Journal of Neuro-Oncology (2005) 73: 145–152 Ó Springer 2005

DOI 10.1007/s11060-004-5173-6

Clinical Study

Advances in surgical management of malignancies of the cranial base: the extended trans-
basal approach

James P. Chandler1, Harold J. Pelzer2, Bernard B. Bendok,3 H. Hunt Batjer,3 and Sean A. Salehi3
1
Department of Neurological Surgery, Northwestern University Feinberg School of Medicine and Center for Cranial
Base Surgery; 2Department of Head Neck Oncology and Otolaryngology, Northwestern Memorial Hospital;
3
Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

Key words: extended frontal, malignancies, orbitonasal osteotomy skull base, transbasal

Summary

The extended transbasal approach combines a bifrontal craniotomy with an orbital nasal and potentially a sphe-
noethmoidal osteotomy to provide excellent access to malignancies of the anterior, middle and posterior skull base.
The approach enables the en bloc resection of tumors within the frontal lobes, orbits, paranasal sinuses and
sphenoclival corridors without brain retraction and may obviate the need for transfacial access. We present our 7-
year experience during which 29 patients underwent surgery with the extended transbasal exposure. In 25 patients
the extended transbasal approach was used alone; in the remaining four it was combined with additional ap-
proaches. With exception of two patients, all lesions were removed en bloc. Reconstruction was accomplished with
the use of pericranium and in some instances a temporalis muscle pedicle or a gracilis microvascular free flap. There
were no mortalities associated with this approach. Seven patients experienced infections, four patients experienced
cerebral spinal fluid (CSF) leakage, two patients who had received adjuvant radiation experienced scalp necrosis,
three patients experienced pneumocephalus, and 29 patients experienced cranial neuropathies, the majority of which
were loss of olfaction. The average follow-up for our patients was 34 months with a range of 2–62 months.

Introduction tients received postoperative radiation and seven pa-

Malignancies of the sphenoclival corridor represent a
unique surgical challenge to the cranial base surgeon.
Historically, the approaches utilized to access this region
have resulted in incomplete resections, cosmetic defor-
mities, and significant morbidity and mortality [1–7].
Recent technological advances including sophisticated
head and neck imaging, neuronavigational systems, and
improved surgical instrumentation have resulted in a
better understanding of cranial base anatomy and
opened the door to a variety of new approaches to the
cranial base. The extended transbasal approach and its
modifications have been previously described by several
authors [1,8–23]. In this report, we detail the manner in
which we have utilized this approach to successfully
resect lesions occupying the anterior, middle, and pos-
terior cranial base with minimal morbidity and no
mortality.
tients received chemotherapy.
Preoperative evaluation
Extensive imaging studies were performed on all pa-
tients including computerized tomography (CT) with
bone windows and in some instances three-dimensional
reconstructions and magnetic resonance imaging (MRI)
of the brain and face. The carotid artery anatomy and
patency were established by means of CT angiography
in three patients, MR angiography in eight patients, and
four patients underwent conventional cerebral angiog-
raphy. In two patients, partial embolization was per-
formed in advance of surgical resection. All patients
who had tumors encroaching on the optic apparatus
underwent visual field examination. The patients with
frontal lobe extension of tumor underwent a standard
battery of neuropsychological testing.

Materials and methods Operative technique

Between January of 1996 and March of 2004, 29 pa-
tients with tumors occupying the anterior, middle and
posterior skull base underwent surgery utilizing the ex-
tended transbasal approach. Patients ranged in age from
14 to 69. Nineteen of the patients were male and 10
female. Table 1 shows the histopathology of the surgi-
cally resected lesions. Eleven of the tumors were high-
grade malignancies and 18 were low grade. Nine pa-
Following a standard endotracheal anesthetic technique,
the head is positioned neutrally and secured in Mayfield
3-point fixation. If appropriate, cranial nerve, somato-
sensory evoked responses, and brainstem auditory
evoked responses are monitored. In situations where
there are significant risks of carotid sacrifice, electroen-
cephalography is available. In our early cases in which
we anticipated dural section, a cerebrospinal fluid drain
146

