Journal of Clinical Neuroscience (2003) 10(3), 340–345

ª 2003 Published by Elsevier Science Ltd.

doi:10.1016/S0967-5868(03)00009-2

Operative technical review

Selected midfacial access procedures to the skull base

K.R. Spencer BHB MBCHB MDSC FRACDS (OMS), A.L. Nastri MBBS MDSC FRACDS (OMS), D. Wiesenfeld MDSC FDSRCPS FRACDS (OMS)

Oral and Maxillofacial Surgery Unit, The Royal Melbourne Hospital, Melbourne, Australia

Summary The indications and operative technique of various procedures commonly used to provide or increase access to the central skull
base, anterior and middle cranial fossae, nasopharynx, infratemporal fossa and retromaxillary space are discussed with illustrative cases.
ª 2003 Published by Elsevier Science Ltd.

Keywords: transfacial access, osteotomy, skull base, infratemporal fossa, anterior cranial fossa, middle cranial fossa, retromaxillary space

INTRODUCTION nasopharyngeal polyp. Kocher described a midline lip and palatal

split to provide improved access to the pituitary fossa.2 In 1987,
Lesions involving the central and lateral skull base, infratemporal
Archer et al.3 used the approach to access distal vertebral and mid-
fossa and retromaxillary region are difficult to access. Tumours
basilar aneurysms and in 1991, James and Crockard4 added a
once considered inoperable by virtue of their site are accessible
midline sagittal split of both maxilla and soft palate to improve
using various techniques that have been developed over many
access to the cranio-vertebral junction.
years to allow access to these sites with minimal morbidity. In co-
Horizontal osteotomy and down-fracture of the maxilla offers
operation with the neurosurgeon, the oral and maxillofacial sur-
wide exposure to the postnasal space, central skull base, and upper
geon is able to select and provide appropriate access in these
clivus and is the procedure of choice for the removal of benign
cases. The purpose of this article is to review some of the more
lesions such as clival chordomas and nasopharyngeal tumours.
commonly used approaches and discuss their indications, opera-
When combined with a mid-palatal split, the improved access
tive details and limitations.
to the cranio-vertebral junction facilitates access to tumours that
extend above and below the foramen magnum, and enables sur-
Anatomy of the skull base gical decompression in cases of severe basilar invagination. The
A systematic approach to tumours of the base of the skull has development of bone miniplate systems has enabled surgeons to
previously been described1 in which the base of skull is divided rigidly replace the osteotomised segments, and pre-location of the
into right and left lateral and central compartments by the internal miniplates before the osteotomy is completed enables rapid fixa-
carotid arteries. The lateral compartments are further subdivided tion with restoration of the occlusion at the completion of the
into anterior, middle and posterior segments. The central com- procedure.
partment contains the anterior cranial fossa (cribriform plate,
planum sphenoidale, orbital roofs and greater wing of sphenoid),
clivus, body of sphenoid and upper cervical spine.
The anterior segment of the lateral compartment extends from
the anterior middle cranial fossa back to the anterior edge of the
petrous temporal bone and contains part of the greater wing of
the sphenoid and the inferior surface of the petrous temporal
bone (the infratemporal and retromaxillary areas) (Fig. 1). The
middle and posterior segments of the lateral compartment are not
accessible via transfacial approaches and will not be discussed in
this article.
Access to the central compartment is achieved via anterior
approaches whilst the anterior segment of the lateral compartment
is accessed from lateral or combined anterolateral approaches.

ANTERIOR APPROACHES
Le Fort I approach
Osteotomy of the maxilla at the Le Fort I level is not a new
concept and was first described by von Langenbeck over 140
years ago. Cheever subsequently used this procedure to remove a

Received 14 August 2002

Accepted 19 September 2002

Correspondence to: Mr. K.R. Spencer BHB MBChB MDSc FRACDS (OMS),
Oral and Maxillofacial Surgery Unit, The Royal Melbourne Hospital, 5th Floor,
766 Elizabeth Street, Melbourne 3000, Australia.
Tel.: +9347-3788; Fax: +9347-3058. Fig. 1 Compartments of the skull base.

340
 Selected midfacial access procedures to the skull base 341

Fig. 2 Anterior view of Le Fort I level osteotomy lines and mini-plate fixation.

