellopontine angle approach and can be replaced to ll the defect without the need for cranioplasty.
concern about dural adhesion, a burr hole can be

placed at the asterion and at the inferomedial corner of the planned craniotomy to allow dural stripping and inspection before bone ap elevation.
This technique often requires additional drilling
of the mastoid bone to provide exposure to the
medial edge of the sigmoid sinus, however.
The muscle layers are reapproximated in their
anatomic positions and anchored to their sites
of insertion to apply tension and preserve muscle bulk. The layered coverage that results from
this technique helps to prevent CSF leakage. We
have adopted this approach not only because
it provides an excellent cosmetic result, but because it has eliminated leakage of spinal uid
through the wound and reduced the incidence of
pseudomeningocele formation and postoperative
pain.
Far lateral approaches

The cosmetic issues relevant to the far lateral
approaches are similar to those encountered in
the RSA. Additional muscle dissection and bone
removal provide the lateral exposure needed for
ventral and ventrolateral exposure of the posterior
fossa and craniocervical junction as well as the
mid- to lower clivus. The indications for and details
of the many variations of far lateral approaches
are reviewed in more detail elsewhere [2733]. The
following discussion describes general strategies to
minimize cosmetic defects from these approaches.
Two approaches commonly used to provide far
lateral surgical access employ either a U- or Cshaped incision (Fig. 5). These two approaches
dier largely in the techniques used for muscle dissection to access the suboccipital bone, mastoid,
and cervical lamina/facets. In both approaches, the
extent of dissection and bone removal is dictated
by the underlying pathologic ndings and the
amount of the exposure required to access lesions
of the ventral/lateral and inferior posterior fossa
as well as the craniocervical junction.
The U-shaped incision starts at or below the
mastoid tip and extends to the mastoid base, medially along the nuchal line, and then vertically into
the midline cervical region as described previously
Fig. 5. Two common skin incisions used for far lateral

approaches: the U-shaped incision and the retroauricular C-shaped incision.
481
for the midline approach. This incision allows reection of the skin and muscles back away from
the surgical site in one large ap, which avoids
muscle transection. As is the case with the Ushaped incision in the RSA, the elevation of
muscles en bloc may create enough bulk to obscure
lateral exposure. Another consideration with this
approach is that the incision or dissection through
the skin, soft tissues, and dura lies more directly in
line and may thus increase the chances of CSF
stula formation when a watertight dural repair
is not achieved.
The approach using the C-shaped incision differs from that employing the U-shaped approach
largely in the technique used for muscle dissection.
Although its potential advantages include reduced
muscle bulk, obscuring the exposure, one advantage relevant to cosmetic outcomes includes a reduced risk of CSF leak. By dissecting the muscles
in layers and repairing them by anchoring them
to their respective sites of attachment, a multilayered closure that resists CSF leaks, preserves
muscle bulk, and provides excellent lateral exposure is achieved. As with the RSA, the skin and
SCM are reected as a myocutaneous ap and
then the splenius capitis, semispinalis capitis,
and rectus capitis muscles are detached o the
nuchal line and suboccipital bone and reected
inferomedially. The muscles of the suboccipital triangle are identied before the dissection of the vertebral artery. The basic surgical steps and exposure
achieved by this approach are outlined in Fig. 6.
As mentioned previously, varying amounts of
bone removal involving the suboccipital bone,
condyle, and mastoid process are employed in the
far lateral approaches. The need for bone repair is
dependent on the extent of bone removal. Because
of the inward curvature of the suboccipital region,
much of the bony removal with this approach is
hidden deep under the soft tissues and reduces
the cosmetic deformity after smaller exposures.
In the more extensive bony removals, particularly
those that involve the mastoid area, bony reconstruction may be used. This bony reconstruction can involve the dierent bone sources as
discussed previously. The choices of repair for
extensive mastoid removal are discussed below in
the section on the petrosal approach. A secondary consideration in cosmesis for the far lateral
approach is the signicant reduction in mobility at the occipital-cervical joint when fusion is
needed after greater than 50% occipital condyle
resection. The awkward movement produced by
limiting movement (approximately 50% in all
482
Fig. 6. Far lateral approach employing a retroauricular C-shaped incision. (A) Skin incision with elevation of the
sternocleidomastoid muscle as a myocutaneous ap. (B) The splenius is reected to expose the longissimus capitis muscle
(LC). (C ) The deeper muscles of the suboccipital triangle and the transverse process of C1 (at the tip of the dissector) are
exposed after reection of the longissimus capitis and semispinalis capitis muscles. (D) After a small suboccipital
craniotomy, mastoidectomy, C1 hemilaminectomy, and partial condylectomy, the vertebral artery (VA) is mobilized and
lateral posterior fossa and upper cervical dura are exposed. (E ) After dural opening, excellent exposure to this lower
clival/upper cervical ventral meningioma is demonstrated.
planes) can have the same emotional impact as

a severe cosmetic defect. Therefore, one must
carefully consider the necessity for condyle resection, particularly because many ventral lesions can
be resected with less aggressive approaches [15].
Presigmoid petrosal approach
The presigmoid petrosal approach provides
access to lesions in the petroclival and tentorial
notch areas; when combined with frontotemporal

or pterional and orbitozygomatic approaches, it
can be used to access lesions that extend to the
cavernous sinus and middle fossa [3437]. For the
standard petrosal approach, a C-shaped retroauricular incision that extends along the superior temporal line and down into the neck in line with the
cervical skin folds is employed (Fig. 7A). If a
combined approach is required, a modied skin
483
Fig. 7. The incisions used for the standard petrosal approach (A) and when used in combination (B) with frontotemporal or pterional craniotomies with or without orbitozygomatic osteotomy.
incision that extends above the temporal line into

the frontotemporal region is made. A preauricular
incision that joins the postauricular incision
provides for the combined approach. Care must
be taken to keep the base of the scalp aps
large enough to ensure adequate blood supply
(see Fig. 7B).
The details and variations of the petrosal
approach have been outlined elsewhere, and we
focus on the major cosmetic issues related to this
approach. Similar to the techniques used in the
RSA or far lateral approaches, the scalp is elevated
as a myocutaneous ap and the deeper muscles are
dissected without transection to maintain bulk
and provide good layers for closure. The additional
exposure of the squamous temporal bone requires
elevation and anterior reection of the posterior
aspect of the temporalis muscle. The mastoidectomy creates a defect over the site of the presigmoid dural incision, which can lead to a
signicant cosmetic deformity and a propensity
for CSF leak if not adequately repaired. There
are numerous ways to provide a good dural repair
and cosmetic closure. Although the presigmoid
dura cannot be primarily repaired in a watertight
fashion, it can be reapproximated with several
dural sutures that also provide a latticework to
support interlocking pieces of autologous fat graft,
which eects a ball-valve closure. This is augmented with brin glue and supported externally
either with a solid graft or with the soft tissue

closure and dressings. A lumbar drain is used for
several days to allow the repair to seal adequately. Small defects can be packed with fat or other
autologous tissue (fascia lata, pericranium) that
is anchored into the opening with a lattice of dural
suture to eect a ball-valve closure.
The bony defect over the sigmoid sinus and
mastoid creates the most signicant cosmetic defect
from this approach. A large number of strategies
similar to those used for bony reconstruction of
retrosigmoid craniectomies are available for reconstruction of the defect created by the petrosal
approach. Among the choices are split-thickness
autograft, bioabsorbable or titanium meshes, bone
cement, methylmethacrylate, and mastoid prosthetic
devices (Fig. 8). We prefer autograft if suitable donor
bone is available. An additional benet from reconstruction is the support it provides for dural repair.
Cosmetic aspects of reconstructive surgery
Reconstruction after posterior fossa surgery
may be required for chronically nonhealing
wounds or when extensive soft tissue or bony
removal is performed during tumor resection
(Figs. 9 and 10) [3842]. The approach to posterior
fossa reconstruction and the optimization of cosmetic outcome starts with careful evaluation of
the patient and the potential defect. This includes
484
Fig. 8. (A) The resulting defect after a petrosal approach is illustrated. (B) The use of a preformed Medpor (Porex
Surgical, Fairburn, GA) implant (I) to repair the defect is shown. A variety of other materials and techniques are suitable
for this repair, including split-thickness autograft (see text for discussion).
assessment of the location and size of the defect

with radiologic evaluation of the depth and bony
or dural defects. Previous surgery or radiation or
ongoing wound infection aects the viability of
the skin around the defect, reducing the available
tissue for local aps. Of course, the pathologic
characteristics of the presenting lesion are also
important in planning reconstruction.
The simplest method of reconstruction should
be considered in all cases while ensuring adequate
resection of the lesion. In the posterior neck, the
abundant collateral soft tissue blood supply allows
for wide elevation of these tissues so that many
wounds can be closed primarily or with simple
adjacent tissue transfer. When larger defects exist,

however, local tissues useful in the anterior cranium, such as pericranial aps and temporalis
aps, do not exist. Moreover, the thick posterior
neck and occipital tissues do not lend themselves
to skin graft reconstruction, because this would
result in a poor cosmetic and functional result.
Excellent cosmesis has been achieved with tissue
expansion when hair-bearing skin has been lost,
and repeated expansion is possible for large defects.
The main advantage is the ability to replace one
tissue with the same tissue. This technique requires
a separate procedure to place the expanders and
time for tissue expansion to occur, however, which
485
Fig. 9. Repair of a nonhealing posterior fossa wound with chronic cerebrospinal uid leakage in a 48-year-old man with
multiple resections, radiation therapy, and local chemotherapy for recurrent medulloblastoma. (A) Demonstration of the
site of chronic wound breakdown with dural graft exposed. (B) After wound debridement, a larger defect is evident that
cannot be primarily repaired. The exposed bovine pericardial dural patch was replaced. (C ) This pedicled lower island
trapezius ap based on the transverse cervical and dorsal scapular vessels was used for reconstruction. Note the proximal
de-epithelialized portion of skin that must lie in the subcutaneous tunnel. (D) The nal reconstruction with the epithelialized skin paddle forming the lower triangular area of the nal scalp closure. The patient did well with no further wound
complications.
may delay surgery for the primary tumor. Tissue

expansion is not generally recommended for infected cases because of the risk of the expander
becoming infected and losing the expanded ap or
for use in radiated skin because of decreased compliance and a higher rate of skin necrosis.
For larger posterior fossa defects, there are several well-vascularized regional aps from the back
that provide good skin color match and appropriate tissue thickness. Because the patient is often
placed in the prone or lateral decubitus position
for tumor extirpation, the back is the ideal donor
site. The trapezius system of aps oers a superior
ap, which is easily elevated and useful for rotational coverage of small neck defects. Its short
arc of rotation limits its use in the posterior fossa.
More commonly, the lower island trapezius ap
based on the transverse cervical and dorsal scapular arteries is used because of its ability to cover
most posterior defects with minimal tension on
the wounds. This pedicled ap allows tissue to be

transferred for up to 15 cm below the scapular
tip and can reach the occiput easily. The skin color
and texture provide an excellent match to the posterior scalp. Donor site morbidity is minimal, and
the wound is closed primarily.
Also on the back, the latissimus dorsi ap based
on the thoracodorsal vessels provides abundant
muscle and skin to cover any posterior fossa
defect. Its arc of rotation at the axilla allows it to
reach to the top of the head if necessary. At times,
the skin portion may be much thicker than the
posterior scalp; the ap can be transferred as
muscle only, and a split-thickness skin graft can
be applied.
When pedicled aps cannot comfortably reach
and cover the defect or the geometry of the ap
inset could compromise vascularity, free tissue
transfer provides optimal results. Tissue can be
placed optimally unencumbered by pedicle length
486
Fig. 10. Resection of a recurrent scalp melanoma in a 68-year-old woman with invasion of the occipital bone.
(A) Preoperative picture showing an extensive scalp lesion. (B) MRI with gadolinium showing extensive involvement
of soft tissue. (C ) Extensive resection of scalp and right suboccipital bone. (D) Dissection of a myocutaneous latissimus
free ap that was inserted into the right transverse cervical artery and right internal jugular vein. (E ) Final intraoperative view with latissimus ap at the inferior portion of the reconstruction and meshed split-thickness skin graft above.
Note that the cutaneous paddle of the ap resides along the cervical region, where the tissue is normally thicker, and
that the skin graft is used to cover the thinner area of the cranial scalp. (F ) Postoperative result after wounds have
matured.
or position. Well-vascularized tissue from a variety

of donor sites can minimize the risk of CSF leak,
cover exposed calvarium, tolerate the burden of
radiation and/or a contaminated wound, and provide optimal function and cosmesis. As described
previously, the latissimus dorsi myogenous or
myocutaneous ap is easily harvested and has

a predictable blood supply with a long vascular
pedicle to reach donor vessels, large size, and minimal donor site morbidity. It is the ap of choice to
reconstruct large scalp defects on any area of the
head.
487
dealing with complex and chronic wound-healing

problems or extensive soft tissue and bony lesions in the posterior fossa.
Summary
Although cosmetic defects produced by posterior fossa surgery may not seem obvious, a poor
cosmetic result can overshadow an otherwise successful operation. It is important to approach the
operation with knowledge that each phase of a surgical procedure either directly or indirectly inuences the eventual cosmetic result. The careful use
of anatomic dissection and repair and attempts
to reconstitute bony defects to their native contour
as well as avoidance of complications all contribute to excellent cosmetic outcomes.
Acknowledgments
The authors thank medical illustrator Raquel
Lourenco Abreu for her preparation of all illustrations included in this article and Paul Schwartz
and Janet Schukar for invaluable assistance with
gure preparation.
References
Fig. 10 (continued )
One other excellent free-ap choice is the fasciocutaneous scapula ap based on the subscapular vessels. It has excellent color match to the
posterior neck and occipital skin as well as thickness and consistency that match surrounding
tissue. The shorter pedicle length when compared
with that of the latissimus dorsi ap may sometimes limit its use because of the diculty in reaching suitable recipient neck vessels.
The expertise of a team of surgeons versed in
dierent cosmetic aspects of reconstructive surgery is invaluable to the neurosurgeon when
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Cosmetic aspects of cranial reconstruction

Kenneth Leong, MD, Chet L. Nastala, MD,
Peter T.H. Wang, MD, DMD*
Division of Plastic and Reconstructive Surgery, University of Texas Health Science Center at San Antonio,
7703 Floyd Curl Drive, San Antonio, TX 782293900, USA
Cranial reconstruction has evolved to achieve

both functional coverage and esthetic appearance.
Hair preservation/reconstruction and free aps
have markedly improved the soft tissue esthetic
outcome. Restoration of bony contour has been
facilitated by advanced craniofacial techniques
and three-dimensional alloplast.
The head and face is the most visible part of the
body. Tumor excision, trauma, burns, and radiation necrosis cause signicant decits of this
important area of the body. Successful reconstruction of these decits requires rst protecting the
cranial/intracranial structures and secondarily
providing the cosmetic appearance. Improvements
in reconstruction with microsurgery and the use of
cranial bone grafting, tissue expanders, microplating systems, and alloplastic materials have added
signicantly to achieving both goals. Currently, it
is no longer acceptable to provide just stable coverage; reconstructive plans should also strive to provide the best possible esthetic appearance.
Anatomy and vascular supply
Bony anatomy
The calvarium provides the structural shape
and support for the overlying soft tissue and protection of the intracranial contents. It is composed
of six bones: the occipital, frontal, paired parietal,
and paired temporal bones. The frontal bone
esthetic units can be divided into the frontal convexity, which contains the frontal sinus, and the
supraorbital region. Accurate reconstruction of
E-mail address: wangp@uthscsa.edu (P.T.H. Wang).
these two regions improves the nal appearance.