Table 1. Tumor Pathology and Survival create a window through which the nerves can be
mobilized forward with the scalp flap. The periorbita is
Diagnosis # of Status
Cases dissected superiorly from the orbital roof to a depth of
Alive Dead approximately 2–2.5 cm, laterally to the point of the
inferior orbital fissure and medially to the anterior eth-
Low-Grade Malignancies moidal foramina.
Atypical meningiomas 3 2 (42) 1 (36)
A series of burr holes are placed adjacent to the sag-
Adenoid cystic carcinoma 3 3 (34)
Chordoma 4 3 (20) 1 (15)
ittal sinus anteriorly and posteriorly just adjacent to the
Chondrosarcoma 2 2 (24) coronal suture. The bone flap should extend from the
Esthesioneuroblastoma 5 3 (37) 2 (16) coronal suture to as far frontal as can be achieved. In
pituitary adenoma 1 1 (48) some instances the frontal sinus may be deep necessi-
Subtotal 18 tating osteotomes or a Gigli saw to take down its pos-
High-Grade Malignancies terior wall. With the bone flap removed, the next step is
Aadenocarcinomas 7 3 (26) 4 (8) to perform the orbitonasal osteotomy and potentially a
Squamous cell carcinoma 3 1 (32) 2 (11) sphenoethmoidal osteotomy depending on the tumor’s
Undifferentiated carcinoma 1 1 (28) epicenter.
Subtotal 11
Total 29
Orbitonasal and sphenethmoidal osteotomies
Number in parenthesis denotes follow-up in months. Resection of tumors with epicenters within the anterior
cranial fossa, including the orbitonasal and perinasal
sinuses, oftentimes are enhanced with the addition of an
was placed prior to final positioning. All patients re-
orbitonasal osteotomy. After dissection of the perior-
ceived broad-spectrum antibiotic prophylaxis. Mannitol
bita, the frontal dura (Figure 1) is elevated from the
and corticosteroids is administered in cases where sig-
orbital roof working laterally towards the midline. In
nificant brain infiltration and edema are present.
the midline, the dura will be tethered to the crista galli
A bicoronal incision is performed from tragus to
and cribriform plate (Figure 2a). The crista galli can be
tragus and potentially more laterally if a zygomatic os-
removed with a narrow bone rongeur and the dura in-
teotomy is anticipated. In general, the incision is placed
cised along the base of the cribriform plate with man-
behind the hairline or approximately 12 cm posterior to
datory transection of anterior and posterior ethmoidal
the glabella. This generally allows for sufficient frontal
arteries and olfactory fibers. The dissection is carried
lobe exposure and the development of an adequate
posteriorly to expose the planum sphenoidale and tu-
pericranial flap for purposes of reconstruction at the end
berculum sella (Figure 2b). Working laterally, the dura
of the case. The length of the pericranial flap can be
overlying the optic foramina is exposed. The incised
increased with the use of traction posteriorly at the time
midline dura is primarily repaired in a meticulous
of skin incision. The scalp flap is mobilized forward with
fashion to eliminate the possibility of cerebrospinal fluid
the pericranium and swept above the temporalis fascia
leakage (CSF). The preservation of olfactory fibers has
bilaterally to expose the frontozygomatic processes lat-
been described [23,24]; however, we have found this
erally and the superior orbital rim and nasion medially.
maneuver to hinder our approach and not result in
If the supraorbital nerves and vessels complex resides in
clinically significant preservation of olfaction. A recip-
a foramen, a fine osteotome or Karresin punch is used to
rocating saw is then used to perform strategic cuts on

Figure 1. Schematic depicting exposure following bifrontal craniotomy, orbitonasal osteotomy. The upper quarter of the clivus remains on blind
spot.

