3 Transfacial Transmaxillary Approach

The transfacial transmaxillary approach is a radical approach that affords the surgeon exposure from the anterior skull base
to the clivus.

Key Steps
Position: Supine
  Step 1. Incise the skin and elevate the flap (Fig. 3.1)
  Step 2. Perform orbito-zygomatic-maxillary osteotomies (Fig. 3.4)
  Step 3. Reflect the temporalis muscle (Fig. 3.7)
  Step 4. Expose the infratemporal fossa (Fig. 3.10)
  Step 5. Perform a frontotemporal craniotomy (Fig. 3.12)
  Step 6. Expose the nasal cavity (Fig. 3.13)

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  Step 7. Expose the parapharyngeal space and the tensor veli palatini muscle (Fig. 3.14)
  Step 8. Expose the clivus and posterior fossa dura (Fig. 3.24)
  Step 9. Remove the ramus of the mandible (Fig. 3.33)
Step 10. Expose the high cervical and paraclival regions (Fig. 3.34)

Illustrated Steps with Commentary

Fig. 3.1 (Step 1) Incise the skin and elevate the

flap.
A preauricular skin incision is made extending a standard fron­
tal skin incision inferiorly along the mandible. A second incision
extends from the inferior orbital rim back along the top of the
zygoma. Thus, the skin incision includes a hemicoronal incision, a
preauricular incision, a high cervical incision, a temporal incision,
a conjunctival incision, and a paranasal incision.
 3 Transfacial Transmaxillary Approach 37

Fig. 3.2 Reflection of the skin flap. DTF

A reflection of the skin flap exposes the frontal bone, the tempo­
ralis and masseteric muscles, the zygoma, and the maxilla. As part
of the temporal incision, the frontal branch of the facial nerve is
transected and tagged. The nerve is reanastamosed at the time Or
of the closure. The preauricular dissection must be deep to the Zy
superficial layer of the parotid gland and lateral to the main trunk
of the facial nerve to avoid facial nerve injury. The facial nerve Mx
and its branches in the parotid gland are elevated with the facial MM
Fig.The
flap. 1.1main(Step
trunk1)of the
Cartilaginous
facial nerve should framework
be preservedofwhen
the
nose. however, if a high cervical incision is required, the facial
possible;
nerve can be
The major or transected,
greater alartagged,
cartilage and repaired
is the during wound
thin flexible clo­
lattice that
sure.
formsInthethis specimen,
anterior, the facial
medial, nervewalls
and lateral is transected. TheThe
of the nares. parotid
sep­
gland, including
tal cartilage the facial
separates thenerve, is raised
two nares. with
(GAC, the facial
greater alarflap. (DTF,
cartilage;
deep temporal
LC, lateral crus offascia; F, frontal
the greater bone;
alar MM, masseteric
cartilage; MC, medialmuscle;
crus of Mx,
the
maxilla; Or, orbit;
greater alar Zy, zygomatic
cartilage; SNC, septalarch)nasal cartilage)

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F

DTF

Or

Zy

Mx

Fig. 1.1 (Step 1) Cartilaginous framework of the RM

nose.
Fig. 3.3 or
The major Reflection
greater alarof the masseteric
cartilage muscle.
is the thin flexible lattice that
forms the
Inferior anterior,of
reflection medial, and lateralmuscle
the masseteric walls ofexposes
the nares. The
the sep­
ramus
talthe
of cartilage separates
mandible. (DTF,the two
deep nares. (GAC,
temporal fascia;greater alarbone;
F, frontal cartilage;
Mx,
LC, lateralOr,
maxilla; crus of the
orbit; greater
RM, ramusalar
ofcartilage; MC, medial
the mandibule; crus of the
Zy, zygomatic
greater alar cartilage; SNC, septal nasal cartilage)
arch)

DTF

Or

Zy

Mx

Fig. 1.1 (Step 1) Cartilaginous framework of the RM

Fig.
nose.3.4 (Step 2) Perform orbito-zygomatic-
maxillary
The major orosteotomies.
greater alar cartilage is the thin flexible lattice that
forms
The the anterior,
zygomatic archmedial, and
and the lateral walls
anterior wall of the nares.
maxillaThe
aresep­
re­
tal cartilage
moved separates
in one the two
piece. (DTF, nares.
deep (GAC,fascia;
temporal greater
F, alar cartilage;
frontal bone;
LC, lateral
Mx, crus
maxilla; Or,oforbit;
the greater alar of
RM, ramus cartilage; MC, medial
the mandibule; crus of the
Zy, zygomatic
greater alar cartilage; SNC, septal nasal cartilage)
arch)
38 I Anterior Skull Base

Fig. 3.5 Exposure after the osteotomy.