Calvarial bone consists of an inner layer of spongy
bone, the diploe, sandwiched between two layers
of cortical bone.
Scalp anatomy
The scalp (Fig. 1) is richly vascularized tissue
composed of the following ve layers:
S: skin
C: subcutaneous tissue containing skin appendages, including hair follicles, sweat glands,
and neurovascular supply to the scalp
A: aponeurosis (galea) contiguous with frontalis and temporal parietal fascia
L: loose connective tissue
P: pericranium
The scalp ranges from 8 mm thick at the occiput to 3 mm thick anteriorly, with a key feature,
the hair follicles [1]. For successful scalp reconstruction, defects should be replaced with hairbearing tissue. Additionally, hair patterns should
be preserved, and the hair in the reconstructed
areas should be oriented in a direction similar to
that of the surrounding hair.
The vascular supply to the scalp comes from
ve pairs of blood vessels (Fig. 2). These vessels
enter the scalp and travel in the subcutaneous layer
before terminating in an extensive anastomotic
network. The scalp is loosely divided into four territories based on its vascular supply. The terminal
branches of the supercial temporal artery supply
the lateral scalp. The postauricular artery supplies
the posterolateral scalp. The lateral and medial
branches of the posterior occipital artery supply
the posterior scalp. These vessels are derived
from the external carotid artery. Only the
PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 5 - 6
492
K. Leong et al / Neurosurg Clin N Am 13 (2002) 491503
Fig. 1. Layers of the scalp, with vascular supply to the

pericranial ap highlighted. (Adapted from Shestak K,
Ramasastry S. Reconstruction of defects of the scalp
and skull. In: Cohen M, editor. Mastery of plastic and
reconstructive surgery. Boston: Little Brown and Company; 1994. p. 831; with permission.)
supratrochlear and supraorbital vessels, which

supply the anterior scalp, derive their blood supply
from the internal carotid. Because of its rich anastomotic network, a single vessel can nourish the entire
scalp.
In designing scalp aps, major vessels should be
preserved and incorporated into the base of the
ap. The galea and pericranium can be elevated
together as a pericranial ap based on microvascular supply from the loose connective tissue [1,2].
Forehead anatomy
The forehead is composed of hairless skin with
a small amount of subcutaneous fat and underlying frontalis muscle, which is contiguous with the
galea of the scalp. Forehead skin is generally paler,
smoother, and thicker than the rest of the face.
Relaxed skin tension lines are transverse, except
in the area of glabella, where they are vertical [1].
Forehead innervation is through the supratrochlear and supraorbital nerves (V1), which are
sensory, and through the frontal branch of facial
nerve, which is motor.
Reconstruction alternatives after oncologic
resection of lesions involving the neurocranium
Cranial decits involve both the hair-bearing
scalp as well as the non-hair-bearing forehead.
Fig. 2. Vascular supply of the scalp and forehead.

(Adapted from Shestak K, Ramasastry S. Reconstruction of defects of the scalp and skull. In: Cohen M,
editor. Mastery of plastic and reconstructive surgery.
Boston: Little Brown and Company; 1994. p. 831; with
permission.)
These defects can be divided based on the degree

of tissue loss and whether it is partial or full thickness. Partial-thickness soft tissue defects can be
reconstructed electively. Small partial-thickness
defects should be reconstructed with either local
aps or skin grafts. Larger defects should be
covered with a skin graft with plans for secondary
reconstruction, usually with tissue expanders.
Full-thickness defects require urgent ap reconstruction to prevent desiccation and infection of
the underlying bone, which could lead to intracranial infection and death [2].
To provide the best esthetic outcome, coverage
is best performed with like tissue replacing like
(ie, bone for calvarium, hair-bearing tissue for
hair-bearing tissue). An accurate assessment of the
amount and type of tissue missing is thus essential.
In addition, other factors, such as prior scarring
and the need for postoperative radiation, must
be considered.
Direct closure
Direct closure provides the ideal coverage with
local tissue. In the scalp, direct closure is particularly advantageous because it provides hair-bearing tissue. Acute wounds without tissue loss may
be directly closed. Wounds with tissue loss may
require galeal scoring to achieve closure without
undue tension. Generally, up to a 3-cm defect
may be closed in this fashion [3]. The galea should
be minimally scored with care to preserve the
vascular supply running in the subcutaneous
layer. Distortion of important adjacent features,
such as the eyebrows, should be avoided.
Skin graft coverage

Closure of clean well-vascularized beds can be
accomplished with a split-thickness skin graft
0.014- to 0.02-inch thick. This results in a contour,
hair, and, generally, color mismatch initially. With
time, the graft contracts, and the contour defect
improves. Skin graft coverage is generally an
interim solution, requiring eventual (usually 68
months later) coverage through serial excision or
tissue expansion or with a local ap.
Generally, skin grafts appear as patches and are
not as durable as the surrounding skin. Additionally, because skin grafts do not contain underlying
skin appendages, such as sebaceous glands or hair
follicles, these grafts are dry and hairless. Skin graft
coverage may be advantageous in situations where
a fast simple procedure is required. Skin grafts can
also be used as a temporizing measure in situations
where the tumor resection margins are unclear.
The graft may be placed directly on the pericranium, or if the pericranium is involved, the outer
cortex of bone may be drilled to provide a vascularized bed [1]. This leads to an unstable scar, which is
removed with secondary procedures. To improve
vascularity and to prepare the wound bed before
skin grafting, a vacuum-assisted closure (VAC)
device (KCI, San Antonio, TX) may be used.
Skin graft coverage can provide an acceptable
long-term result if used appropriately. Because skin
grafts lack hair, they should be placed in areas
where hair is not required, such as the forehead,
or where they can be hidden by surrounding hair,
such as the posterior occiput. Color match to the
face/forehead can be improved by using donor sites
above the clavicle, such as the postauricular region
for full-thickness grafts and the scalp for split
grafts. Unmeshed grafts should be used in visible
areas. Secondary hair transplantation may be performed on skin grafts over a well-vascularized bed.
Tissue Expanders
Tissue expanders enable closure of large defects
with local hair-bearing tissue. They are arguably
the preferred method of secondary scalp reconstruction. Up to 50% of the scalp can be covered
without creating a new donor site or visible thinning of the hair [4,5]. They are used for secondary
reconstruction because they require slow expansion (up to 25 months) to minimize complications
like extrusion or deformation/erosion of the skull.
Placement can be done at the time of the initial surgery using a skin graft. Delayed placement after
493
tumor excision may be advisable to minimize disturbance of additional tissue planes.

Tissue expanders are generally placed at the
periphery of the defect with care to place the incisions so as not to devitalize subsequent ap rotation. These incisions may be incorporated with
the incisions needed to elevate the ap. We usually
place expanders through a small inverted V-shaped
incision. After approximately 1 week for wound
healing, we begin expansion at a weekly rate of
approximately 10% of the expander volume (or
just before skin blanching and pain). Overexpansion by 30% to 50% more than the estimated defect
is recommended (Fig. 3). Subsequent rotation or
advancement of the expanded tissue should take
orientation of adjacent hair into consideration.
Expansion does not result in an increased number of hair follicles, but no visible thinning is noted
until the scalp is expanded more than twofold
(Fig. 4). An increased percentage of hair follicles
in anagen, the hair growth phase, has been noted
on histologic studies of expanded scalps, however
[6]. Other histologic changes include thickening of
the epidermis, thinning of the dermis and subcutaneous fat (masked by the capsule formation
around the expander), and increased vascularity.
In addition to the scalp, the forehead may be expanded as part of a staged reconstruction (Fig. 5).
Local aps
For acute coverage of full-thickness defects that
are too large for direct closure, up to 30% of the
total scalp can be covered with a local ap [2].
Local ap closure requires more undermining
and additional incisions compared with direct closure; however, it also provides coverage with like
tissue and hair-bearing tissue.
For secondary reconstruction, local aps are
generally used for defects smaller than 10 cm2 in
area. Backgrafting at the donor site may be necessary [2]. Incisions should be placed within the hair
and beveled with the direction of hair growth to
avoid transection of hair follicles and subsequent
alopecia.
Scalp rotation aps
Scalp rotation aps are designed to include one
of the major vessels of the scalp and are elevated in
the subgaleal plane, leaving the pericranium intact
[1]. Flap design should be generous to account for
the convex calvarium, which decreases usable ap
length [2]. For defects larger than 10 cm2 in area,
skin grafting of the donor site may be required.
494
Fig. 3. (A) Recurrent dermatobrosarcoma protuberans in the scalp. (B) Full-thickness excision and immediate
coverage with a skin graft. Tissue expanders were placed in the periphery at the time of excision. (C, D) Tissue expansion
after 3 months.
Rotation of the scalp may unfavorably change the

direction of hair growth (Fig. 6).
Scalp transposition aps
Ortichochea aps, initially described by
Ortichochea [7] in 1967, can cover defects up to
20 cm2 in area. The three-ap design is based on
blood supply to the anterior ap from the supratrochlear, supraorbital, and supercial temporal
vessels, with the two posterior aps supplied by
the occipital and postauricular vessels (Fig. 7) [7].
Multiple parallel galeal relaxing incisions are
needed to obtain the necessary ap length.
Bipedicled scalp aps
Bipedicled scalp aps are described elsewhere in
this issue.
Pericranial aps
Pericranial aps can be designed as described
previously to cover full-thickness defects up to
7 cm in diameter acutely. Skin grafting of the pericranial ap is required. Secondary reconstruction

with tissue expanders is generally performed to
achieve the nal result.
Regional aps
Regional aps are used for coverage of fullthickness decits that are too large (greater than
30% of the scalp) to be covered by local aps.
There may be additional confounding factors,
such as irradiation and prior incisions. These
defects require coverage with reliable vascularized
tissue. Regional aps, such as the trapezius muscle
or myocutaneous ap, can provide such coverage.
A short pedicle and arc of rotation limit the reach
of regional aps only to inferior cranial defects,
however [8].
Trapezius ap
The trapezius ap, based on the descending
branch of the transverse cervical artery, is the most
495
Fig. 4. Reconstruction of scalp alopecia with tissue expanders in a young boy. Expanders are well tolerated even in
children if slowly expanded. (A, B) Multiple large tissue expanders are placed at the periphery of the alopecia. Incisions
used for expander placement are placed so that they are included with the excision. (C, D) Excision and rotation of
expanded scalp result in coverage of the entire area with hair-bearing scalp. No visible thinning of hair with scalp
expansion to twofold its original dimensions.
useful ap for this region. It may be elevated as a

muscle or myocutaneous ap and rotated on its
pedicle to cover the posterior neck, postauricular
area, temporal area, and skull base. It is nonhair-bearing and bulky, however, with a signicant
donor defect. Postoperative shoulder droop may
occur if innervation to the transverse portion of
this muscle is interrupted [2].
Temporoparietal fascia
The temporoparietal fascia ap, based on the
supercial temporal artery, has limited usefulness
as a pedicled ap for cranial reconstruction. It
may be elevated as a fascial ap, fasciocutaneous
ap, or osseous ap [8]. Preoperative assessment
of the presence of the supercial temporal vessels
is crucial, however, because those vessels may have
been divided with prior scalp incisions.
Temporalis muscle ap
The temporalis muscle ap is based on the
deep temporal artery. It is elevated as a muscle
ap for coverage of adjacent calvaria, the cranial
base, the orbit, and intraoral defects. Unlike the
temporoparietal fascia ap, the deep temporal

vessels lie deep to the temporalis muscle and are
protected from prior scalp incisions. Temporal
hollowing is an undesirable result of using this
muscle ap [8].
Latissimus dorsi ap
The latissimus dorsi ap may be based on the
thoracodorsal artery or from multiple posterior
intercostals and lumbar arteries. For cranial
reconstruction, the muscle is based on the thoracodorsal vessels. As a pedicled ap, its use is limited
to the to occipital area. Donor defects are small,
because function is preserved by the remaining
shoulder girdle muscles. It may be elevated as a
muscle or myocutaneous ap with the donor site
closed if the width of the skin paddle is 7 to 10 cm,
depending on skin laxity [8]. Like the trapezius
ap, it is bulky.
Microvascular free aps
Microvascular free aps are available in a number of dierent types ranging from fascia only to
496
Fig. 6. Scalp rotation ap. Note the backgraft of the