Figure 2. Orbital frontal dura dissection with sectioning of olfactory fibers and ethmoidal vessels. (a) Dissection exposing planum sphenoidale.
(b) (Cadaveric dissection demonstrating) Orbitonasal osteotomy complete (c).
the exposed orbitonasal bar. The first cuts are per-
formed across the supraorbital rim and orbital roof just
medially to the supraorbital foramina. Approximately
2.5 cm of the orbital roof should be included in this cut
so as to minimize the possibility of a postoperative en-
ophthalmos. For more broad-based tumors these cuts
may be expanded to include the frontal zygomatic pro-
cess and for lesions extending laterally into the infra-
temporal fossa, a zygomatic osteotomy may be
considered. The next cut is across the superior aspect of
the nasion just adjacent to the frontal nasal suture.
Here, the saw is angled parallel to the plane of the
cribriform plate and is directed towards the anterior
ethmoidal foramina bilaterally. A narrow osteotome is
then used to perform a linear cut across the floor of the
anterior cranial fossa inclusive of the midline cribriform
plate. This same osteotome can then be used to gently
displace the orbitonasal bar. Once complete, pathology
within the frontal lobes, orbits, midline nasal cavity and,
potentially the maxillary sinus are completely accessible
(Figure 2c).
For lesions based more posteriorly and medially
within the sphenoclival region, the addition of a sphe-
noethmoidectomy should be considered. On completion
of the orbital nasal osteotomy, the microscope is
brought into the field and the high-speed air drill with a
147
3 mm cutting burr is used to drill through the planum
sphenoidale medially to expose the sphenoid sinus and
then more laterally to enter the ethmoid sinuses. Sinus
trabeculations and mucosa are removed with a narrow
pituitary rongeur. The optic nerves can then be unroo-
fed utilizing a 2–3 mm diamond burr and microdissec-
tors. Continuous irrigation is critical to minimize a
thermal optic nerve injury (Figure 3a). At this point the
orbital apex contents are completely exposed. With
further drilling through the posterior wall of the sphe-
noid cavity, sella dura is revealed. Working more cau-
dally, the cancellous bone of the clivus can be
progressively removed to expose clival dura from
approximately 5–10 mm inferior to the posterior cli-
noids to the foramen magnum. In the depths of this
exposure the hypoglossal nerves may be skeletonized as
they course through the hypoglossal canal of the fora-
men magnum and occipital condyle (Figure 3b).
Resection and reconstruction
Dural defects are closed primarily, or if necessary a
pericranial or fascia lata graft may be employed to en-
sure a water-tight closure. Larger defects may require
cadaveric dura or bovine pericardium for reconstruc-
tion. Exposed mucosa from the frontal, ethmoidal, and
148

Figure 3. Sphenoethmoidectomy complete, optic nerves skeletonized (a); : Completed dissection with exposure to foramen magnum (b).

sphenoid sinus is exonerated. Small portions of fat,
typically harvested from the abdomen are then packed
into the above-mentioned sinus cavities. A generous
pericranial flap is then harvested and insinuated into the
depths of the exposure as far caudal as the margins of
the bone resection. This flap serves as a barrier between
the sinus cavities and the brain, minimizing the risk of
post-operative infection or spinal fluid leakage. Care
should be taken to preserve blood supply of the flap,
which typically arises from the supraorbital vessel
complex. The dead space is then filled with fat and fibrin
glue or equivalent. More substantial defects which
cannot be adequately covered with pericranium due to
prior operations or poor tissue quality may require a
temporalis, a muscle rotational flap, or a vascularized
free flap. We have had success utilizing gracilis and
rectus abdominus muscle for this purpose [25]. The
orbitonasal bone flap may then be secured with titanium
plates followed by replacement of the bifrontal crani-
otomy. Central dural tack-ups are helpful in minimizing

Figure 4. Case 1. Preoperative frameless navigational axial, sagittal, and coronal T1-weighted MRI with gadolinium. Tumor extends onto right
temporal lobe, infratemporal fossa, and paranasal sinuses and is obstructing this patient’s nasopharynx. Right eye was blind at presentation.