An osteotomy of the zygoma and the maxilla exposes the coro­
noid process of the mandibule, the fat tissue in the pterygopala­
tine fossa, and the maxillary sinus. The lateral wall of the orbit has
also been removed. (DTF, deep temporal fascia; F, frontal bone;
Fat, fat tissue; MxS, maxillary sinus; Or, orbit; RM, ramus of the
mandibule)

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F

TM
Or

MxS
Fig. 3.6 Removal of adipose tissue exposing the
contents of the pterygopalatine fossa. RM
The removal of the adipose tissue behind the posterior wall of
the maxillary sinus exposes the pterygopalatine fossa. The deep
temporal fascia is removed to show the relationship between the
insertion of the temporalis muscle and the coronoid process. (F,
frontal bone; MxS, maxillary sinus; Or, orbit; RM, ramus of the
mandibule; TM, temporalis muscle)

Or

MxS
TM
Fig. 3.7 (Step 3) Reflect the temporalis muscle.
An inferior reflection of the temporalis muscle exposes the base
of the middle fossa. The temporalis muscle with the coronoid
process is detached with a drill and reflected. (F, frontal bone;
MxS, maxillary sinus; Or, orbit; T, temporal bone; TM, temporalis
muscle)
 3 Transfacial Transmaxillary Approach 39

T
DTA MA Or

MxS
Fig. 3.8 Reflection of the temporalis muscle with
the coronoid process to preserve the posterior
TM
deep temporal artery.
The coronoid process is fractured obliquely and left attached to
the temporalis muscle to preserve the blood supply to the muscle
through the posterior deep temporal artery. (DTA, deep temporal
artery; F, frontal bone; MA, maxillary artery; MxS, maxillary sinus;
Or, orbit; T, temporal bone; TM, temporalis muscle)

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F

T
sLPM Or
iLPM

MxS

Fig. 3.9 Exposure of the lateral pterygoid muscle. DTA

Removal of a main trunk of the internal maxillary artery and the
TM
pterygoid venous plexus exposes the superior and inferior heads
of the lateral pterygoid muscle. (DTA, deep temporal artery; F,
frontal bone; iLPM, inferior head of the lateral pterygoid muscle;
MxS, maxillary sinus; Or, orbit; sLPM, superior head of the lateral
pterygoid muscle; T, temporal bone; TM, temporalis muscle)

T
V3 Or

MxS

DTA
Fig. 3.10 (Step 4) Remove the lateral pterygoid
muscle. TM
Removal of the superior and inferior heads of the lateral pterygoid
muscle exposes the infratemporal and pterygopalatine fossae.
The branches of the mandibular nerve are exposed. (DTA, deep
temporal artery; MxS, maxillary sinus; Or, orbit; T, temporal bone;
TM, temporalis muscle; V3, mandibular nerve [third division of
the trigeminal nerve])
40 I Anterior Skull Base

T
V3 Or

LL
MxS

Fig. 3.11 Removal of the posterior wall of the DTA

maxillary sinus.
The infratemporal and pterygopalatine fossae and the maxillary TM
sinus that become a corridor to the anterior and anterolateral
skull base are well exposed. (DTA, deep temporal artery; F, frontal
bone; LL, lateral lamina of the pterygoid process; MxS, maxillary
sinus; Or, orbit; T, temporal bone; TM, temporalis muscle; V3,
mandibular nerve [third division of the trigeminal nerve])

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FD

TD

Or

V3 LL
Fig. 3.12 (Step 5) Perform a frontotemporal
craniotomy. MxS
A frontotemporal craniotomy is elevated. (DTA, deep temporal ar­ DTA
tery; FD, frontal dura; LL, lateral lamina of the pterygoid process;
MxS, maxillary sinus; Or, orbit; TD, temporal dura; TM, tempora­ TM
lis muscle; V3, mandibular nerve [third division of the trigeminal
nerve])

FD

TD

Or
SS
V3

Vi
Fig. 3.13 (Step 6) Flattening the floor of the TM
middle fossa and removal of the medial wall of the
maxillary sinus to expose the nasal cavity.
Flattening the floor of the middle fossa with a diamond drill ex­
poses the mandibular (V3), maxillary (V2), and vidian nerves, and
the sphenoid sinus. A medial wall of the maxillary sinus is also re­
moved. (FD, frontal dura; Or, orbit; SS, sphenoid sinus; TD, tem­
poral dura; TM, temporalis muscle; V3, mandibular nerve [third
division of the trigeminal nerve]; Vi, vidian nerve)
 3 Transfacial Transmaxillary Approach 41