donor site. The skin graft can be removed with secondary reconstruction using tissue expanders. (Adapted
from Shestak K, Ramasastry S. Reconstruction of defects of the scalp and skull. In: Cohen M, editor.
Mastery of plastic surgery. Boston: Little Brown and
Company; 1994. p. 831; with permission.)
osseocutaneous aps. The ap can be chosen to

meet the specic needs of reconstruction, taking
into consideration the nal appearance and the
donor site defect. They require longer operative
times, microsurgical anastomoses, and postoperative ap monitoring, however. In those patients
with defects too large for local aps, a history of
irradiation, or multiple unstable scars, microvascular free aps provide versatile reconstructive
options.
Muscle aps
Muscle aps provide good vascularized tissue
with bulk to ll defects. They are particularly
suited for large defects because of their size.
Because they are well vascularized, they can be
used in contaminated wounds. A skin graft is then
placed over the ap. Secondary hair transplantation can be performed as needed.
Commonly used muscle aps are the latissimus
dorsi, rectus, and serratus. The latissimus dorsi
muscle provides the largest muscle available for
reconstruction (Fig. 8). In addition, the latissimus
has a long vascular pedicle. Harvesting of this ap
requires positioning the patient in the lateral decubitus position. The rectus provides less muscle
than the latissimus but can be harvested with the
497
Fig. 7. Three-ap Orticochea ap. Note the parallel

galeal scoring required for expansion. The two smaller
aps are used to cover the defect, with the large ap
rotated to close the donor defect. Defects up to 20 cm2
can be covered. (Adapted from Longacre JJ, Converse JM.
Deformities of the forehead, scalp, and calvarium. In:
Converse JM, editor. Reconstructive plastic surgery,
vol. 2. 2nd edition. Philadelphia: WB Saunders; 1977.
p. 837; with permission.)
patient in the supine position concurrently with

preparation of the recipient site. The vascular
pedicle for the free rectus is the deep inferior epigastric artery. The serratus provides a modest
amount of muscle with a long pedicle, the serratus
branch of the thoracodorsal artery. Harvesting of
the ap can be performed with the patient bumped
up on the side.
Myocutaneous aps
Myocutaneous aps provide advantages of the
muscle ap with cutaneous coverage; however,
these aps are bulkier. Commonly used myocutaneous aps are the latissimus dorsi with a skin
paddle and vertical or transverse rectus (TRAM)
myocutaneous aps.
Fasciocutaneous aps
Fasciocutaneous aps are particularly suited
for forehead and scalp reconstruction. They
b
Fig. 5. (A) Forehead expansion for reconstruction of a defect from linear scleroderma. (B) An expander is placed in the
forehead through a scalp incision and slowly expanded over 3 months to 50% over capacity. (C) Expanders are removed
at a second stage, and aps are rotated into position using the soft tissue excised for additional bulk. (D) Early
postoperative result shows good contour but prominent scar.
Fig. 8. (A) A 14-cm squamous cell carcinoma on the scalp, involving the calvarium. (B) Full-thickness soft tissue excision is
performed. Because the deep tumor margin involves the calvarium, a portion of the calvarium is resected, leaving exposed
dura. (C) The bony defect is reconstructed with split rib grafts. (D) A latissimus dorsi free ap anastomosed to the supercial
temporal artery and vein is used because of the large defect. (E) Appearance 10 days after surgery. Some atrophy of the
muscle is anticipated. Secondary hair transplantation should improve the overall appearance.
499
Fig. 9. (A) A 56-year-old man with exposed dura and titanium mesh after multiple failed reconstructions of a bony
defect. Note the areas of prior incisions and the unstable scar. (B) All questionable soft tissue is removed along with
involved mesh. New mesh was placed to reconstruct the bony defect. (C) A radial forearm fasciocutaneous ap was
harvested concurrently with debridement. (D) A radial forearm ap anastomosed to supercial temporal vessels was
inset to cover the new mesh. (E) Early postoperative appearance, with good contour. Note the color dierence in the ap
versus native skin. (F) Early appearance of donor site showing contour deformity as well as skin color and texture
mismatch.
500
provide thin and pliable vascularized tissue. Common fasciocutaneous aps include the radial forearm and parascapular aps. The radial forearm
provides the largest fasciocutaneous ap with good
color match. Preoperative evaluation of the donor
hand using an Allens test is essential to assess vascular supply to the hand from the ulnar artery. The
radial forearm donor site is visible and may not be
appropriate in young women (Fig. 9). Although
the parascapular ap is bulkier than the radial
forearm ap and requires a lateral decubitus position to harvest, the donor site is well hidden.
Composite/osseocutaneous aps
Osseocutaneous or myo-osseous aps can
be designed whenever vascularized bone is required. Examples of composite aps include the
radial forearm with a segment of radius, scapular
with a segment of scapula, and free bula. Free
bula aps are commonly used for mandible
reconstruction.
Omentum ap
For large defects, omentum may harvested
either through a small upper midline incision or
laparoscopically. Disadvantages of the omentum
ap include sagging because of lack of structural
support and the need for intra-abdominal harvest.
Fig. 10. Calvarial reconstruction with split rib grafts of

the same patient as in Fig. 8. Up to two adjacent ribs
may be harvested before ail chest. To minimize chest
deformity, nonadjacent ribs may be used.
of small simple defects, split calvarium is readily

available nearby (Fig. 11) [11]. It is dicult to create
complex shapes using autogenous bone. Autoclaved autogenous bone from the bony resection
has been used; however, resorption of autoclaved
autogenous bone can be signicant [1222].
Alloplastic reconstruction
Cranial bone reconstruction

The bony skeleton serves the dual functions of
protection as well as structural support for the
overlying soft tissue. Thus, reconstruction of this
layer, if larger than 1 cm2, is essential to provide
protection of intracranial contents and to minimize contour irregularities [2]. With small defects
or where the shape of the bony defect is simple,
autogenous bone graft harvested from the calvarium is often adequate. With large defects or in
areas such as the orbital rim, where the bony shape
involves a complex three-dimensional structure,
prefabricated alloplastic material may be simpler,
however.
Autogenous reconstruction
Autogenous bone can be harvested from a number of sites, including the rib (Fig. 10), calvarium,
and iliac crest [9,10]. Other sites, such as the bula
and radius, may be used as a vascularized free ap.
A maximum of two adjacent ribs may be harvested
to prevent the occurrence of ail chest. Alternatively, nonadjacent ribs may be harvested [1] but
may require a larger incision. For reconstruction
The major advantage of alloplastic reconstruction of the calvarium is that it is readily available in
large quantities without the requirement of a
donor site. Advances in this area have allowed
complex shapes to be customized for each patient.
Alloplastic materials should only be used when
good soft tissue coverage is available via either
direct closure or a ap. Absence of infection as well
as good soft tissue coverage is absolutely crucial
[1,2]. A variety of materials, including titanium
mesh [23], polyethylene [23,24], hydroxyapatite
[2529], and acrylics (methylmethacrylate) as well
as cadaveric bone [30] are available. Of these,
methylmethacrylate has been associated with a
37% infection rate [1]. Three-dimensional CT
may be used either in fabricating the alloplastic
material or as a template in reconstruction [31,32].
Alternatives and techniques for repair

of craniofacial skeletal defects after
resection of benign bony processes
Benign processes that require only bony resection should be approached as outlined previously
501
Fig. 11. (A) Calvarial defect after excision of a calvarial hemangioma. A template of the excised calvarium was used to
harvest bone from the contralateral side. (B) The harvested calvarial graft was split, and the inner half was used to reconstruct the defect. The outer half was replaced in the harvest site. (C) Plates and screws were used to xate the grafts.
for bone-only reconstruction. Flat or minimally

curved areas, such as the temporal, parietal, or
occipital bone, are readily reconstructed with bone
graft, either calvarium or split rib. Harvesting
mirror-image full-thickness calvarial bone with
subsequent splitting and insetting of the bone
aps is a useful technique. Larger defects may
require alloplastic reconstruction because of lack
of available bone. Large complex areas like the
frontal/orbital region can be reconstructed with
shaped alloplastic materials.
30,33]. Porous polyethylene has demonstrated

vascular ingrowth and can be carved intraoperatively. Titanium mesh can be formed into dierent
shapes and xed to the underlying bony structure.
New materials such as hydroxyapatite cements
allow for bony replacement and can be mixed
and shaped by hand in situ. A number of materials, including acrylic and porous polyethylene,
have been prefabricated with the aid of preoperative three-dimensional models (Fig. 12). A method
for using a mirror image of the contralateral side
as a model has also been described [31].
Prosthetics and their use/limitations/indications

A number of materials have been used in alloplastic reconstruction of complex bony decits.
None are ideal; however, they provide structural
support for the soft tissue and the ability to create
the best appearance after reconstruction. Cadaveric bone has been used because it has less resorption than autoclaved autogenous bone [1517,
Considerations in irradiated tissue

Although there are reports of skin grafts placed
on irradiated tissue [34,35], free ap reconstruction
of irradiated scalp defects is recommended to provide vascularized tissue [20,36,37]. Local aps are
usually not adequate because of collateral radiation damage to adjacent tissue. In addition, osteor-
502
Fig. 12. (A) Preoperative three-dimensional CT is used to create a model of the skull and defect. (B and C) A block of
methylmethacrylate is also created from the same model to ll the defect exactly. (D) After exposure of the defect, the
methylmethacrylate is placed into the defect and secured in place.
adionecrosis may be present. Unless infected,

radionecrotic bone can be left in situ and covered
with well-vascularized tissue. Infected bone should
be removed with immediate soft tissue reconstruction, followed by calvarial reconstruction in 3 to 6
months [20,38].
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Cosmetic concerns in pediatric craniofacial surgery

Deepak Narayan, MD, John. A. Persing, MD*
Section of Plastic Surgery, 330, Cedar Street, Boardman Building-330, New Haven,
CT 06520, USA
This article highlights the technical details

of the authors techniques in the surgical management of craniosynostosis. The role of orthotic devices vis-a vis positional plagiocephaly and
postsurgical molding is discussed. A method of
avoiding temporal hollowing in cranioplasty is
presented.
This article focuses on various technical aspects
of pediatric craniofacial surgery that we have used
in practice to optimize the cosmetic quality of the
outcome.
Craniosynostosis surgery
The correction of premature sutural closure is
performed primarily for two reasons: normalization of the skull deformity and reduction of intracranial pressure. Renier [1] and Thompson et al [2].
The procedure adopted depends on the suture
that is fused, the age of the patient, and the associated anomalies present. Highlights of the
techniques used for the various forms of craniosynostosis in our practice are presented below.
Sagittal synostosis
Sagittal synostosis remains the most commonly
encountered form of craniosynostosis. The simplest form of surgical treatment for this disorder
is the strip or linear craniectomy, where the prematurely fused suture is excised in the hope that once
the restrictive force is released, the brain will
expand and the skull will then mold itself into a
more normal shape. In terms of the degree of correction obtained, the results of this procedure are
E-mail address: john.persing@yale.edu
(J.A. Persing).
suboptimal compared with those of the more comprehensive cranioplasty procedures [3]. There may
still be a place for the strip craniectomy, however,
in the mild and early forms of sagittal synostosis.
The procedures primary appeal rests on its simplicity and, in some cases, eectiveness, particularly if coupled with a skull molding cap. The
advantages of this approach lie in the smaller scar
and potentially lesser blood loss, which have to be
balanced against a less complete correction and
the need for prolonged (approximately 1 year)
use of a skull molding cap.
For most cases of more advanced sagittal synostosis, the cardinal features of our cranioplasty
technique are (1) release of sutural stenosis, (2)
remodeling of cranial bone, (3) active reduction
of the abnormally long dimension of the skull,
and (4) active expansion of abnormally narrow
areas [4].
The technique we currently favor in children
less than 1 year of age is a modication of the p
procedure originally described by Jane and Persing
[4]. The patient is placed in a modied prone position [5], which allows easy access to the anterior
and posterior skull. A frontal craniotomy is performed with the cephalad osteotomy posterior to
the hairline, followed by separate parietal and
parieto-occipital osteotomies. The squamous part
of the temporal bone is out-fractured along with
the overlying temporalis. The frontal and occipital
bossing is reduced by radial osteotomies, and the
parietal bone is remodeled in a similar fashion to
produce a more convex form. The anteroposterior
(AP) dimensions are reduced by 1 to 1.5 cm by
removal of a segment of bone in the midline, and
the frontal bone is attached to the supraorbital
rim with removal of triangular wedges of bone
laterally to allow posterior tilting of the forehead
(Fig. 1).
PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 2 - 0
506
Fig. 1. Sagittal synostosis: operative detail. (Top panel)

(1) Frontal craniotomy and osteotomy, (2) parietal
osteotomy, (3) occipital osteotomy, and (4) temporal
bone out-fracture. (Lower panel) Fixation of radially
osteotomized segments and reduction of anteroposterior
diameter. Note removal of triangular wedge of bone.
(Modied from Cohen MM, MacLean RE, editors.
Craniosynostosisdiagnosis, evaluation and management. 2nd edition. New York: Oxford University Press;
2000:215; with permission.)
The brittleness of the bones in children

older than 1 year of age prevents remodeling as
described previously. In such instances, we have
modied the approach described by Marchac
and Renier [6], wherein serial osteotomies are performed anteriorly to posteriorly, with the most
basal frontal osteotomy being performed at the
height of the forehead, followed by serial posterior
frontoparietal and parieto-occipital osteotomies
(Fig. 2) [4], with a reversal of the midparietal and
posterior frontal bone if required. Kerfs (Fig. 3)
are placed on the inner surface of the bone seg-
Fig. 2. Sagittal synostosis (late treatment). (From

Cohen MM, MacLean RE, editors. Craniosynostosis
diagnosis, evaluation and management. 2nd edition.
New York: Oxford University Press; 2000:215; with
permission.)
ments to allow for remodeling. Although the illustrations depict the use of sutures (wires), we now
use absorbable plating systems, which are particularly useful in decreasing the length of the skull
and achieving a wider biparietal diameter.
Metopic synostosis
The metopic suture is the rst to fuse in the normal calvarium. Premature fusion of the metopic
507
Fig. 3. Placement of kerfs. (From Persing JA, Edgerton MT, Jane JA, editors. Scientic foundations and surgical treatment of craniosynostosis. Baltimore: Williams & Wilkins; 1989:1645; with permission.)
suture results in trigonocephaly and hypotelorism.