Figure 5. Case 1. Frontal orbitotemporal exposure with extensive pericranial flap (a). Orbitonasal zygomatic osteotomy complete. Spheno-
ethmoidal region tumor excision. Note exposure of optic nerves (b).
postoperative pneumocephalus and epidural hemato-
mas. A subgaleal drain to gravity is left in place 48 h.
Illustrative cases
Case 1: Extensive cranial base esthesioneuroblastoma
This 16 year-old male presented with severe headaches,
progressive right visual loss, a palpable right facial mass,
and airway obstruction (Figure 5). He underwent a
transnasal biopsy of the intranasal portion of his tumor,
which confirmed for diagnosis of esthesioneuroblastoma.
Given the apparent encasement of both carotid arteries
and the extremely vascular appearance of the lesion on
MRI, an angiogram and embolization procedure were
performed. An extended transbasal approach with the
addition of an orbitozygomatic osteotomy and temporal
craniotomy was utilized to achieve a gross total resection
Figure 6. Postoperative day 2 CT of brain.
149
of this lesion (Figure 6). Subsequent to the operation the
patient received radiation and chemotherapy. Four weeks
following the surgery he experienced a superficial wound
infection, which responded to intravenous antibiotics.
Twelve months postoperatively he developed a recurrence
and expired 18 months following his initial operation.
Case 2: Extensive clival chordoma
This 41 year-old male presented to the emergency room
with the worst headache of his life following blowing his
nose. A CT of the brain performed at that time dem-
onstrated diffuse intracranial air and a very large sphe-
noclival mass generating significant brain stem
compression and encasing both the basilar and bilateral
carotid arteries (Figure 7a and b). He was treated with
a transbasal approach with the addition of sphenoeth-
moidectomy. The soft nature of the tumor facilitated a
150

Figure 7. Case 2. Admission computerized tomography (CT) scan demonstrating marked pneumocephalus (a). T1-weighted magnetic MRI
following gadolinium administration revealing large nonenhancing sphenoclival mass with brainstem compression (b). T2-weighted MRI image
demonstrating cavernous carotid encasement and erosion of right petrous apex and clivus (c). Postoperative axial T1-weighted MRI with
gadolinium (d).

gross total resection. Clival dura from the foramen Complications

magnum to mid pons was resected (Figure 7c and d).
The vertebral-basilar complex and abducens nerves were
preserved with the resection. Postoperatively, the patient
experienced a small amount of CSF rhinorrhea, which
persisted despite attempts of resolution with lumbar
drainage and ultimately required a ventricular perito-
neal shunt. He remains disease-free 8 months postop-
eratively.
Postoperative complications are listed in Table 2. Four
patients experienced cerebral spinal fluid leakage, one in
the immediate postoperative and the remaining in a
delayed fashion. In two instances spinal fluid leak was
Table 2.

Complications # of Cases

CSF leak 4 (14%)

Results Partial flap necrosis 2 (7%)
Infections
Superficial wound 4 (14%)
The patients in this series were followed for an average Cerebritis 1 (3%)
of 34 months with the range of 2–62 months. The Epidural abcess 2 (7%)
malignancies treated in the disease status at follow-up Cranial nerve dysfunction
are indicated in Table 1. There were 18 patients (62%) Olfactory 29 (100%)
with low-grade malignancies and 11 (38%) with high- Optic 2a (7%)
grade malignancies. At the most recent follow-up, 15 Abduces 0 (0%)
Pneumocephalus 3 (10%)
patients (83%) with low-grade malignancies and 5
patients (45%) with high-grade malignancies were a
One patient presented with visual loss which persisted postopera-
disease-free or with stable disease. The postoperative tively, and the second underwent anucleation due to the extent of
hospitalization ranged from 3–14 days. orbital involvement.