TD
Or
V2
SS
Vi
V3
Fig. 3.14 (Step 7) Expose the parapharyngeal
space and the tensor veli palatini muscle. TVPM
The tensor velli palatini muscle arises from the scaphoid fossa at
the top of the pterygoid process and posteriorly from the medial
aspect of the spine of the sphenoid bone. This thin and triangular
shaped muscle is attached to the anterolateral membranous wall TM
of the eustachian tube lateral to the levator veli palatine muscle.
The tendon passes around the pterygoid hamulus. (Or, orbit; SS,
sphenoid sinus; TD, temporal dura; TM, temporalis muscle; TVPM,
tensor veli palatini muscle; V2, maxillary nerve [second division of
the trigeminal nerve]; V3, mandibular nerve [third division of the
trigeminal nerve]; Vi, vidian nerve)

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TD
V2 Or
SS
Vi
V3
ET

TM
Fig. 3.15 Exposure of the eustachian tube
(auditory or pterygotympanic tube).
Removal of the tensor velli palatini muscle exposes the eustachian
tube. (ET, eustachian tube; Or, orbit; SS, sphenoid sinus; TD, tem­
poral dura; TM, temporalis muscle; V2, maxillary nerve [second
division of the trigeminal nerve]; V3, mandibular nerve [third divi­
sion of the trigeminal nerve]; Vi, vidian nerve)

TD
V2
SS Or

Vi
Fig. 3.16 Enlargement of Fig. 3.15.
The superior constrictor muscle of the pharynx is well seen. The
fibrous layer that supports the pharyngeal mucosa is thickened V3 PhxBF
above the superior constrictor to form the pharyngobasilar fascia.
ET
The fascia is attached to the basilar part of the occipital bone and
the petrous part of the temporal bone medial to the eustachian
tube, and to the posterior border of the medial pterygoid plate
and pterygomandibular raphe. (DTA, deep temporal artery; ET,
eustachian tube; LVPM, levator velli palatini muscle; Or, orbit; DTA LVPM
PhxBF, pharyngobasilar fascia; SCPhx, superior constrictor muscle
of the pharynx; SS, sphenoid sinus; TD, temporal dura; V2, maxil­
SCPhx
lary nerve [second division of the trigeminal nerve]; V3, mandibu­
lar nerve [third division of the trigeminal nerve]; Vi, vidian nerve)
42 I Anterior Skull Base

FD

TD Or
V2
SS
V3
ET
Vi

TM

Fig. 3.17 Overview of the exposure.

(ET, eustachian tube; FD, frontal dura; Or, orbit; SS, sphenoid
sinus; TD, temporal dura; TM, temporalis muscle; V2, maxillary
nerve [second division of the trigeminal nerve]; V3, mandibular
nerve [third division of the trigeminal nerve]; Vi, vidian nerve)

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Or
V3

ET
Fig. 3.18 Identification of the longus capitis and
rectus capitis anterior muscles. RCAM
LCpM
The longus capitis and rectus capitis anterior muscles are seen ICA
through the retropharyngeal space. The rectus capitis is a short SCPhx
muscle originating from the anterior mass and transverse pro­ SPhM
cesses of the atlas. The longus capitis originates from the anterior
tubercle of C3­6. Both insert into the occipital bone anterior to the
foramen magnum. (DTA, deep temporal artery; ET, eustachian
tube; ICA, internal carotid artery; LCpM, longus capitis muscle;
Or, orbit; RCAM, rectus capitis anterior muscle; RM, ramus of the DTA RM
mandibule; SCPhx, superior constrictor muscle of the pharynx;
SPhM, stylopharyngeal muscle; V3, mandibular nerve [third divi­
sion of the trigeminal nerve])

Or
V3

ET

RCAM
LCpM
IX
ICA
SCPhx
Fig. 3.19 Identification of the glossopharyngeal
nerve. SPhM
The glossopharyngeal nerve is observed passing over the stylo­
pharyngeal muscle. The nerve passes lateral to the internal ca­
rotid artery. (ET, eustachian tube; ICA, internal carotid artery; IX,
glossopharyngeal nerve; LCpM, longus capitis muscle; Or, orbit;
RCAM, rectus capitis anterior muscle; SCPhx, superior constrictor
muscle of the pharynx; SPhM, stylopharyngeal muscle)
 3 Transfacial Transmaxillary Approach 43