The three anatomic features that mark this condition are deciency of the projection of the lateral
orbital rims, recession of the lateral frontal bone,
and narrowing of the squamous part of the temporal bone.
Because a wide range of acceptable appearances may result from this process, operative intervention requires careful judgment. A prominent
metopic ridge, for instance, in the absence of the
other hallmarks of metopic synostosis can merely
be burred down to restore a normal contour.
Our approach to more evident trigonocephaly
involves bilateral orbital rim osteotomies as well
as a bifrontal osteotomy performed to the level
of the hairline (Fig. 4). Temporalis myo-osseous
aps are raised, and these are advanced to support
the repositioned orbital rims and provide more
fullness in the temporal squamous area. The bifrontal graft is remodeled using radial osteotomies and Tessier rib benders.
Coronal synostosis
Coronal synostosis may present with unilateral
or bilateral fusion of the sutures. The clinical features of unilateral coronal synostosis are distinct
from the bilateral form and are described individually, because each of these features needs to be
addressed separately.
In unilateral coronal synostosis, on the side of
the fused coronal suture:
1. The frontal and parietal bones are attened.

2. The orbital rim is recessed, and the mediolateral width of the orbit is smaller than the
opposite side.
3. The temporal squamous bone is protuberant.
4. The ear is anteriorly displaced.
5. The contralateral frontal bone is unduly
prominent.
6. The orbital rim is depressed inferiorly compared with the orbital rim on the fused side.
Additional ndings include mandibular asymmetry (mandibular midline deviated to the side
opposite the synostosis) and deviation of the nasal
radix to the ipsilateral side. These are usually
minor and rarely require surgical correction.
Surgical correction involves performing a coronal incision in the supraperiosteal plane to the orbital rims, at which level the dissection is continued in
a subperiosteal plane intraorbitally. The patent
coronal suture at the fontanelle on the contralateral
side is used as access for a craniotomy. A bifrontoparietal craniotomy with radial osteotomies is
performed in children less than 1 year of age. In
children 1 year of age or older, the deformed frontal
bone on the aected side may be replaced by parietal bone graft harvested by a separate biparietal
osteotomy, followed by trimming of the greater
wing of the sphenoid on the side of the aected
suture. The orbital rims are reshaped with burrs
to attain a normal form. Internal support for the
newly fashioned orbital rim is provided for by a
508
Fig. 4. Metopic synostosis. (Top panel) Frontoparietal osteotomy and burring down of metopic prominence. (Lower
panel) Fixation to orbital rim. (From Persing JA, Edgerton MT, Jane JA, editors. Scientic foundations and surgical
treatment of craniosynostosis. Baltimore: Williams & Wilkins; 1989:1645; with permission.)
separate bone graftthe bowstring procedure. The

composite temporalis myo-osseous ap (see below)
is used to prevent temporal hollowing after the
orbital rims are attached to the midline and laterally at the frontozygomatic suture (Fig. 5). Molding
of bone in older children is done using kerfs on the
endocranial surface of the skull.
In patients with localized residual defects or in
patients who are not desirous of extensive surgery,
we have used methylmethacrylate or a bone paste
to reconstruct the defects.
Bilateral coronal synostosis
The turricephalic skull resulting from bilateral
coronal synostosis can present in either a nonsyndromic or syndromic form, where it may be
associated with craniofacial syndromes such as
Aperts, Crouzons, or Pfeiers. A modied prone

position is used to provide simultaneous access to
the anterior and posterior skull. Cervical spine
lms and, in the case of craniofacial syndromes,
MRI are obtained to determine cervical spine instability and the presence of an Arnold-Chiari
malformation, respectively. The presence of these
conditions dictates the use of a staged cranioplasty
technique.
The key features of the one-stage operative
procedure are illustrated in Fig. 6. A bifrontal craniotomy is performed at the level of the forehead. A
disk of bone is left attached to the vertex of the skull
with two parietal struts as shown. Separate parietal
craniotomies are also carried out. Occipital barrel
stave osteotomies are performed and out-fractured
to increase the AP dimensions. The orbital rims are
replaced after contouring with the temporal ap,
509
Fig. 5. Coronal synostosis. (Top panel) Frontoparietal osteotomy. (Middle panel) Radial osteotomy and remolding.
(Lower panel) Fixation of osteotomized fragments. (From Persing JA, Edgerton MT, Jane JA, editors. Scientic
foundations and surgical treatment of craniosynostosis. Baltimore: Williams & Wilkins; 1989:1645; with permission.)
holding it in position. The height of the skull is

reduced between 1 and 2 cm depending on the correction required by cinching the basal and parietal
bones together (see Fig. 6, lower panel), and forehead projection is reduced by posterior migration/
movement of parietal struts.
Prevention of temporal hollowing

Orbital rim advancement in coronal and
metopic synostosis, although enhancing periorbital esthetics, commonly creates an unattractive
temporal depression. Various methods are used
510
temporal hollowing based on the creation of a

temporalis myo-osseous ap [7]. A brief description of our technique is given below (Fig. 7).
A burr hole is placed superior to the superior
temporal line, giving access to the epidural space,
and a bifrontal craniotomy is performed. The temporalis muscle is then minimally dissected o the
posterior portion of the zygomatic process of the
frontal bone (0.51 cm) to allow access to osteotomize the lateral orbital roof. With epidural dissection and the orbital rim removal completed, the
most posterior aspect of the temporalis muscle is
divided. The division is done in line with the orientation of the muscle bers superior and posterior
to the pinna. A vertical osteotomy is performed
anterior to this line. One limb of a Giglis wire
saw or Midas Rex bit is placed in the osteotomy
site in the posterior squamous portion of the temporal bone. Another is placed in the osteotomy site
in the region of the pterion. The squamous temporal bone and its overlying temporalis muscle are
elevated out of the temporal fossa with a saw cut
of the squamous temporal bone, yielding a myoosseous ap. The temporal fossa is then cleared
of the remaining temporalis muscle, and the superior portion of the greater wing of the sphenoid is
trimmed for easier inset of the ap.
For patients with metopic synostosis, the
remaining basolateral sphenoid wing is split sagittally. Barrel stave osteotomies and lateral fractures
of the temporal and lateral sphenoid bones are performed to increase projection locally. In coronal
synostosis, the posterior bone segments undergo
in-fracture to decrease projection.
Fig. 6. Bilateral coronal synostosis. A biparieto-occipital bone graft is developed posteriorly with a bone bridge
between the two hemicrania located below the level of
the torcula. The remaining occipital bone undergoes barrel stave osteotomy. (From Cohen MM, MacLean RE,
editors. Craniosynostosisdiagnosis, evaluation and
management. 2nd edition. New York: Oxford University
Press; 2000:215; with permission.)
to counteract this deformity, including lling the

hollow with bone chips and posterior detachment
of the temporalis muscle to rotate it anteriorly
either unfolded or folded over itself to add additional bulk to obliterate the hollow. Although
these techniques may prevent hollowing to some
degree initially, the long-term results are unsatisfactory.
We have described a technical innovation that
provides a reliable method for the prevention of
Lambdoid synostosis
The increased incidence of deformational plagiocephaly (see below) has caused considerable
confusion in the diagnosis of lambdoid synostosis.
Typically, unilateral lambdoid synostosis is characterized by a attening of the ipsilateral parietal
occiput asymmetry at the base of the skull and
posterior and inferior displacement of the ipsilateral ear. Radiologically, a deviation of the foramen magnum to the aected side and premature
fusion of the lambdoid suture are demonstrable.
Rarely, it may mimic the deformational plagiocephaly skull pattern but diers in that it is progressive and nonremitting despite conservative
methods, such as physical therapy and skull
molding helmet use.
The parieto-occiput is removed as a single unit
with a coronal suture, providing access. The major
511
Fig. 7. Prevention of temporal hollowing. (1) Burr hole made at superior temporal line, (2) bifrontal craniotomy is
performed, (3) temporalis fascia is detached from posterolateral orbital rim, (4) orbital rim is elevated and advanced, (5)
osteotomy in the greater wing of the sphenoid is deepened in the sagittal plane with a sagittal saw, (6) temporalis muscle
bers are divided in a plane parallel to their orientation, (7) osteotomy of squamous part of temporal bone is performed,
(8) Gigli saw osteotomy preserves temporalis attachment to bone, (9) musculo-osseous ap is reected laterally, (10)
23 mm of squamous temporal bone is removed by rongeur to allow anterior rotation of bone without overlap, (11)
barrel staves are fractured laterally in the anterior squamous temporal region and medially in the posterior region (in
coronal synostosis), (12) musculo-osseous ap is attached anteriorly, (13) musculo-osseous ap is attached to the
advanced orbital rim, and (14) musculo-osseous ap is attached to the reshaped frontal bone. (From Cohen MM,
MacLean RE, editors. Craniosynostosisdiagnosis, evaluation and management. 2nd edition. New York: Oxford
University Press; 2000:215; with permission.)
venous structures, such as the torcula and sagittal

and transverse sinuses, make this a particularly
tedious dissection. Radial osteotomies are performed on the piece removed, whereas barrel stave
osteotomies are performed on the calvarium basal
to the parieto-occiput. Contralateral to the fused
suture, the staves are fractured inward, whereas,
ipsilaterally, they are fractured outward.
Bilateral lambdoid synostosis is vanishingly
rare in isolation from craniofacial syndromes.
Correction of positional molding

Positional or deformational plagiocephaly is a
term that is applied to an abnormal head shape
in an infant that develops as a result of positional
molding of the cranium unrelated to premature
sutural fusion. A variety of factors have been
implicated in the development of this deformity, including a restrictive intrauterine environment, birth trauma, torticollis, cervical anomalies,
512
sleepingposition, lackof full mineralization, neurologic factors, or a combination of these factors [8].
In 1992, the American Academy of Pediatrics
[9] issued a recommendation that infants be positioned to sleep either on their back or sides to
reduce the risk of sudden infant death syndrome
(SIDS). Subsequently, multiple centers noted an
increase in craniofacial deformities of nonsynostotic origin, although this had a benecial
eect in reducing the number of deaths related
to SIDS.
Supine positioning is to be condemned, but frequent position changes in the earliest stages of life
may reduce the likelihood of skull deformities.
Appropriate management of positional deformities, once formed, include simple repositioning of the infant, avoidance of prolonged periods
of rest in one position, exercises to increase the
range of movement of the neck, and the use of
orthotic devices. Planned cranial deformation has
been used for centuries by various cultures. Literature describing the therapeutic eect of orthotic
devices is available [8,10,11]; however, a criticism
leveled against published studies is that they lack
appropriate controls. In other words, it is not
known whether simple repositioning and exercising of the infant alone can produce the results
achieved with the use of orthotic devices. The
general impression is that properly designed and
applied devices are more eective and rapid in
reducing skull deformities, however.
Potential risks to health associated with this
type of device include (1) skin irritation, breakdown, and subsequent infection; (2) head and neck
trauma caused by alteration of the functional center of the mass of the head; (3) impairment of brain
growth and development from mechanical restriction of cranial growth; (4) eye trauma caused by
mechanical failure or poor t; and (5) contact
dermatitis [12].
We believe that helmets have a role, particularly in the severely deformed skull, in patients
who have the condition when exercises are either
ineective or not followed, in patients with gastric
reux precluding prone positioning even while
supervised, and in older infants ([9 months of
age) and those with signicant facial deformity.
Resorbable materials
The use of resorbable plates in the xation
of the craniofacial skeleton represents a major
advance in the eld, particularly in the pediatric
age group. The advantages are inherent in the

biodegradability of the product. Concerns about
long-term visibility of the plates in thin skinned
individuals, malpositioned implants, or the eects
of intracranial migration are mitigated. The plates
are generally thicker than their metal counterparts
and are therefore more easily palpable in the early
postoperative stages. A representative series describing the use of bioresorbable xation in pediatric
craniofacial surgery is that described by Kurpad
et al [13].
The rst bioabsorbable xation system for the
craniofacial skeleton approved by the US Food
and Drug Administration was the Lorenz Lactosorb system (Walter Lorenz, Jacksonville, FL)
[1416]. The material used, Lactosorb, is a copolymer of L-lactic acid (which is slowly absorbed,
thus providing strength) and glycolic acid (which
is rapidly absorbed) at a ratio of 82:18. This, being
substantially amorphous, has marked advantages
in terms of long-term stability and degradation
compared with implants made of the pure forms
of its component chemicals. Clinical complications, such as pronounced brous encapsulation,
sterile abscess and sinus formation, and bone
osteolysis, have been reported for the homopolymers. One of the few studies showing a reaction
to a copolymer (sinus formation) involved polyglactin 910, a copolymer with an almost inverse
ratio of polylactic acid and polygalactic acid compared with Lactosorb. In vivo, the material has
been histologically demonstrated to be eliminated
by approximately 1 year. Implants of another bioabsorbable product, MacroPore (Macropore Biosurgery, San Diego, CA), are manufactured from
medical grade 100% amorphous 70:30 poly(Llactide-co-D,L-lactide). This is produced from a
mixture of 70% L-lactide and 30% DL-lactide,
which retains approximately 70% of its initial
strength after 9 months and approximately 50%
after 12 months, converts into carbon dioxide and
water by the process of bulk hydrolysis, and resorbs completely in approximately 18 to 36 months.
The use of bioabsorbable materials has now
extended to the construction of distraction devices.
Cohen and Holmes [17] describe their experience
with biodegradable mesh Macropore as a substitution for metallic xation plates. In discussing distraction in a 4-year-old with Crouzons syndrome,
the clinical results achieved by this device are equivalent to those achieved by the metal counterpart
with the added advantage of permitting internal
distraction without the need for complete removal
of the xation device.
Our experience with distraction devices for