controlled with 4–5 days of lumbar drainage. All of the
patients experiencing CSF leak had significant intra-
dural extent of their tumor, necessitating primary dural
repair or grafting. In one instance due to the low clival
position of our dural resection, a primary closure could
not be achieved. This patient ultimately required a
ventricular peritoneal shunt. In our early experience,
lumbar drains were routinely placed in many patients at
risk for CSF leakage; however we found this strategy to
result in an increased incidence of pneumocephalus and
neurologic changes secondary to overdrainage. We now
only place drains in patients demonstrating CSF leakage
postoperatively.
There were seven patients who developed wound
infections. In each of these instances, the tumors were
quite large and the operations long. Four patients
experienced superficial wound infections, which were
effectively treated with local wound care and intrave-
nous antibiotics. Two patients experienced epidural
abscesses and required surgical evacuation, irrigation,
and debridement. The bone flaps, both craniotomy and
osteotomy, were not removed and the patients were
treated with a six to eight week course of appropriate
IV and oral antibiotic therapy. In one case of a giant
esthesioneuroblastoma infiltrating the frontal lobes,
there were clinical and radiographic findings suspicious
for cerebritis. This was not confirmed by tissue sam-
pling; however, it was treated with a 6-week course of
intravenous antibiotics. The patient responded favor-
ably both clinically and radiographically.
Cranial nerve injuries may occur with this operation
[21]. All patients undergoing a true transbasal approach
will experience loss of olfaction. In the vast majority of the
cases olfaction had been lost preoperatively. There was
one patient who presented with right eye blindness, which
persisted postoperatively, and another patient with
squamous cell carcinoma who underwent an anucleation
procedure as a significant tumor burden within the orbit
was encountered at the time of surgery.
Significant pneumocephalus was apparent in three pa-
tients. All were treated successfully with cessation of
lumbar drainage in one patient and flatbed rest with
oxygenation in two others. Oftentimes pneumocephalus
occurs in combination with CSF leak. This was noted to
be the case in two of our patients.
Discussion
Malignancies along the sphenoclival corridor and asso-
ciated nasal sinuses represent a unique surgical chal-
lenge. Oftentimes these tumors may extend into the
brain or brainstem. Standard anterior approaches,
including the transfacial, transmaxillary, transsphenoi-
dal, and transoral may fail to yield enough exposure to
achieve gross total resection. The concept of gaining
better access to these lesions through removal of the
orbital rims was introduced initially by Frazier in 1913
[26]. In 1972 Derome et al. described the transbasal
approach for removal of sphenoid ethmoidal tumors
[13]. Since that time there have been several reports from
a variety of authors detailing the addition of osteoto-
151
mies to gain better access to tumors and fractures of the
cranial base [1,3,6,8,14,17,18,21,23,27–29]. In particular,
Raveh et al. have authored reports in the literature
detailing his anterior subcranial approach for skull base
tumors and fractures without the addition of a bifrontal
craniotomy [17,18]. Sekhar was the first to introduce the
concept of a bifrontal craniotomy with addition of
orbital nasal and sphenoid ethmoidal osteotomies [21].
All of these techniques are relatively similar and must be
tailored to the epicenter of the lesion and the surgeon’s
experience. The ultimate goal in cranial base surgery for
malignant disease is appropriate access to achieve gross
total resection with minimal damage to neural vascular
structures. In some instances this may require the
addition of a transfacial or subtemporal infratemporal
approach to the extended transbasal approach as de-
tailed in this report [11,20,28].
Until more recently, aggressive approaches to anterior
cranial base lesions were treated primarily with transfa-
cial and transmaxillary approaches which while providing