ET

RCAM

IX LCpM
IC A
Fig. 3.20 Review of anatomical relationships in SCPhx
the retropharyngeal space.
The rectus capitis anterior muscle lies posterior and medial to
SPhM
the longus capitis muscle and under the internal carotid artery, the
glossopharyngeal nerve, and the stylopharyngeal muscle in the
retropharyngeal space. (ET, eustachian tube; ICA, internal carotid
artery; IX, glossopharyngeal nerve; LCpM, longus capitis muscle;
RCAM, rectus capitis anterior muscle; SCPhx, superior constrictor
muscle of the pharynx; SPhM, stylopharyngeal muscle)

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TD V2

SS
Vi
V3
PhxBF

ET

Fig. 3.21 The course of the eustachian tube.

A metal bar is inserted into the eustachian tube that connects the
middle ear to the nasopharynx. (ET, eustachian tube; LCpM, lon­ LCpM
gus capitis muscle; PhxBF, pharyngobasilar fascia; SCPhx, superior
constrictor muscle of the pharynx; SS, sphenoid sinus; TD, tem­
poral dura; V2, maxillary nerve [second division of the trigemi­
nal nerve]; V3, mandibular nerve [third division of the trigeminal SCPhx
nerve]; Vi, vidian nerve)

V3

Fig. 3.22 After removal of the eustachian tube.

The longus capitis muscle originates from the anterior tubercles
of the third, fourth, fifth, and sixth cervical vertebrae and be­
comes broad and thick above, where it is inserted into the infe­ RCAM
rior surface of the basilar part of the occipital bone. The rectus
capitis anterior is a short, flat muscle situated behind the upper
LCpM
part of longus capitis. It arises from the anterior surface of the
lateral mass of the atlas and the root of its transverse process, and
DTA
ascends almost vertically to the inferior surface of the basilar part
of the occipital bone immediately anterior to the occipital con­ SCPhx
dyle. (DTA, deep temporal artery; LCpM, longus capitis muscle;
RCAM, rectus capitis anterior muscle; SCPhx, superior constrictor
muscle of the pharynx; V3, mandibular nerve [third division of the
trigeminal nerve])
44 I Anterior Skull Base

TD Or

RCAM LCpM
Fig. 3.23 Division of the mandibular nerve.
A spine of the sphenoid bone is well seen after the mandibular
nerve is divided. The spine is the inferior lateral corner of the SSph IX
greater wing of the sphenoid bone. The spine fits into the groove SCPhx
between the petrous and squamosal portions of the temporal
bone and lies just behind the foramen spinosum. (DTA, deep tem­
DTA
poral artery; IX, glossopharyngeal nerve; LCpM, longus capitis
muscle; Or, orbit; RCAM, rectus capitis anterior muscle; SCPhx,
superior constrictor muscle of the pharynx; SSph, spine of the
sphenoid bone; TD, temporal dura)

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V2
TD
SS Or
V3 Vi

CL
Fig. 3.24 (Step 8) Exposure of the basilar
part of the occipital bone (clivus) through the
retropharyngeal space. RCAM LCpM
An upper part of the basilar part of the occipital bone is exposed
compressing the pharyngobasilar fascia and the superior con­
strictor muscle anteriorly. (CL, clivus; DTA, deep temporal artery;
LCpM, longus capitis muscle; Or, orbit; RCAM, rectus capitis an­ SCPhx
terior muscle; SCPhx, superior constrictor muscle of the pharynx;
SS, sphenoid sinus; TD, temporal dura; V2, maxillary nerve [sec­
ond division of the trigeminal nerve]; V3, mandibular nerve [third
DTA
division of the trigeminal nerve]; Vi, vidian nerve)

TD
SS
V3 Or
Vi

AM CL
RC

Fig. 3.25 Removal of the longus capitis muscle.