midface advancement has been favorable to date.
We have obtained 30 mm of midface advancement
using these devices.
[8]
[9]
References
[1] Renier D. Intracranial pressure in craniosynostosis:
pre and postoperative recordingscorrelation with
functional results. In: Persing J, Edgerton M, Jane J,
editors. Scientic foundations and surgical treatment
of craniosynostosis. Baltimore: Williams & Wilkins;
1989. p. 2639.
[2] Thompson DNP, Malcom GP, Jones BM, et al.
Intracranial pressure in single suture craniosynostosis. Pediatr Neurosurg 1995;22:23540.
[3] Panchal J, Marsh JL, Park TS, et al. Sagittal
craniosynostosis outcome assessment for two methods and timings of intervention. Plast Reconstr Surg
1999;103:157484.
[4] Jane JA, Persing J. Neurosurgical treatment of
craniosynostosis. In: Cohen MM, MacLean RE,
editors. Craniosynostosisdiagnosis, evaluation
and management. New York: Oxford University
Press; 2000. p. 20927.
[5] Park TS, Haworth CS, Jane JA, et al. Modied prone
position for cranial remodeling in children with
craniofacial dysmorphism. Neurosurgery 1985;16:
2124.
[6] Marchac D, Renier M. Craniofacial surgery in craniosynostosis. Boston: Little Brown & Company; 1982.
[7] Persing JA, Mayer PL, Spinelli HM, et al. Prevention of temporal hollowing after fronto orbital
[10]
[11]
[12]
[13]
[14]
[15]
[16]
[17]
513
advancement for craniosynostosis. J Craniofac Surg

1994;5:2714.
Ripley CE, Pomatto J, Beals SP, et al. Treatment of
positional plagiocephaly with dynamic orthotic
cranioplasty. J Craniofac Surg 1994;5:1509.
Anonymous. American Academy of Pediatrics task
force on infant positioning and SIDS. Pediatrics
1992;89:11206.
Kelly KM, Littleeld TR, Pomatto JK, et al.
Importance of early recognition and treatment of
deformational plagiocephaly with orthotic cranioplasty: cleft palate. Craniofac J 1997;36:12730.
Kelly KM, Littleeld TR, Pomatto JK, et al. Cranial
growth unrestricted during treatment of deformational plagiocephaly. Pediatr Neurosurg 1999;30:
1939.
Federal Register, vol. 63, no. 146. 21CFR, part 882,
July 1998.
Kurpad SN, Goldstein JA, Cohen AR. Bioresorbable xation for congenital pediatric craniofacial
surgery. Pediatr Neurosurg 2000;33:30610.
Pietrzak WS, Verstynen ML, Sarver DR. Bioabsorbable xation devices: status for the craniomaxillofacial surgeon. J Craniofac Surg 1997;8:926.
Pietrzak WS. Critical concepts of absorbable
internal xation. J Craniofac Surg 2000;11:33541.
Rubin PJ, Yaremchuk MJ. Complications and
toxicities of implantable biomaterials used in facial
reconstructive and aesthetic surgery. A comprehensive review of the literature. Plast Reconstr Surg
1997;100:133653.
Cohen SR, Holmes RE. Internal LeFort III distraction with biodegradable devices. J Craniofac Surg
2001;12:26472.
Subject Index to Volume 13

Volume 13
January
CONTEMPORARY MANAGEMENT OF MALFORMATIONS

OF CORTICAL DEVELOPMENT, pages 1148
April
NONACCIDENTAL NEUROTRAUMA IN CHILDREN, pages 149264
July
SPONTANEOUS INTRACRANIAL HEMORRHAGE, pages 265400
October
AESTHETIC CONSIDERATIONS IN CRANIAL NEUROSURGERY, pages 401533
Note: Page numbers of article titles are in boldface type
A
Abdominal injuries, in child abuse, 150, 159
Abrasions, in child abuse, 157
Abuse, child. See Child abuse.
Acute-phase response, in head injury, 177
Adams hemispherectomy modication, 121
Adenosine, formation of, in head injury, 171
Age factors, in intracerebral hemorrhage
outcome, 344
Agyria, pathology of, 1718
Airway management, in head injury, 213214
Albumin, for intracerebral hemorrhage, 336
Alcohol abuse, intracerebral hemorrhage in,
276, 282, 306307
Alloderm, for soft tissue reconstruction, 407
a-Amino-hydroxy-5-methyl-4-isoxazole
propionic acid (AMPA) receptors
epilepsy and, 173175
therapies involving, in head injury, 173175
with arteriovenous malformations,

290291
Angiography
for intracerebral hemorrhage, 290
intracerebral hemorrhage due to, 302
Angioma, venous, intracerebral hemorrhage
in, 273274, 294295
Angiopathy, amyloid, intracerebral hemorrhage
in, 270271, 283, 295, 323
Angioplasty, intracerebral hemorrhage in
carotid percutaneous transluminal, 302
for intracranial atherosclerosis, 302303
for vasospasm, 303
Animal models, of intracerebral hemorrhage,
385393
bacterial collagenase, 389390
blood infusion in, 386389
ischemia-perfusion, 390
pathologic responses in, 385386
Anticoagulant therapy, intracerebral
hemorrhage in, 305306
Antiepileptic drugs, for head injury, 218
Amphetamine, intracerebral hemorrhage due

to, 306
Antioxidants, for head injury, 176177
Amyloid angiopathy, intracerebral hemorrhage

in, 270271, 283, 295, 323
Antiplatelet therapy, intracerebral hemorrhage

in, 306
Anaphylatoxin, in intracerebral hemorrhage,

edema due to, 377
Apiectomy, petrous, partial labyrinthectomy

with, 426427
Aneurysms, intracerebral hemorrhage in,

293294, 303, 329
Apolipoprotein E, in amyloid angiopathy,

intracerebral hemorrhage and, 270271, 323
PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 8 9 - X
516
Subject Index / Neurosurg Clin N Am 13 (2002) 515533
Apoptosis, in head injury, 177178

Arteriovenous malformations, intracerebral
hemorrhage in, 271272, 290291, 303, 324
Aspiration, in intracerebral hemorrhage, 350
Aspirin, intracerebral hemorrhage in, 306
B
Bacterial collagenase model, of intracerebral
hemorrhage, 389390
Balloon cells, in cortical dysplasia, 3, 57, 22,
43, 72
Birth trauma
epidural hematoma in, 186187
retinal hemorrhage in, 206207
skull fractures in, 184
subdural hematoma in, 187189
Bloodbrain barrier, disruption of, in
intracerebral hemorrhage, edema due to,
285286, 379
Blood ow, cerebral. See Cerebral blood ow.
Blood infusion model, of intracerebral
hemorrhage, 386389
Band heterotopia, radiologic-pathologic

correlations in, 5152
Blood oxygen level-dependent (BOLD)

functional magnetic resonance imaging.
See Magnetic resonance imaging, in
cortical dysplasias, functional.
Barbiturates
for coma, in intracerebral hemorrhage, 336
for increased intracranial pressure, 220222
Bone
removal and repair of, 476477
substitutes for, 407408
Battered child syndrome. See Child abuse.
Brain
biopsy of, intracerebral hemorrhage in,
300301
edema of. See Edema, brain.
infarction of, intracerebral hemorrhage
after, 275
Bcl-2 proteins, in head injury, 178

Behavioral disorders, in cortical dysplasias, 36
Bicoronal incision, cosmetic considerations in,
411412, 437438
Bifrontal craniotomy, 462
in extended transbasal approach, 464
Big black brain, in child abuse, 172,
190192
Bilirubin, formation of, in intracerebral
hemorrhage, edema due to, 376377
Biliverdin, formation of, in intracerebral
Bioabsorbable xation systems, for
craniosynostosis surgery, 408409,
520521
Biomechanics, of nonaccidental head
injury. See Head injury, in child abuse,
biomechanics of.
Brain injury. See also Head injury.

in child abuse
blood ow in
monitoring of, 217218
perturbations of, 169172
contusions, 157158
diuse axonal, 158, 192193
edema in, 158159
metabolic perturbations in, 169172
primary diuse, 158
secondary, 158159
Breathing management, in head injury,
213214
Bruises, in child abuse, 150
Burns, in child abuse, 150
Biopsy, brain, intracerebral hemorrhage in,

300301
Biorbital osteotomy, 460464
circumferential cribriform osteotomy
with, 466
unilateral zygomatic osteotomy with,
471473
Biorbitofrontoethmoidal osteotomy,
464466
C
C-shaped incision, for posterior fossa
approach, 481
Callosotomy, in cortical dysplasia, 108
Cancer, cranial surgery for, reconstruction
after, 492501
direct closure in, 492493
aps for, 496501

skin graft coverage for, 493494
tissue expanders in, 495496
Capillary telangiectasia, intracerebral
hemorrhage in, 295
Caput succedaneum, radiology of, 184
Carbon monoxide, formation of, in intracerebral
Cardiopulmonary resuscitation, retinal
Carotid arteries
cervical incision for, 402
endarterectomy of, intracerebral hemorrhage
in, 301302
percutaneous transluminal angioplasty of,
intracerebral hemorrhage in, 302
Catalase, neuroprotective eects of, in head
injury, 176
Cervical spinal injuries, in child abuse

mechanisms of, 228230
radiology of, 193195
Child abuse
epidemiology of, 149, 183, 227228,
248249
head injury in. See Head injury, in child
abuse; Shaken baby syndrome.
medicolegal aspects of, 243246
ophthalmology consultation in,
201211
prevention of, 252255
radiology in, 183199
sequelae of, 183
spinal injury in. See Spine and spinal cord
injuries, in child abuse.
Circulatory management, in head injury,
213214
Circumferential cribriform osteotomy(ies), with
biorbital osteotomy, 466
Cavernous malformations, intracerebral

hemorrhage in, 272273, 291293,
324325
Clinoidectomy, anterior, in orbital osteotomy,

448449
Cells, programmed death of, in head injury,

177178
Clot retraction, in intracerebral hemorrhage,

edema due to, 372373
Central vertical hemispherectomy, 128129
Coagulation cascade, in intracerebral

Cephalohematoma, radiology of, 183184

Cerebral arteries, middle, aneurysm of, rupture
of, 293294
Cerebral blood ow
in head injury
assessment of, 217218
perturbations of, 169172
in intracerebral hemorrhage, 355370
blood pressure eects on, 364366
clinical implications of, 364368
clinical studies of, 359363
hematoma evacuation eects on, 367368
in hibernation phase, 363
in normalization phase, 364
in reperfusion stage, 363364
intracranial pressure reduction and,
366367
laboratory studies of, 355359
theoretical considerations in, 355
Cerebral perfusion pressure, monitoring of, in
head injury, 219
Cerebrospinal uid, drainage of, for increased
intracranial pressure, 221
517
Coagulopathy
intracerebral hemorrhage in, 275, 305308,
327328
versus retinal hemorrhage in shaken baby
syndrome, 204
Cobblestone lissencephaly, radiologic-pathologic
correlations in, 51, 53
Cocaine, intracerebral hemorrhage due to,
295296, 306, 328329
Cognitive function, in cortical dysplasias,
hemispheric, 106
Cohens reversal sign, in intracranial
hemorrhage, 190
Collagen, injection of, for soft tissue
reconstruction, 407
Coma, barbiturate, for intracerebral
hemorrhage, 336
Complement activation, in intracerebral
hemorrhage, edema due to, 285, 377
Composite/osseocutaneous aps, for cranial
reconstruction, 501
518
Computed tomography
in head injuries, 215
diuse axonal, 192
epidural hematoma, 187
intracranial hemorrhage, 189190
scalp, 184
skull fractures, 184, 186
subdural hematoma, 187188
xenon scan with, 217218
in intracerebral hemorrhage, 267, 349321
advantages of, 313
cerebral blood ow and, 359363
hypertensive, 321
in tumors, 325327
temporal evolution and, 319321
Computer-aided design, of implants, for
reconstruction, 408
Consciousness level, in intracerebral
hemorrhage, versus treatment outcome,
343344
Contusions, in child abuse, 157158
Coronal synostosis, correction of, 515517
Cortical dysplasias
abnormal cell proliferation in, 4150
agyria, pathology of, 1718
balloon cells in, 3, 57, 22, 43, 72
bilateral opercular, 5758
cellular migration disorders, 5156
classication of, 116
clinical features of, 3536
coactivation in, functional magnetic
resonance imaging of, 65
conditions associated with, 2223, 7273
cortical disorganization, 5661
deep infolding in, 54, 56
dysmorphic neurons in, 34, 68
electroencephalography in, 3639, 8788,
105, 138140
embryology of, 41, 51, 56
epileptogenicity of, 2733, 7374
familial diuse, electroencephalography in, 38
focal, 910, 8792
clinical relevance of, 910
diagnosis of, 88
epileptogenicity of, 2733, 7374
imaging of, 9, 8889
pathology of, 7172
radiologic-pathologic correlations in,
43, 4546
subdural electrode studies of, 8991
surgical treatment of, 93102
age considerations in, 138