Operative technique
Following either tracheostomy or more commonly, orotracheal
intubation, a local anaesthetic containing adrenalin is infiltrated
along the maxillary mucogingival reflection. A horizontal incision
is performed at this level and a mucoperiosteal flap is raised over
the anterior surface of the maxilla. Subperiosteal dissection is
developed medially to expose the piriform apertures, laterally
around the zygomatic buttress areas and superiorly to the level of
the infraorbital nerves. The nasal mucosa is then elevated from the
floor and lateral walls of the nose, and nasal septum. Using a
reciprocating saw or fissure bur, a horizontal osteotomy is per-
formed above the apices of the teeth. Before any further bone cuts
are made, four 2 mm titanium miniplates are adapted to the bony
surface to enable the occlusion to be restored at the end of the
procedure (Fig. 2). The lateral nasal wall and septum are divided
with guarded osteotomes, and the pterygoid plates are separated
by means of a curved osteotome. The maxilla can now be down-
fractured, exposing the nasal floor. An Archer or modified-
Dingman gag, which is inserted to retract the maxilla inferiorly,
provides approximately 8 cm of horizontal anterior exposure and Fig. 3 Diagram demonstrating arc of maxillary rotation.
5 cm posteriorly5 (Fig. 3).
For access to the lower clivus, and cranio-vertebral junction, a osteotomy reduces this risk. Occasional velo-pharyngeal incom-
midline palatal split through the hard and soft palate can be per- petence can occur, especially when extensive vertebral bone re-
formed (Fig. 4). The divided maxilla can be separated by a self- moval leaves a depression in the posterior pharyngeal wall. This risk
retaining retractor and maintains its blood supply from the greater can be diminished if a dermal fat graft is placed before closure.
palatine and ascending pharyngeal arteries, as well as smaller
unnamed pharyngeal vessels traversing the fauceal pillars.
Maxillo-nasal-cheek flap approach
At the end of the procedure, the maxilla is returned to its initial
position, stabilised with the previously adapted miniplates and the This technique was popularised by Curioni et al.8 and is useful in
wound is closed in layers with a continuous absorbable suture. providing access to tumours extending to involve the central skull
This approach has the advantage of being a commonly per- base from the soft palate, retromaxillary and postnasal spaces.8;9
formed, well-understood, predictable and safe procedure that pro- The maxillo-nasal-cheek flap has been used to remove a wide
vides wide anatomical exposure with minimal morbidity, and a variety of tumours including adenocarcinomas, malignant sch-
hidden intraoral incision. Alternative transfacial approaches offer wannomas, and adenoid cystic carcinomas, and provides excellent
limited exposure; have the potential to divide sensory or motor access for oncologic surgery in this region.10
nerves, or destroy the anterior facial skeleton. Reported complica- Variations of this procedure follow the same basic concept of
tions include CSF fistula and meningitis (intradural lesions), post- mobilising facial structures on a viable pedicle, and when in-
operative nasal haemorrhage,6 and ischaemic necrosis of the max- creased exposure is required, the nose can be included in the flap
illa.7 Oronasal fistulae can occur in those cases where the palate is (maxillo-nasal cheek flap), or the face can be opened like a book
split, but offsetting the mucosal incision with respect to the palatal (maxillo-nasal cheek flap and contralateral maxillo-cheek flap).

ª 2003 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2003) 10(3), 340–345
342 Spencer et al.

Fig. 4 Intra-operative photo following mid-palatal osteotomy (NF, nasal floor; RP, right palate; LP, left palate; NP, nasopharynx).

Operative technique
Following tracheostomy or orotracheal intubation, a standard
Weber–Ferguson skin incision is made, for a maxillo-cheek flap.
For a maxillo-nasal-cheek flap, the paranasal incision is made on
the contra-lateral side, extended across the nasal bridge and then
into the ipsilateral lower eyelid. As the blood supply to the skel-
etal segments is derived from the cheek flap, minimal periosteal
elevation is performed. A horizontal osteotomy is made along the
anterior surface of the maxilla inferior to the orbital rim, and
extended laterally through the body of the zygoma to the
pterygomaxillary fissure. The medial extent of this osteotomy
depends on the type of flap. With a maxillo-cheek flap the medial
extent of the osteotomy runs vertically and lateral to the piriform
aperture, then inferiorly between the ipsilateral central and lateral
incisors. With a maxillo-nasal-cheek flap the horizontal osteotomy
is extended across the nasal bridge anterior to the lacrimal fossa to
join a vertical osteotomy on the contra-lateral side (Fig. 5). To
allow for mobilisation, a palatal Osteotomy is performed back-
wards between the central and lateral incisors, and the pterygoid
plates are separated with a curved osteotome through a small
vestibular incision. The infraorbital nerve is divided, and after
miniplate pre-localisation, the osteotomised segment is mobilised Fig. 5 Diagram of left maxillo-cheek flap.
(Fig. 6). At the conclusion of the procedure the segment is re-
placed and fixed with the pre-contoured plates, and the wounds surgery for congenital anomalies, and the Ôlow fronto-orbital
closed. technique for sphenoethmoid tumoursÕ or transbasal approach
This versatile procedure is mainly used to access malignant described by Derome etal.12 , various skull base teams introduced
lesions in the postnasal and retromaxillary spaces as it provides more direct approaches.13;14 Raveh15 described the extended sub-
wider access than the Le Fort I approach and can be modified to cranial or transbasal approach for use in craniofacial trauma and
include sub-total maxillary resection. This approach allows access later adapted it to tumour resection.16 Spetzler further modified
to the buccal fat pad, which can be used for palatal reconstruction the approach to involve an osteotomy of the cribriform plate with
in selected cases.10 This procedure has increased morbidity a view to olfactory preservation in appropriate cases, and to fa-
compared with a Le Fort I maxillotomy, with facial scarring and cilitate reconstruction of the anterior fossa.17
infra-orbital anaesthesia. The extended transbasal approach involves the en-bloc mo-
bilisation of the supra-orbital rim, orbital roofs and nasoethmoidal
complex. This approach provides access to the sphenoethmoidal
Extended transbasal approach region, clivus and foramen magnum.