for reasonable surgical access, may be associated with a
high incidence of postoperative infection, CSF leakage,
cosmetic deformity, and unacceptable mortality [2,4,7,
11,12]. The extended transbasal approach is specifically
well suited for lesions with epicenters in the sphenoclival
region extensive into the frontal lobe paranasal sinus and
orbits. It is a cosmetically sound approach yielding
excellent visualization of the anterior cranial fossa con-
tents without brain retraction and creates an excellent
window for primary dural repair or reconstruction if
warranted [29]. Malignancies in the nasal and paranasal
sinuses can be accessed through this approach; however,
lesions confined to these sinus cavities may be more
appropriately treated by transmaxillary or transfacial
approaches. Similarly, lesions confined to the sphenoid
sinus or clivus may be better accessed through a trans-
sphenoidal or transoral route [1–3,12,22]. When appro-
priate, the wide exposure offered by the extended
transbasal approach affords the safest opportunity for
preservation of the carotid arteries, optic, and abducens
nerves.
Bilateral loss of olfaction is a mandatory consequence
of this approach. Patients must be counseled carefully
preoperatively as loss of olfaction is oftentimes associ-
ated with transient disturbances in taste and can in fact
significantly affect the patient’s lifestyle. In two patients
we attempted to preserve olfaction as described by
Spetzler et al. [23,24]; however, postoperatively the pa-
tients reported anosmia. The majority of the patients
with lesions amenable to this particular approach have
lost all or a substantial part of olfaction prior to surgery.
Despite appropriate antibiotic prophylaxis, infection
did occur in our patients. The risk factors for infection
include prolonged operative time, exposure of nasal and
paranasal sinuses to exposed brain and prior radiation.
All of our patients received either unasyn or combina-
tion Vancomycin and Gentamicin prior to incision.
Antibiotics were continued for a minimum of 72 h or
longer if drains remained in place. We found the risk of
infection could be minimized by first resecting extra-
dural disease and then, following a complete instrument
change, preceding forward with intradural tumor
152
resection. The importance of a water-tight primary dural
closure or dural repair cannot be overemphasized.
Important anatomic limits exist with this approach.
In general, the lateral extent of the approach is limited
by the optic nerves, cavernous sinuses, carotid arteries,
petrous apexes, and the hypoglossal canals [21,23,27].
The rostral extent of the exposure along the clivus is
just inferior to the base of the posterior clinoid pro-
cess (Figure 1). Thus, tumors extending superior to
the posterior clinoid involving in the petrous apexes or
cavernous sinus may require the addition of a more
lateral approach such as a petrosal craniotomy or
subtemporal–infratemporal technique [11,20].
This relatively novel approach lends itself to a wide
variety of application and obviates the need for many of
the traditional more aggressive anterior cranial base
approaches. However, the approach requires a very
clear knowledge of cranial base anatomy and an ability
to deal with all potential complications. Our results
suggested this approach can be utilized alone to treat the
vast majority of sphenoclival malignancies with minimal
complications and good short immediate results. Fur-
ther long-term results are needed.
Acknowledgment
We wish to thank Angela L. Park for her assistance in
preparation of this manuscript.
References
1. Blacklock JB, Weber RS, Lee YY, Goepfert H: Transcranial
resection of tumors of the paranasal sinuses and nasal cavity. J
Neurosurg 71(1): 10–15, 1989
2. Jackson IT, Marsh WR, Hide TA: Treatment of tumors involving
the anterior cranial fossa. Head Neck Surg. 6(5): 901–913, 1984
3. Jackson IT, Marsh WR., Bite U, Hide TA: Craniofacial osteot-
omies to facilitate skull base tumour resection. Br J Plast Surg
39(2): 153–160, 1986
4. Ketcham AS, Hoye RC, Van Buren JM, Johnson RH, Smith RR:
Complications of intracranial facial resection for tumors of the