case study of, 9798
functional mapping before, 9495
invasive monitoring before, 9495
outcome of, 136139, 141
postoperative concerns in, 95
preoperative evaluation for, 9394
techniques for, 95
Yale University experience in, 9598
Taylor type, 6, 35
types of, 9
four-layered, 51
functional magnetic resonance imaging in,
6369, 137, 139140
functionality of, 74
giant neurons in, 56
hemimegalencephaly.
See Hemimegalencephaly.
hemispheric malformations in, 103111
surgical treatment of
evaluation before, 105106
outcome of, 139141
techniques for, 106108
timing of, 108110
heterotopias. See Heterotopias.
histopathology of, 68
imaging in, 36. See also specic techniques.
immature neurons in, 56
lissencephaly, 1718, 3738, 51, 53
magnetic resonance imaging in. See
Magnetic resonance imaging.
microcephaly, 42
microdysgenesis, 3, 61
microscopic patterns of, 2022
mild, 89
neuropsychology of, 36
pachygyria, 1718
pathogenesis of, 1
pathology of, 1725, 7173
agyria, 1718
focal, 7172
heterotopias, 1820
lissencephaly, 1718
pachygyria, 1718
surgical outcome and, 139
versus surgical outcome, 139140
polymicrogyria, 1112
positron emission tomography in, 7782
in infantile spasms, 7982
in localization-related epilepsies, 7779
methodology of, 77
preoperative evaluation of, 3539

radiologic-pathologic correlations in, 4162
focal, 43, 4546
in abnormal cell proliferation, 4150
in cellular migration disorders, 5156
in cortical disorganization, 5661
schizencephaly, 12, 5760
single photon emission computed
tomography in, 7477
clinical applications of, 7577
methodology of, 7475
hemispherectomy in, 113134
in hemispheric malformations, 103111
outcome of, 135144
in focal malformations, 136139, 141
in hemispheric malformations, 139141
in infants, 141143
in lobar malformations, 136139
neurologic, 141
versus medical treatment, 136
terminology of, 26
treatment of, subdural grids in, 8792
tumors in, 1011, 2223, 43, 4850
without balloon cells, 58, 61
Cortical vein sign, in subdural hematoma, 188
Cosmetic considerations
hair sparing in, 411419
in cranial base surgery, 421441
in cranial reconstruction, 491511
in pediatric craniofacial surgery, 513521
in posterior fossa skull base surgery, 475489
new developments in, 401403
osteotomies for, 443474
plastic surgical perspective in, 405410
Court system, child abuse matters in, 245246
Cranial base surgery. See also Posterior
fossa surgery.
cosmetic considerations in, 421441
cranial nerve preservation in, 439
in combined approaches, 437
in extended orbital osteotomy, 424
in extended subfrontal transbasal
approach, 435
in extradural approaches, 434437
in extreme lateral complete transcondylar
approach, 435436
in extreme lateral partial transcondylar
approach, 403, 431434
in eyebrow incisions, 423424
in frontotemporal craniotomy with
519
orbital osteotomy, 422423

in frontotemporal craniotomy with
orbitozygomatic osteotomy, 424, 434
in intradural approaches, 422434
in partial labyrinthectomy/petrous
apiectomy petrosal approach, 425426
in presigmoid petrosal approach,
425429, 482483
in retrolabyrinthine petrosal
approach, 425
in retrosigmoid approach, 402403,
429431, 478480
in subfrontal-infratemporal approach,
434435
in total petrosectomy, 426
in transfacial approaches, 403, 421422,
437438
in translabyrinthine petrosal
approach, 426
in transoral approach, 436437
in transsphenoidal approach, 436
repair in, 402
Cranial nerves, preservation of, cosmetic
importance of, 401, 439
Cranial reconstruction, cosmetic
considerations in, 483487, 491511
anatomy of, 491492
bone, 501506
bone substitutes in, 407408
evaluation for, 483484
aps for, 402, 485487
implants for, 408
in benign lesion excision, 505506
in biorbital osteotomy, 463464
in irradiated tissue, 417418, 507508
in mastoidectomy, 428429
in oncologic surgery, 492501
in orbital osteotomy, 450451
extended, 454455
in orbitozygomatic osteotomy, 459460
in zygomatic osteotomy, 470471
indications for, 483
materials for, 477
prosthetics for, 506507
soft tissue supplements in, 407408
tissue expansion in, 484485
Craniectomy
strip, for sagittal synostosis, 513
Cranioplasty, in synostosis.
See Craniosynostosis surgery.
520
Craniosynostosis surgery, cosmetic

considerations in, 513521
coronal
bilateral, 516517
unilateral, 515516
lamboid, 518519
metopic, 514515
positional molding correction in, 519520
resorbable materials for, 408409, 520521
sagittal, 513514
temporal hollowing prevention in, 517518
Craniotomy
bifrontal, 462
extended transbasal approach to, 464
extreme lateral complete transcondylar
approach to, 403, 435436
extreme lateral partial transcondylar
approach to, 403, 431434
eyebrow incisions for, 424425
aps for, 402
for head injury, 218
frontotemporal, 402
extended orbital osteotomy with, 425
with orbital osteotomy, 422
with orbitozygomatic osteotomy, 425, 434
in biorbital osteotomy, 462
in orbital osteotomy, 447448
extended, 452453
in orbitozygomatic osteotomy, 457458
in zygomatic osteotomy, 468469
petrosal approach in
partial labyrinthectomy/petrous
apicectomy, 426427
presigmoid, 425429, 482483
retrolabyrinthine, 426
retrosigmoid approach to, 402403, 429431,
478480
total petrosectomy in, 427
Cribriform osteotomy, circumferential, with
biorbital osteotomy, 466
Cytochrome c, in head injury, 178
Cytokines, formation of, in head injury, 177
D
Deformational plagiocephaly, correction of,
408, 518520
Developmental delay
cortical dysplasia surgery eects on, 142
in cortical dysplasias, 35
Developmental outcome, in child abuse,

237240
Diuse axonal injury, in child abuse, 158
biomechanics of, 250251
Disappearing subdural sign, in subdural
hematoma, 189
Distraction osteogenesis, for cranial
reconstruction, 409
Dopamine, for cerebral perfusion pressure
management, 219
Double cortex syndrome,
electroencephalography in, 38
Drugs, intracerebral hemorrhage due to,
295296, 306307, 328329
Dura, opening and closure of, 477478
Dysembryoplastic neuroepithelial tumors,
1011, 23, 43, 4849
Dyslamination, in cortical dysplasias, 6
Dysmorphic neurons, 34, 68
Dysplasias, cortical. See Cortical dysplasias.
Dysplastic tumors, 1011, 2223
radiologic-pathologic correlations
in, 43, 4850
E
Ear injuries, in child abuse, 157
Ecstasy, intracerebral hemorrhage due to, 306
Edema, brain
in child abuse, 158159
in intracerebral hemorrhage, 267,
371383
bloodbrain barrier disruption in, 379
classication of, 371372
clot retraction in, 372373
coagulation cascade activation in, 373374
complement activation in, 377
cytotoxic, 371
hemoglobin degradation
products in, 376377
hydrostatic pressure and,
372373
intact-barrier or open-barrier type of, 371
interstitial, 371
mass eect in, 377378
osmotic, 371
pathology of, 284286
red blood cell lysis in, 374376
resolution of, 379
secondary ischemic/reperfusion injury in,
378379
time line of, 372
vasogenic, 371
Education, for child abuse prevention, 252255
Electrodes, subdural, in focal cortical dysplasia,
8991
Electroencephalography, in cortical dysplasias,
3639
focal, 8788
hemispheric, 105
versus functional magnetic resonance
imaging, 66
Eloquent cortical regions, localization of
functional magnetic resonance imaging
in, 6566
subdural electrodes in, 90
Eye injuries, in child abuse, 208.

See also Retinal hemorrhage.
Eyebrow incisions, for basal frontal exposure,
424425
F
Face
incisions in, for cranial base surgery, cosmetic
considerations in, 403, 421422, 437438
injuries of, in child abuse, 157
Falls
head injury in, biomechanics of,
159162, 249
Familial diuse cortical dysplasia,
Far lateral approaches, to posterior fossa,
480482
Fasciocutaneous aps, for cranial
reconstruction, 501, 504
Encephalitis, intracerebral hemorrhage in, 309
Fat, for soft tissue reconstruction, 407
Endarterectomy, carotid, intracerebral

Fentanyl
for intubation, in head injury, 214
Endoscopy
Fibrinolysis, of intracerebral hemorrhage,

351353
Endothelin-1, release of, in head injury, 169
Fibroblast growth factor, for wound healing,

Epidural hematomas, radiology of, 186187
521
Extreme lateral complete transcondylar

approach, 403, 435436
Flaps, for cranial reconstruction, 406, 485487,

496501
composite/osseocutaneous, 501
fasciocutaneous, 501
latissimus dorsi, 499
local, 406, 496
microvascular free, 499500
muscle, 406, 500501
myocutaneous, 406, 501
omentum, 501
pericranial, 497498
regional, 498
rotation, 406, 496
temporalis muscle, 499
temporoparietal fascia, 499
transposition, 497
trapezius, 498
Extreme lateral partial transcondylar approach,

403, 431434
Fluid therapy, for nonaccidental head

injury, 214
Epilepsia partialis continua,

Epilepsy, in cortical dysplasias.
See Cortical dysplasias.
Epileptogenic zone concept, in cortical
dysplasia, 6465
Erythrocytes, lysis of, in intracerebral
Excitotoxicity, in head injury, 172176
Expert witnessing, in child abuse case, 245246
Extended subfrontal transbasal approach, 435
522
Forehead, anatomy of, for reconstruction, 492

Fractures, in child abuse, 150151, 159
skull, 157, 184186
spinal, 193195, 227231
Free radical production, in head injury,
176177
Frontotemporal craniotomy, 402
with orbital osteotomy, 422
with orbitozygomatic osteotomy, 425, 434
Functional mapping, for cortical dysplasia
surgery, 9495
Furosemide
G
Gamma-aminobutyric acid receptors
and circuits, epilepsy and, 2930
Gangliogliomas, 1011, 48, 50
Giant neurons, in cortical dysplasia, 56
Glasgow Coma Scale, in nonaccidental head
injury, 214
in infants, 152
Glutamate, excitotoxic eects of, in head injury,
172176
Glutamate receptors, ionotropic, epilepsy and,
2829
Glutathione peroxidase, neuroprotective eects
of, in head injury, 176
Goretex, for soft tissue reconstruction, 407
Grids, subdural electrodes in, in focal cortical
dysplasia, 8991
H
Hair, cosmetic considerations concerning,
411419
anatomy of, 411
closure methods, 414
in bicoronal incision, 411412
in straight line versus zigzag incision,
412414
physiology of, 411
scalp elevation for, 413, 415416
shaving practices, 401, 414415
Hangmans fracture, in child abuse, radiology

of, 194
Head, positioning of, for intracranial pressure
management, 220
Head injury
acceleration-based, biomechanics of, 163164
direct-impact, biomechanics of, 163
in child abuse. See also Shaken baby
syndrome.
behavior in, 162
biomechanics of, 155168, 249252
acceleration-based, 163164
associated injuries, 159
cerebral contusions,
157158
cerebral edema, 158159
clinical presentation and, 162163
direct-impact, 163
event-related, 159162
experimental models of, 163165
external abrasions and
contusions, 157
falls, 160162
history and, 162
occult injuries, 159
overview of, 156
primary diuse brain injury, 158
prior injuries, 159
skull fractures, 157
stairway injuries, 162
subdural hematomas, 158
criteria for, 164165
diagnosis of
biomechanics for, 155168
radiology for, 183199, 215, 252
epidemiology of, 248249
evaluation of, 156
experimental models of, 163165
future directions in, 247257
history-taking in, 155156
identication of, 247248
in infants. See Infant(s), nonaccidental
head injury in.
injuries associated with, 157159
intensive care in. See Intensive care,
in child abuse.
missed diagnosis of, 155
nomenclature of, 247248
ophthalmologic consultation in.
See Ophthalmologic consultation.
outcomes of, 235241
developmental, 237240
in younger children, 235237

radiology of. See Radiology, of
nonaccidental head injury.
repeat
biomechanics of, 159, 162163
ischemic tolerance in, 178179
secondary damage after, 169182
blood ow perturbations in,
169172, 217218
excitotoxicity in, 172176
inammation in, 177
metabolic perturbations in, 169172
overview of, 169170
oxidative stress in, 176177
programmed cell death in, 177178
timing of, 252
versus accidental injury, outcome of,
236237
Head Injury Criteria, 164165
Healing, wound, cosmetic considerations in,
409, 475
Helmets, for skull deformation prevention, 520
Hemangioma calcicans, 292
Hematomas
evacuation of. See Intracerebral hemorrhage,
treatment of.
in child abuse
epidural, 186187
subdural, 158, 187189, 252
subgaleal, 184
Hemianopia, homonymous, after
hemispherectomy, 141
Hemidecortication, in cortical dysplasia,
114, 121122
Hemimegalencephaly, 11
hemispherectomy in, 116118, 130131
Hemiparesis, after hemispherectomy, 141
Hemispherectomy, 107, 113134
denition of, 113
outcome of, 139141
persistent seizures after, 131132
postoperative management in, 131
repeated, 131132
techniques for
Adams modication of, 121
anatomic, 119121, 140
523
central vertical, 128129