Over the past two decades many craniofacial techniques have

Operative technique
been described which improve exposure to the anterior cranial
fossa and central skull base. Based on the outlines described by A bicoronal flap is raised and developed further anteriorly so that
Tessier et al.11 of the fronto-orbital bandeau as used in craniofacial the subperiosteal dissection exposes the nasal bones, nasal process

Journal of Clinical Neuroscience (2003) 10(3), 340–345 ª 2003 Published by Elsevier Science Ltd.
 Selected midfacial access procedures to the skull base 343

Fig. 6 Intra-operative photo of reflected right maxillo-nasal-cheek flap.

of the maxilla and continues into the orbits to the level of the
anterior ethmoidal artery. The medial canthal ligaments and upper
lateral nasal cartilages are detached, and the nasolacrimal duct is
exposed and preserved. After bifrontal craniotomy and dural ex-
ploration and/or dissection have been performed, the fronto-nasal
complex is outlined and osteomised (Fig. 7). The anterior oste-
otomies run upwards from the piriform aperture, across the nasal
process of the maxilla to the medial orbital floor. Crossing the
medial orbital floor onto the medial orbital wall, they end at the
level of the anterior ethmoidal artery. The medial orbital walls and
roof are osteotomised, and if this technique is used to approach a
tumour that does not involve the cribriform plate, the design of the
orbital roof osteotomy is modified to include a circumferential
cribriform plate osteotomy to preserve the plate and olfactory
nerves.18 Following removal of the frontonasal unit, an osteotomy
Fig. 8 Anatomical dissection showing access on removal of fronto-nasal unit.
is performed posterior to the cribriform plate through the planum
sphenoidale. The cribriform plate, released from all bony con-
nections, can then be elevated attached to the frontal lobe dura
(Fig. 8). At the conclusion of the procedure fixation of the oste- ligaments are reattached. The cribriform region is usually repaired
otomised bones is accomplished with a combination of plates and/ with a pericranial flap.
or wires, and the upper lateral nasal cartilages and medial canthal Advantages of this procedure include a wide vertical exposure
of the anterior cranial fossa and central skull base with minimal
brain retraction, avoidance of facial incisions and preservation of
olfaction in some cases. Complications of this procedure include
CSF leakage, transient pituitary dysfunction, cranial nerve defi-
cits, and nasolacrimal duct injury.18

Fig. 7 Anatomical dissection showing osteotomy lines of extended
transbasal approach.
LATERAL APPROACH
Transzygomatic approach
Described by Obwegeser19 as an approach to the temporoman-
dibular joint, orbit and retromaxillary-infracranial region, this
approach has many applications. It can be used to access tumours
arising within the infratemporal fossa such as schwannomas, and
can provide access to the posterior extension of orbital, maxillary
and palatal tumours, as well as those tumours with perineural
spread along the trigeminal nerve. This approach can also access
tumours of the anterolateral skull base, and intracranial tumours
with inferior extension such as meningiomas as when combined