The rectus capitis anterior muscle is well exposed after the longus
capitis muscle is removed. (CL, clivus; DTA, deep temporal artery; SCPhx
Or, orbit; RCAM, rectus capitis anterior muscle; SCPhx, superior DTA
constrictor muscle of the pharynx; SS, sphenoid sinus; TD, tem­
poral dura; V3, mandibular nerve [third division of the trigeminal
nerve]; Vi, vidian nerve)
 3 Transfacial Transmaxillary Approach 45

TD V2
SS
V3 Or
Vi

OcC CL
Fig. 3.26 Removal of the rectus capitis anterior
muscle.
Removal of the rectus capitis anterior muscle exposes the basilar
part of the occipital bone. (CL, clivus; DTA, deep temporal artery;
OcC, occipital condyle; Or, orbit; SCPhx, superior constrictor SCPhx
muscle of the pharynx; SS, sphenoid sinus; TD, temporal dura; DTA
V3, mandibular nerve [third division of the trigeminal nerve]; Vi,
vidian nerve; V2, maxillary nerve [second division of the trigemi­
nal nerve]; V3, mandibular nerve [third division of the trigeminal
nerve]; Vi, vidian nerve)

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TD
Or

CL
ICA OcC
Fig. 3.27 Exposure of the occipital and C1
condyles. IX C1C
The occipital, C1 condyle, and facet lie behind the rectus capitis
anterior muscle. The anatomical relationship between the internal
aC1
x
carotid artery that enters into the carotid canal, the spine of the SPh Ph
M
SC
sphenoid bone, the facet, and the anterior arch of the atlas is well
seen from an anterolateral direction. (aC1, anterior arch of the C1
[atlas]; C1C, C1 condyle; CL, clivus; DTA, deep temporal artery; DTA
ICA, internal carotid artery; IX, glossopharyngeal nerve; OcC, oc­
cipital condyle; Or, orbit; SCPhx, superior constrictor muscle of
the pharynx; SPhM, stylopharyngeal muscle; TD, temporal dura)

TD
C5

Or

Fig. 3.28 Elevation of the temporal base with the SSph

dura mater. CL
Elevation of the basal temporal dura exposes the C5 portion of ICA OcC
the internal carotid artery as it exits the carotid canal in the mid­
dle fossa. (C1C, C1 condyle; C5, C5 portion of the internal carotid
artery; CL, clivus; ICA, internal carotid artery; OcC, occipital con­
C1C
dyle; Or, orbit; SSph, spine of the sphenoid bone; TD, temporal
dura)
46 I Anterior Skull Base

TD

C5

C6 Or

CL
Fig. 3.29 Exposure of the intracranial extradural
portion of the internal carotid artery.
OcC
The C5 and C6 segments of the internal carotid artery can be ex­
posed by opening the intrapetrous carotid canal. The canal can
be opened from a lateral direction by drilling through the bony
eustachian canal and the canal that houses the tensor tympani
muscle. (C5, C5 portion of the internal carotid artery; C6, C6 por­ DTA
SCPhx
tion of the internal carotid artery; CL, clivus; DTA, deep temporal
artery; OcC, occipital condyle; Or, orbit; SCPhx, superior constric­
tor muscle of the pharynx; TD, temporal dura)

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TD

C5

C6 Or

PD
CL

Fig. 3.30 Drilling of the basilar part of the

occipital bone (clivectomy). OcC
The basilar part of the occipital bone is drilled under the internal
carotid artery. The posterior fossa dura is exposed. (aC1, anterior C1C
arch of the C1 [atlas]; C1C, C1 condyle; C5, C5 portion of the in­
ternal carotid artery; C6, C6 portion of the internal carotid artery; aC1
CL, clivus; DTA, deep temporal artery; OcC, occipital condyle; Or,
DTA SCPhx
orbit; PD, posterior fossa dura; SCPhx, superior constrictor muscle
of the pharynx; TD, temporal dura)

TD

DS

PD Or

CL

OcC
C1C
Fig. 3.31 Partial clivectomy.
The bony edge of the dorsum sellae is seen by lifting the internal
carotid artery. (aC1, anterior arch of the C1 [atlas]; C1C, C1 con­
aC1
dyle; CL, clivus; DS, dorsum sellae; DTA, deep temporal artery; SCPhx
OcC, occipital condyle; Or, orbit; PD, posterior fossa dura; SCPhx, DTA
superior constrictor muscle of the pharynx; TD, temporal dura)
 3 Transfacial Transmaxillary Approach 47

TD

Or
PD

CL

OcC

Fig. 3.32 Exposure of the posterior fossa dura. C1C

Removal of the basilar portion of the occipital bone with a diamond
drill exposes the posterior fossa dura. (aC1, anterior arch of the
C1 [atlas]; C1C, C1 condyle; CL, clivus; DTA, deep temporal artery; aC1 SCPhx
OcC, occipital condyle; Or, orbit; PD, posterior fossa dura; SCPhx, DTA
superior constrictor muscle of the pharynx; TD, temporal dura)