paranasal sinuses. Am J Surg 112(4): 591–596, 1966
5. Sundaresan N, Shah JP: Craniofacial resection for anterior skull
base tumors. Head Neck Surg 10(4): 219–224, 1988
6. Uttley D, Moore A, Archer DJ: Surgical management of midline
skull-base tumors: a new approach. J NeuroSurg 71(5 Pt 1): 705–
710, 1989
7. Van Buren JM, Ommaya AK, Ketcham AS: Ten years’ experi-
ence with radical combined craniofacial resection of malignant
tumors of the paranasal sinuses. J NeuroSurg 28(4): 341–350,
1968
8. Alaywan M, Sindou M: Fronto-temporal approach with orbito-
zygomatic removal. Surgical anatomy. Acta Neurochir 104(3–4):
79–83, 1990
9. Al-Mefty O: Supraorbital-pterional approach to skull base
lesions. NeuroSurg 21(4): 474–477, 1987
10. Banerji D, Behari S, Tyagi I, Pandey T, Jain VK, Chhabra DK:
Extended frontobasal approach to the skull base. Neurol India
49(3): 253–261, 2001
11. Carillo FJ, Leon RB, Celis AM, et al.: Anterolateral and lateral
skull-based approaches for treatment of neoplastic diseases. Am J
Otolaryngol 25: 57–58, 2004
12. Cocke EW Jr, Robertson JH, Robertson JT, Crook JP Jr: The
extended maxillotomy and subtotal maxillectomy for excision of
skull base tumors. Arch Otolaryngol – Head Neck Surg 116(1):
92–104, 1990
13. Derome P, Akerman M, Anquez L et al.: Les Tumeurs Spheno-
Ethmo€1dales. Possibilities de réparation chirurgicales. Neuro-
chirurgie (Suppl). 18: 1–164, 1972
14. Jane JA, Park TS, Pobereskin LH, Winn HR, Butler AB: The
supraorbital approach: technical note. NeuroSurg 11(4): 537–542,
1982
15. Kawakami K, Yamanouchi Y, Kubota C, Kawamura Y, Mat-
sumura H: An extensive transbasal approach to frontal skull-base
tumors. Technical note. J NeuroSurg 74(6): 1011–1013, 1991
16. Persing JA, Jane JA, Levine PA, Cantrell RW: The versatile
frontal sinus approach to the floor of the anterior cranial fossa.
Technical note. J NeuroSurg 72(3): 513–516, 1990
17. Raveh J, Laedrach K, Speiser M, Chen J, Vuillemin T, Seiler R,
Ebeling U, Leibinger K: The subcranial approach for fronto-
orbital and anteroposterior skull-base tumors. Arch Otolaryngol
– Head Neck Surg 119(4): 385–393, 1993
18. Raveh J, Turk JB, Ladrach K, Seiler R, Godoy N, Chen J,
Paladino J, Virag M, Leibinger K: Extended anterior subcranial
approach for skull base tumors: long-term results. J NeuroSurg
82(6): 1002–1010, 1995
19. Schramm VL Jr, Myers EN, Maroon JC: Anterior skull base
surgery for benign and malignant disease. Laryngoscope 89(7 Pt
1): 1077–1091, 1979
20. Sekhar LN, Janecka IP, Jones NF: Subtemporal-infratemporal and
basal subfrontal approach to extensive cranial base tumours. Acta
Neurochir 92(1–4): 83–92, 1988
21. Sekhar LN, Nanda A, Sen CN, Snyderman CN, Janecka IP: The
extended frontal approach to tumors of the anterior, middle, and
posterior skull base. J NeuroSurg 76(2): 198–206, 1992
22. Spetzler RF, Pappas CT: Management of anterior skull base
tumors. Clin NeuroSurg 37: 490–501, 1991
23. Spetzler RF, Herman JM, Beals S, Joganic E, Milligan J:
Preservation of olfaction in anterior craniofacial approaches. J
NeuroSurg 79(1): 48–52, 1993
24. Honeybul S, Neil-Dwyer D, Lang DA, Evans BT: Extended
transbasal approach with preservation of olfaction: an anatomical
study. Br J Oral Maxillofac Surg 39(2): 149–157, 2001
25. Sukkar SM, Daw JA, Chandler JP, Dumanian GA: Gracilis
muscle free flap transfer using a radial artery/venae comitantes
composite vascular pedicle. Plast Reconstr Surg 108: 156–161,
2001
26. Frazier CH: An approach to the hypophysis through the anterior
cranial fossa. Annals Surg 57: 145–150, 1913
27. Gupta SK, Khosla VK, Sharma BS: Bilateral fronto-orbito-
zygomatic craniotomy – a combined extended frontal and
orbitozygomatic approach. Neurol India 48(4): 361–364, 2000
28. Hakuba A, Liu SS, Nishimura S: The orbitozygomatic infratem-
poral approach: a new surgical technique. Surg Neurol 26(3):
271–276, 1986
29. Jones NF, Schramm VL, Sekhar LN: Reconstruction of the
cranial base following tumour resection. Br J Plast Surg 40(2):
155–162, 1987
Address for offprints: James P. Chandler, MD, Department of Neu-
rological Surgery, 233 E. Erie St., Suite 614, Chicago, 60611 Illinois,
USA; Tel.: 312-695-0491; Fax:+312-695-0225; E-mail: jchan-
dler@nmff.org