ª 2003 Published by Elsevier Science Ltd. Journal of Clinical Neuroscience (2003) 10(3), 340–345
344 Spencer et al.
with a pteryonal approach it provides excellent access to the
middle cranial fossa, allowing tumours above and below the skull
base to be simultaneously accessed. This versatile approach can
also be combined with an anterior approach if required.20
Operative technique
The planned surgical incision is marked and local anaesthetic
infiltrated. A full bicoronal scalp flap is raised from the most
caudal point of the tragus to the contralateral temporo-parietal
suture, approximately 2 cm posterior and parallel to the hairline.
No hair is shaven, and the incorporation of a wavy coronal inci-
sion helps to better camouflage the scar, especially when the hair
is wet.21
The incision is deepened to the subgaleal plane, superficial to
the pericranium over the top of the scalp and temporalis fascia
laterally. The flap is developed forwards in this plane to 3–4 cm
superior to the orbital rims where the pericranium is incised across
the forehead from one superior temporal line to the other. The
scalp flap is turned back from the root of the zygomatic arch to the
ipsilateral supraorbital rim. Near the ear, the flap is dissected in-
feriorly to the root of the zygomatic arch. Starting at the root of
the zygomatic arch, an incision running 45 upwards and forwards
is made through the superficial layer of temporalis fascia, joining
the cross-forehead incision previously made through the pericra-
nium. The periosteum of the zygoma is incised, and the layers
turned forwards as one flap. The upper branches of the facial
nerve lie superficial to the dissection on the undersurface of the
temporo-parietal fascia and are thus preserved.22
Depending on the requirements of the case, the body of the
zygoma or the arch alone is osteotimised and outfractured after
miniplate prelocalisation. Now the separated body or arch can be
swung downward, pedicled to the masseter muscle. The upper half
of the mandibular ramus, with the insertion of the temporalis
muscle, is now presented in the operative field (Fig. 9).
The temporalis muscle is carefully detached from its origin to
avoid damaging its blood supply from the anterior and posterior
deep temporal arteries which enter the muscle below the zygo-
matic arch and deep to the coronoid process. The temporalis is
Fig. 9 Diagram of zygoma reflected inferiorly and pedicled on origin of mas-
seter muscle.
Journal of Clinical Neuroscience (2003) 10(3), 340–345
swung inferiorly, or alternatively the coronoid process is cut off
from the ramus of the mandible and the temporalis and attached
coronoid swung superiorly. The site of the pathology dictates the
direction of displacement of the muscle. If the lesion is primarily
intracranial with extension into the infratemporal fossa, the tem-
poralis muscle is usually displaced inferiorly. Sub-cranial lesions
extending to the skull base require superior temporalis muscle
reflection. Access to the middle cranial fossa is achieved with a
fronto-temporal craniotomy.
If access to the retromaxillary and infratemporal regions is
required, the pterygoid muscles are divided and the maxillary
artery ligated and divided. The lateral aspect of the lateral pter-
ygoid plate should now be visible and if followed superiorly to its
junction with the base of the skull, will guide the surgeon to fo-
ramen ovale. At the completion of the procedure, the zygomatic
body or arch is replaced and secured with pre-contoured mini-
plates.
If the temporalis muscle has been devitalised it will need to be
excised. If it is viable it can be replaced, the coronoid process is
removed to minimise post-operative limitation of mouth opening.
This approach provides direct lateral access, preserving the
facial nerve and temporo-mandibular joint, whilst avoiding a
visible facial scar. The disadvantages of this approach are an in-
creasingly restricted medial exposure as the depth of the dissec-
tion increases, and the inability to follow the internal carotid
artery through the skull base. Should exposure of the internal
carotid artery be necessary, the post-auricular approach described
by Fisch and Pillsbury23 may be used.
DISCUSSION
The most important step in access surgery is the selection of the
most appropriate technique or combinations thereof. This depends
on the anatomical location as well as the nature of the pathology
in question, with each approach designed to provide short,
straight-line access, maximal exposure, and minimal morbidity.
The Le Fort 1 downfracture is generally reserved for access to
benign pathology in the nasopharynx and central skull base and is
the most cosmetic and least morbid of all the approaches de-
scribed. It however lacks the versatility of the maxillo-nasal-cheek
flap and gives poor access when dealing with malignant lesions. In
these cases, the maxillo-nasal-cheek flap, which can include
maxillary resection, is the approach of choice.
Access to lesions within the anterior cranial fossa, as well as
those extending into the superior, medial and posterior aspects of
the orbit is achieved via the extended transbasal approach. For
lesions in the middle cranial fossa, infratemporal fossa, retro-
maxillary space, and lateral orbit the lateral transzygomatic ap-
proach is the procedure of choice and can be combined with other
mid-facial approaches for extensive oncological resections.
ACKNOWLEDGEMENTS
The authors gratefully acknowledge contributions by Mr B.T.
Evans and members of the Departments of Neurosurgery and
Head and Neck Oncology at The Royal Melbourne and South-
ampton University Hospitals.
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