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C5
C6

ICA
IX
Sty
P

SC
M
Fig. 3.33 (Step 9) Remove the ramus of the
mandible. SPhM
After the ramus of the mandible is removed, the stylopharyngeal, SGM
styloglossus, and the styloid muscles are well exposed. (C5, C5 SHL
portion of the internal carotid artery; C6, C6 portion of the inter­ SHM
nal carotid artery; ICA, internal carotid artery; IX, glossopharyn­
geal nerve; SCM, sternocleidomastoid muscle; SGM, styloglossus
muscle; SHL, stylohyoid ligament; SHM, stylohyoid muscle; SPhM,
stylopharyngeal muscle; StyP, styloid process)

ICA
Sty

IX
OcC
P

C1C

SP
hM
aC1

Fig. 3.34 (Step 10) Expose the three muscles that

SC

IC
attach to the styloid process (magnification of A
SG
M

Fig. 3.33).
IX
SH SH

The stylopharyngeal, styloglossus, and stylohyoid muscles are

L

well seen. The stylohyoid ligament runs parallel to the stylohy­

M

oid muscle. The glossopharyngeal nerve and the high cervical

portion of the internal carotid artery are seen between the sty­
loglossus and the stylopharyngeal muscles. (aC1, anterior arch
of the C1 [atlas]; C1C, C1 condyle; ICA, internal carotid artery;
OcC, occipital condyle; IX, glossopharyngeal nerve; SCM, sterno­
cleidomastoid muscle; SGM, styloglossus muscle; SHL, stylohyoid
ligament; SHM, stylohyoid muscle; SPhM, stylopharyngeal mus­
cle; StyP, styloid process)
48 I Anterior Skull Base

TD

Or
C5
C6
CL Vo
PD NS

ICA
Sty
P
Fig. 3.35 Removal of the lateral wall of the nasal
cavity.

SC
M
The nasal septum is seen after the lateral wall of the nasal cavity SMs
is removed. (C5, C5 portion of the internal carotid artery; C6, C6
portion of the internal carotid artery; CL, clivus; ICA, internal ca­
rotid artery; NS, nasal septum; Or, orbit; PD, posterior fossa dura;
SCM, sternocleidomastoid muscle; SMs, muscles that attached
to the styloid process; StyP, styloid process; TD, temporal dura;
Vo, vomer)

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FD

TD

Et
C5
C6
Vo
PD NS
CL
Sty
ICA

Fig. 3.36 Removal of the orbit.

P

The orbit is removed and the ethmoid sinus is skeletonized

through the medial wall of the orbital cavity. (C5, C5 portion of
SC

the internal carotid artery; C6, C6 portion of the internal carotid

M

artery; CL, clivus; Et, ethmoid sinus; FD, frontal dura; ICA, internal SMs
carotid artery; NS, nasal septum; PD, posterior fossa dura; SCM,
sternocleidomastoid muscle; SMs, muscles that attach to the sty­
loid process; StyP, styloid process; TD, temporal dura; Vo, vomer)

FD

TD

Et

C5 SS
C6
Vo
PD NS
CL
Sty

ICA
P

Fig. 3.37 Ethmoidectomy.

After ethmoidectomy the anterior skull base is exposed. (C5, C5
SC
M

portion of the internal carotid artery; C6, C6 portion of the inter­

nal carotid artery; CL, clivus; Et, ethmoid sinus; FD, frontal dura; SMs
ICA, internal carotid artery; NS, nasal septum; PD, posterior fossa
dura; SCM, sternocleidomastoid muscle; SMs, muscles that attach
to the styloid process; SS, sphenoid sinus; StyP, styloid process;
TD, temporal dura; Vo, vomer)
 3 Transfacial Transmaxillary Approach 49

FD

TD

Et
ST
C5
C6 MT

PD
CL

ICA
Sty
IT
Fig. 3.38 Removal of the nasal septum.

P
After the nasal septum is removed the superior, middle, and in­

SC
ferior turbinates on opposite sides are exposed. (C5, C5 portion

M
of the internal carotid artery; C6, C6 portion of the internal ca­
rotid artery; CL, clivus; Et, ethmoid sinus; FD, frontal dura; ICA, SMs
internal carotid artery; IT, inferior turbinate; MT, middle turbinate;
PD, posterior fossa dura; SCM, sternocleidomastoid muscle; SMs,
muscles that attach to the styloid process; ST, superior turbinate;
StyP, styloid process; TD, temporal dura)

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