development of, 114115
functional, 140
hemidecortication in, 114, 121122
in hemimegalencephaly, 116118,
130131
in pediatric patients, 129130
Japanese peri-insular, 129
peri-insular, 127129
previous experience with, 115118
Rasmussens functional, 122
transsylvian, transventricular functional,
122127
types of, 118119
terminology of, 113
Hemispheric malformations, of cortical
development, 103111
evaluation before, 105106
outcome of, 139141
techniques for, 106108. See also
Hemispherectomy.
timing of, 108110
Hemispherotomy, in cortical dysplasia, 113
Hemoglobin, formation of, in intracerebral
hemorrhage, 313315, 374376
Hemophilia, intracerebral hemorrhage in,
307308
Hemorrhage
intracerebral. See Intracerebral hemorrhage.
intracranial, radiology of, 189190
retinal. See Retinal hemorrhage.
subarachnoid, radiology of, 189
Hemosiderosis, after hemispherectomy, 141
Heparin, intracerebral hemorrhage due to,
305306
Hereditary hemorrhagic telangiectasia,
Heterotopias, 56, 1213
band, 5152
laminar, 19
marginal, 21
pathology of, 1820
periventricular nodular, 51, 54
radiologic-pathologic correlations in,
5156
subcortical gray matter, 5455
subependymal, 54, 56
524
Hibernation phase, in intracerebral

hemorrhage, 363
Holoprosencephaly, electroencephalography
in, 37
Homonymous hemianopia, after
Homonymous quadrantanopia, after focal
cortical dysplasia resection, 141
Hydrostatic pressure, in intracerebral
Hydroxyapatite, in bone reconstruction, 407408
Hyperosmolar therapy, for intracerebral
hemorrhage, 336
Hypertension
after intracerebral hemorrhage, 364366
intracerebral hemorrhage due to, 269,
281283, 286, 321323
Hyperventilation, controlled
Hypocholesterolemia, intracerebral hemorrhage
in, 275276, 282
Hypomelanosis of Ito, electroencephalography
in, 38
Hypotelorism, in metopic synostosis, correction
of, 514515
Hypothermia
Hypsarrhythmia, surgical treatment of, 142
I
Iatrogenic intracerebral hemorrhage, 299312
categories of, 299300
in alcohol abuse, 276, 282, 306307
in aneurysm repair, 303
in angioplasty
carotid percutaneous transluminal, 302
for intracranial atherosclerosis, 302303
for vasospasm, 303
in anticoagulant therapy, 305306
in antiplatelet therapy, 306
in arteriovenous malformation
treatment, 303
in carotid endarterectomy, 301302
in coagulopathy, 275, 305308, 327328
in diagnostic angiography, 302
in
in
in
in
in
in
in
in
drug abuse, 306307, 328329

infections, 309
intracranial pressure monitoring, 300
spinal procedures, 301
stereotactic surgery, 300301
thrombocytopenia, 307
thrombolytic therapy, 275, 303305
tumors, 308309, 325327
Imaging. See also specic modalities.

of intracerebral hemorrhage, 267269,
313334
cerebral blood ow and, 359363
computed tomography in.
See Computed tomography.
magnetic resonance imaging in.
See Magnetic resonance imaging.
methods for, 313
versus etiology, 321330
Immature neurons, in cortical dysplasia, 56
Implants, for reconstruction, computer-aided
design of, 408
Incisions
cosmetic considerations in, 401403, 406407.
See also Cosmetic considerations; specic
procedure.
principles of, 405
Infant(s)
birth trauma to. See Birth trauma.
nonaccidental head injury in, 149154.
See also Shaken baby syndrome.
big black brain in, 190192
biomechanics of. See Head injury,
in child abuse, biomechanics of.
clinical history in, 150151
diuse axonal, 192193
epidural hematomas in, 186187
examination of, 151152
injuries associated with, 149150
intracranial hemorrhage in, 189190
skull fractures in, 184186
subdural hematomas in, 187189
spinal injury in, radiology of, 193195
Infant Face Scale, in head injury, 214
Infantile spasms, surgical treatment of, 142
Infarction, cerebral, intracerebral hemorrhage
after, 275
Infections, intracerebral hemorrhage in, 309,

329330
Inammation, in head injury, 177
Inicted head injury. See Child abuse.
Intellectual impairment, in cortical
dysplasias, 36
Intensive care, in child abuse, 213226
cerebral blood ow management in, 217219
craniotomy in, 218219
initial evaluation in, 213215
intracranial pressure monitoring and control
in, 216217, 219223
laboratory studies in, 215216
neurophysiologic considerations in, 218219
radiology in, 215
Interleukin(s), formation of, in head injury, 177
Interparietal sutures, versus eggshell
fractures, 185
Intracerebral hemorrhage, 265279
animal models of, 385393
biochemical evolution of, 313314
brain edema in, 267, 284286, 371383
cerebral blood ow in, 355370
clinical presentation of, 265267
consciousness level in, versus treatment
outcome, 343344
epidemiology of, 265, 281
etiology of, 313, 321330
evaluation of, in vascular lesions,
289290
aneurysms, 293294
arteriovenous malformation, 271272, 290
cavernous malformation, 292
hematoma enlargement in, 284
hematoma volume in, versus outcome, 343
iatrogenic, 299312
imaging of. See Imaging.
in alcoholism, 276, 282, 306307
in angiography, 302
in angioplasty, 302303
in carotid procedures, 301302
in coagulopathy, 275, 305308, 327328
in hypocholesterolemia, 275276, 282
in intracranial pressure monitoring, 300
in spinal procedures, 301
in telangiectasia, 274275
in thrombolytic therapy, 275, 303305
in vascular lesions, 271274, 289297
increased intracranial pressure in,
335338
525
location of, versus outcome, 342343

morbidity and mortality in, 266267
pathophysiology of, 282286
risk factors for, 269276, 281282
temporal evolution of, 315321
treatment of, 286
aspiration in, 350
cerebral blood ow changes in,
364368
endoscopic, 351
brinolysis in, 351353
hypertensive, 322323
in vascular lesions
amyloid angiopathy, 295
aneurysms, 294
arteriovenous malformation, 290291
cavernous malformation, 292293
venous angioma, 295
intracranial pressure reduction in,
335338
mechanical devices for, 350351
medical versus surgical, 286,
339347
nonrandomized controlled studies of,
341342
randomized trials of, 339341
recommendations for,
344345
variables aecting, 342344
minimally invasive, 349354
timing of, versus outcome, 343
with prior infarction, 275
Intracranial hemorrhage, radiology
of, 189190
Intracranial pressure
in intracerebral hemorrhage, reduction of,
366367
increased
control of, in head injury,
219223
monitoring of
in head injury, 216217
Intubation, in head injury, 214
Ionotropic glutamate receptors, epilepsy and,
2829
Iron, formation of, in intracerebral
hemorrhage, 313314, 376
526
Ischemia-perfusion, in intracerebral hemorrhage

animal model of, 390
edema due to, 378379
Ischemic tolerance, in repeat head injury,
178179
J
Jane and Persing procedure, for sagittal
synostosis, 513514
Japanese peri-insular hemispherectomy, 129
Jeerson fracture, in child abuse,
radiology of, 194
L
Labyrinthectomy, partial, petrous apiectomy
petrosal approach, 426427
Lamboid synostosis, correction of, 518519
Language, cortical regions for
functional magnetic resonance imaging
of, 6566
subdural electrode localization of, 90
Latissimus dorsi ap, for cranial
reconstruction, 499
Laws, on child abuse, 243246
Le Fort I osteotomy, 438
Leptomeningeal cyst, radiology of, 186
Leukemic retinopathy, versus retinal
hemorrhage in shaken baby syndrome, 204
Limbus fracture, in child abuse, 195
Lipohyalinosis, in intracerebral hemorrhage,
282283
Lissencephaly
cobblestone, radiologic-pathologic
correlations in, 51, 53
pathology of, 1718
Liver, injury of, in child abuse, 159
Local aps, for cranial reconstruction,
406, 496
Lumbar puncture, intracerebral hemorrhage
in, 301
M
Magnetic resonance imaging
in cortical dysplasias, 36, 137
functional, 6369
advantages of, 64
electroencephalographic-correlated, 66
epileptic zone concept in, 6465
language sites in, 6566
principles of, 6364
task-related, 6566
hemispheric, 105106, 139140
in head injuries, 215
diuse axonal, 192193
epidural hematoma, 187
subarachnoid hemorrhage, 189
subdural hematoma, 188
advantages of, 313
hemoglobin byproducts in, 314315
hypertensive, 322323
in amyloid angiopathy, 323324
in arteriovenous malformations, 324
in cavernous malformations, 324325
in tumors, 325327
in venous occlusive disease, 329
Malformations, of cortical development.
See Cortical dysplasias.
Mannitol
for increased intracranial pressure,
221222
Mastoidectomy, reconstruction after, 428429
Medicolegal aspects, of child abuse,
243246
attorneys oces, 245
eective witnessing, 245246
record keeping, 245
reporting laws, 243245
Membrane attack complex, in intracerebral
Metabolism, cerebral, perturbations of,
N-Methyl-D-aspartate receptors
epilepsy and, 2829
Metopic synostosis, correction of, 514515
Microaneurysms, intracerebral hemorrhage
in, 283
Microdysgenesis
denition of, 3
Micropolygyria, pathology of, 18
Microvascular free aps, for cranial
reconstruction, 499500
Midline approaches, to posterior fossa, 478
Migration, neuronal, disordered, to cortex,
Miller-Dieker syndrome, lissencephaly in, 53
Minimally invasive therapy
endoscopic, 351
brinolysis, 351353
mechanical devices for, 350351
rationale for, 349350
simple aspiration, 350
527
Neuroepithelial tumors, dysembryoplastic,

1011, 23, 43, 4849
Neurointensive care. See Intensive care.
Neurologic examination, in head injury, 152,
214215
Neuromuscular blockade, for increased
intracranial pressure, 220221
Neuron(s)
disordered migration of, to cortex,
radiologic-pathologic correlations
in, 5156
dysmorphic, 34, 68
giant, in cortical dysplasia, 56
immature, in cortical dysplasia, 56
Neuron-specic enolase, release of, in head
injury, 178, 216
Neuronal heterotopias, 56, 1213
Mitochondrial damage, in head injury, 178
Neuroprotection, endogenous, in head injury,

169171
Morphine, for increased intracranial

pressure, 220
Neuropsychologic testing, in cortical dysplasias,

hemispheric, 106
Motor vehicle accidents, retinal hemorrhage

in, 207
Neurotransmitters, excitotoxic eects of, in head

injury, 172176
Moyamoya disease, intracerebral hemorrhage

in, 330
NMDA (N-methyl-D-aspartate) receptors

epilepsy and, 2829
Multilobar resection, in cortical dysplasia, 107

Muscle aps, for cranial reconstruction, 406,
500502
Muscle relaxants, for increased intracranial
pressure, 220221
Myelography, intracerebral hemorrhage in, 301
Nonaccidental trauma, to children.

See Child abuse.
Noonan syndrome, electroencephalography
in, 38
Normalization phase, in intracerebral
hemorrhage, 364
Myocardial infarction, thrombolytic therapy

for, intracerebral hemorrhage in, 303304
Myocutaneous aps, for cranial
reconstruction, 406, 501
N
National Highway Transportation Safety
Administration, Head Injury Criteria of,
164165
Neck injuries, in child abuse
Nerve damage, in scalp incisions, 411
O
Odontoid fractures, in child abuse, radiology
of, 194
Omentum ap, for cranial reconstruction, 501
Ophthalmologic consultation, in shaken baby
syndrome, 201211
anatomic considerations in, 201203
associated eye injuries and, 208
dierential diagnosis in, 204208
outliers in, 209210
pathophysiologic considerations in,
203204
528
Ophthalmologic (continued )
prognosis and, 208
timing of injury and, 204
treatment recommendations in,
208209
Optic nerve damage, in shaken baby
syndrome, 204
Orbital osteotomy, 402, 443451
anterior clinoidectomy in, 448449
background of, 443444
biorbital, 460464, 466, 471472
craniotomy in, 447448
dural incision in, 450
exposure in, 446447
extended, 425, 451455
incision in, 445446
indications for, 444445
positioning for, 445
reconstruction in, 450451
with frontotemporal craniotomy, 422
Orbitozygomatic osteotomy, 455460
including condylar fossa, 471
with frontotemporal craniotomy, 425, 434
Orthosis, for skull deformation prevention,
408, 520
Osmotic therapy, for increased intracranial
pressure, 221222
Osteogenesis, distraction, for cranial
reconstruction, 409
Osteotomy(ies), 443474
biorbital, 460464
circumferential cribriform osteotomy with,
466
zygomatic osteotomy with, 471473
biorbitofrontoethmoidal, 464466
circumferential cribriform, with biorbital
osteotomy, 466
combined, 471473
extended transbasal, 464467
in craniosynostosis surgery. See
Craniosynostosis surgery.
Le Fort I, 438
orbital, 402, 443451
biorbital, 460464, 466, 471473
extended, 425, 451455
with frontotemporal craniotomy, 422
orbitozygomatic, 455460
including condylar fossa, 471
with frontotemporal craniotomy, 425, 434
zygomatic, 467471
biorbital osteotomy with, 471473

Outcomes, of child abuse injuries, 235241
Oxidative stress, in head injury, 176177
Oxygen therapy, for intracerebral hemorrhage,
335
Oxyhemoglobin, formation of, in intracerebral
hemorrhage, 285286, 313315, 374377
P
Pachygyria, pathology of, 1718
Pallidotomy, intracerebral hemorrhage in, 300
Papilledema, retinal hemorrhage in, 203, 206
Partial labyrinthectomy/petrous apicectomy
petrosal approach, 426427
Pediatric patients. See also Child abuse;
Infant(s).
cortical dysplasias in, surgical
treatment of, outcome of, 141143
craniosynostosis surgery in, 513521
hemispherectomy in, 129130
Pentobarbital
for coma, in intracerebral hemorrhage, 336
Percutaneous transluminal carotid angioplasty,
Peri-insular hemispherectomy, 127129
Pericranial aps, for cranial reconstruction,
497498
Perisylvian syndrome, 5758
PET. See Positron emission tomography.
Petrosal approach
partial labyrinthectomy/petrous apicectomy,
426427
precautions with, 402
presigmoid, 425429, 482483
retrolabyrinthine, 426
translabyrinthine, 427
Petrosectomy, total, 427
Pituitary apoplexy, 327
Plagiocephaly, deformational, correction
of, 408, 518520
Plastic surgical perspective, in cranial surgery,
405410
Platelet-derived growth factor, for wound

healing, cosmetic considerations in, 409
Question mark incision, for cranial base

surgery, 422
Plates, resorbable, for craniosynostosis surgery,

408409, 520521
Quinolinic acid, formation of, in head injury,

177, 216
529
Polymicrogyria, 1112, 5758

Pons, capillary telangiectasia of, 295
Positron emission tomography

hemispheric, 106
in localizationrelated epilepsies, 7779
methodology of, 77
in intracerebral hemorrhage, cerebral blood
ow and, 359363
Radial artery, harvesting of, 402
Posterior fossa surgery, cosmetic considerations

in, 475489
in bone removal and repair, 476477
in dural opening and closure, 477478
in lateral approaches, 480482
in midline approaches, 478
in presigmoid petrosal approach, 482483
in reconstruction, 483487
in retrosigmoid approach, 478480
in scalp dissection and repair, 476
in soft tissue dissection and repair, 476
wound healing principles and, 475
Radiation therapy, tissue changes in,

cranial reconstruction in, 417418,
507508
Radiology
of nonaccidental head injury, 183199,
215, 252
big black brain, 190192
diuse axonal injury, 192193
epidural hematomas, 186187
for injury timing, 252
intracranial hemorrhage, 189190
scalp, 183184
skull fractures, 184186
subarachnoid hemorrhage, 189
subdural hematomas, 187189
of nonaccidental spinal injury, 193195
Radiosurgery, for cavernous
malformations, 293
Rasmussens functional hemispherectomy, 122
Posttraumatic stress disorder, in child abuse,

237240
Reactive oxygen species, in head injury,

176177
Pregnancy, intracerebral hemorrhage in, 309
Reconstruction, cranial.
See Cranial reconstruction.
Prematurity, retinopathy of, versus retinal

Presigmoid petrosal approach, 425429,
482483
Record keeping, in child abuse, 245
Primary diuse brain injury, in child abuse, 158
Red blood cells, lysis of, in intracerebral

hemorrhage, edema due to, 285286,
374376
Procalcitonin, release of, 169, 171
Regional aps, for cranial reconstruction, 498
Prosthesis, for cranial reconstruction,

506507
Rendu-Osler-Weber syndrome, intracerebral

Prourokinase, intracerebral hemorrhage caused

by, 304305
Reperfusion phase, in intracerebral

hemorrhage, 363364
Psychiatric disorders, in cortical dysplasias, 36
Reporting laws, for child abuse, 243245

Resorbable plates, for craniosynostosis surgery,
408409, 520521
Q
Quadrantanopia, homonymous, after focal
cortical dysplasia resection, 141
Resuscitation
530
Retinal hemorrhage
in nonaccidental head injury, 150, 160
examination of, 152
in resuscitation, 207208
in shaken baby syndrome, 201211
anatomic considerations in, 201203
dating of, 204
dierential diagnosis of, 204208
outlier cases in, 209210
pathophysiology of, 203204
prognosis for, 208
treatment of, 208209
versus other eye injuries, 208
Retinopathy of prematurity, versus retinal
Retroauricular approach, to posterior fossa, 479
Retrolabyrinthine petrosal approach, 426
Retrosigmoid approach, 402403, 429431,
478480
Rib fractures, with nonaccidental head
injury, 150
Rotation aps, for cranial reconstruction,
406, 496
S
Sagittal synostosis, correction of, 513514
Saline solution, for intracerebral
hemorrhage, 336
Scalp
anatomy of, 411
closure of, 416
defects of, 406
elevation of, for scar minimizing, 413, 415416
hair on. See Hair.
incisions in, 405, 476
injuries of, in child abuse, 157, 183184
radiation therapy aecting, reconstruction
in, 417418, 507508
reconstruction of, 406, 476
anatomy of, 491492
direct closure in, 492493
aps for, 417418, 496501
skin graft coverage for, 406, 493494
tissue expanders in, 406, 484485,
495496
replantation of, 406
scar width in, 413, 415416
shaving of, 405, 416417

temporal hollowing in, 417, 517518
Scalpel, heated versus standard, 405
Scars
linear versus zigzag, 412414
minimizing width of, 413, 415416
Schizencephaly, 12, 5760
SCIWORA (spinal cord injuries without
radiographic abnormality), 195
Sedation
Seizures
in cortical dysplasias. See Cortical dysplasias.
prevention of, in head injury, 218
Shaken baby syndrome
Bcl-2 protein levels in, 178
case study of, 229230
cerebral blood ow dysregulation in,
171172
diuse axonal injury in, 192193
excitotoxicity in, 175
future considerations in, 179
history in, 151
identication of, 247248
nomenclature of, 247248
ophthalmologic consultation in.
See Ophthalmologic consultation,
in shaken baby syndrome.
outcome of, 235241
oxidative stress in, 176
radiology of, 252
spinal injuries in, mechanisms of, 228230
timing of, 252
Shaving, of scalp, 405, 416417
Single-photon emission computed tomography
clinical applications of, 7577
hemispheric, 106
methodology of, 7475
in intracerebral hemorrhage, cerebral blood
ow and, 359363
Skin grafts, for cranial reconstruction, 493494
substitutes for, 406
Skull
deformation of, correction of, 408, 518520
fractures of, in child abuse, 157, 184186
reconstruction of, 501506
alloplastic, 407408, 503, 505
anatomy of, 491
autogenous, 503
in benign lesion removal, 505506
Skull base surgery. See Cranial base surgery.
Subdural hematomas, in child abuse, 158,

187189, 252
Subependymal heterotopias, radiologicpathologic correlations in, 54, 56
Subfrontal-infratemporal approach, 434435
Subfrontal transbasal approach, extended, 435
Subgaleal hematoma, radiology of, 184
Smoking, intracerebral hemorrhage in, 282
Superoxide dismutase, neuroprotective eects

of, in head injury, 176177
Soft tissue
dissection and repair of, 476
supplements for, 407408
Sutural closure, premature, correction of.

See Craniosynostosis surgery.
Spasms, infantile
in cortical dysplasias, positron emission
tomography in, 7982
531
Sylvian ssures, primitive, 5758

Sympathomimetic drugs, intracerebral
hemorrhage due to, 306
SPECT. See Single-photon emission computed

tomography.
Spine and spinal cord injuries, in child abuse,
227233
demographics of, 227228
historical background of, 227
pathology of, 230232
prevention of, 232
without radiographic abnormality
(SCIWORA), 195
Spleen, injury of, in child abuse, 159
Stairway injuries, biomechanics of, 162
Stereoencephalography, in focal cortical
dysplasia, 8788
Stereotactic techniques
T
Target sign, in intracranial hemorrhage,
190
Taylor type focal cortical dysplasia, 6, 35
Telangiectasia, intracerebral hemorrhage
in, 274275, 295
Temporal region, hollowing of, prevention of,
417, 517518
Temporalis muscle
ap from, for cranial reconstruction, 499
protection of, 401402
Temporalis myo-osseous ap, for synostosis
correction, 518
Temporoparietal fascia ap, for cranial
reconstruction, 499
Terson syndrome, in shaken baby syndrome,
203204
Strips, subdural electrodes in, in focal cortical

dysplasia, 8991
Thalamotomy, intracerebral hemorrhage

in, 300
Stroke
hemorrhagic. See Intracerebral hemorrhage.
thrombolytic therapy for, intracerebral
Thiopental, for intubation, in head injury, 214
Subarachnoid hemorrhage, radiology of, 189
Thoracolumbar spinal injuries, in child abuse

mechanisms of, 230
radiology of, 195
Subcortical gray matter heterotopias, 5455
Thrombin formation, in intracerebral

Subdural electrodes, in focal cortical dysplasia,

8991
Thrombocytopenia, intracerebral hemorrhage

in, 307
532
Thrombolytic therapy, intracerebral

hemorrhage due to, 275, 303305
Turricephaly, in bilateral coronal synostosis,

correction of, 516517
Tin ear syndrome, in child abuse, 157

Tirilazad, for oxidative stress, in head injury,
176177
Tissue expanders, for cranial reconstruction,
406, 484485, 495496
Tissue plasminogen activator
Transbasal approach, extended, 435, 464467
Transcondylar approach
extreme lateral complete, 403, 435436
extreme lateral partial, 403, 431434
Transfacial approaches, to cranial base,
cosmetic considerations in, 403, 421422,
437438
Translabyrinthine petrosal approach, 402, 427
Transnasal transsphenoidal approach, 436
Transoral approach, 436437
Transplantation, fat, for soft tissue
reconstruction, 407
Transposition aps, for cranial
reconstruction, 497
Transsphenoidal approach, 436
Transsylvian, transventricular functional
Trapezius ap, for cranial reconstruction, 498
Trauma, nonaccidental, to children.
See Child abuse.
Traumatic retinoschisis. See Retinal hemorrhage.
Trigonocephaly, in metopic synostosis,
correction of, 514515
Tumor(s)
dysembryoplastic neuroepithelial, 1011, 23,
43, 4849
dysplastic, 1011, 2223, 43, 4850
gangliogliomas, 1011, 48, 50
intracerebral hemorrhage in, 308309,
325327
surgery for, cranial reconstruction after,
492501
Tumor necrosis factor, formation of, in head
injury, 177
U
U-shaped incision, for posterior fossa approach,
481
Ultrasonic aspirator, for intracerebral
hemorrhage, 350351
Ultrasonography, in subdural hematoma, 188
Urokinase
intracerebral hemorrhage caused by, 305
V
Vacuum closure device, for wounds, 409
Vascular lesions, intracerebral hemorrhage in,
289297
amyloid angiopathy, 270271, 283, 295, 323
aneurysms, 293294, 303, 329
arteriovenous malformations, 271272,
290291, 303, 324
capillary telangiectasia, 295
cavernous malformations, 291293,
324325
diagnosis of, 289290
in illicit drug use, 295296
venous angioma, 273274, 294295
venous occlusion, 329
Vasospasm
angioplasty for, intracerebral hemorrhage
in, 303
thrombolytic therapy for, intracerebral
hemorrhage in, 305
Vecuronium
for intubation, in head injury, 214
Venous angioma, intracerebral hemorrhage in,
273274, 294295
Venous occlusive disease, intracerebral
hemorrhage in, 329
Ventricular drains, for intracranial pressure
monitoring, in head injury, 216218
Vertebral compression, in child abuse, 195
Visitation programs, for child abuse
prevention, 253
Visual loss, in shaken baby syndrome, 208

Vitreous, traction on, retinal hemorrhage in,
201, 203
Wound healing
cosmetic considerations in, 409, 475
vacuum closure device for, 409
Von Willebrands disease, intracerebral

hemorrhage in, 307
Xenon isotopes, for cerebral blood ow

monitoring, in head injury, 217218
Wandering vertebral body, in child abuse,

radiology of, 195
Warfarin, intracerebral hemorrhage due to,
305306
Whiplash injury, in child abuse, 228230
Witnessing, in child abuse case, 245246
Z
Zigzag incisions, cosmetic considerations in,
412414
Zygomatic osteotomy, 467471
biorbital osteotomy with, 471473
533

02.04 - Aesthetic Considerations in Cranial Neurosurgery PDF

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Neurosurg Clin N Am 13 (2002) ixx

Aesthetic considerations in cranial neurosurgery

There is no question that the attention of a

hair-shaving techniques; craniotomy ap design

C.A. Bogaev / Neurosurg Clin N Am 13 (2002) ixx

surgeons using remarkably dierent techniques,

that they will look the same as they did before

Neurosurg Clin N Am 13 (2002) 401403

The cosmetic aspects of neurosurgery

Advances in neurosurgical operative techniques and instrumentation have resulted in great

Cranial nerve problems

For most neurosurgical operations nowadays,

* 3301 Woodburn Rd., Suite 202, Annandale, VA

Incisions made in the scalp should always be

L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403

to the motor branch of the temporalis muscle may

unacceptable by the patient, subsequent plastic

Specic operative approaches and incisions

Transpetrosal and translabyrinthine approaches

Cervical incision for carotid exposure

L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403

approach such that the skin ap is located away

ceal. When a transfacial approach is performed,

Neurosurg Clin N Am 13 (2002) 405410

Cosmetic considerations in cranial surgery:

D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410

Massive scalp losses, such as those resulting

D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410

exposure, and cosmesis. A number of incisions/

Soft tissue supplements

D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410

Computer-aided design/computer-aided machined

Recent advances: cosmetic implications

D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410

The rst bioabsorbable xation system for the

undergoing monoblock midface advancement.

D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410

[2] Farnworth TK, Beals SP, Manwaring KH, et al.

[20] Hollinger JO, Brekke J, Gruskin E, et al. The role of

Neurosurg Clin N Am 13 (2002) 411419

Hair sparing techniques and scalp ap design

There are numerous surgical scalp exposures

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

the hair in the temporal region parts to either side

even if the scar widens in the future. In general,

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

The scar width is a result of alopecia adjacent to

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

the high temperature conduction can damage the

clamping by Raney clips on the scalp edge, as in a

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

resulted in minimal linear scar formation [8]. This

Fig. 9. Beveled incision parallel with hair follicles for

this certainly facilitates preoperative markings and

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419

aspect is also improved, especially for female

Fig. 10. Separate bundles of hair braided with needle

Fig. 11. Only the surgical strip is shaved. The anterior

occurs once the muscle has been elevated. Another

Local scalp aps and management

J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419