Elsevier

World Neurosurgery

Volume 97, January 2017, Pages 49-57
World Neurosurgery

Original Article
Orbitozygomatic Craniotomy with Modified Zabramski's Technique: A Technical Note and Anatomic and Clinical Findings

https://doi.org/10.1016/j.wneu.2016.09.085Get rights and content

Background

The surgical technique of orbitozygomatic craniotomy reported by Zabramski et al. is an excellent procedure, facilitating wide surgical exposure, easy orbital reconstruction, and a satisfactory postsurgical aesthetic outcome; however, it is anatomically complicated and technically difficult. We introduce a simplified technique of Zabramski's orbitozygomatic craniotomy and present the anatomic and clinical findings with cadaveric photos, illustrations, and a video.

Methods

The orbitozygomatic craniotomy was performed on 20 sides of 11 cadaveric heads, in which the cut between the inferior orbital fissure and superior orbital fissure was modified and simplified, and the shortest distance between them was measured. This technique was applied to 13 clinical cases, and craniotomy-associated aesthetic and functional complications were evaluated.

Results

The average of the shortest distance from the inferior orbital fissure to superior orbital fissure was 21.3 mm (range, 19–23 mm) on the 20 sides of the 11 cadaveric heads. In all 13 clinical cases, orbitozygomatic craniotomy could be achieved in a short time, while preserving the structure of the orbital wall. A hollow at the temple was noted in 1 patient, cerebrospinal fluid leak occurred in 2 patients, and transient facial pain occurred in 1 patient; however, no other craniotomy-associated aesthetic or functional complications, including enophthalmos, were found in any of the 13 patients.

Conclusions

With this modified technique, Zabramski's ideal orbitozygomatic craniotomy could be achieved easily with only minimal complications, while realizing all advantages of the technique.

Introduction

The orbitozygomatic approach was originally reported by Pellerin et al. in 19841 and Hakuba et al. in 1986.2 Pellerin et al.1 applied an “orbitofrontomalar approach” to 7 cases of frontotemporosphenoid meningioma, and Hakuba et al.2 applied an “orbitozygomatic infratemporal approach” in 26 patients with parasellar tumors or aneurysms around the basilar bifurcation. These authors could reach and expose such deep-seated lesions safely with a shorter distance and minimal brain retraction. Since then, an orbitozygomatic approach has been adopted in surgeries for inaccessible lesions, such as cavernous sinus tumors,3, 4 cerebral peduncle and mesial temporal lobe lesions,4 and orbital tumors5 with various modifications.

It is necessary to remove the orbital wall sufficiently to realize the benefits of orbitozygomatic craniotomy. Therefore, reconstruction of the orbital wall is also inevitable to avoid postoperative enophthalmos, disturbance of ocular movement, and other aesthetic or functional complications. The surgical technique of orbitozygomatic craniotomy introduced by Zabramski et al.6 is an excellent procedure that facilitates wide exposure, easy orbital reconstruction during surgery, and a satisfactory postsurgical aesthetic outcome; however, it is anatomically complicated and technically difficult. We performed Zabramski's orbitozygomatic craniotomy on cadavers and developed a modified technique to reduce the technical difficulty and time needed. The anatomic and clinical findings of the orbitozygomatic craniotomy with the modified Zabramski's technique are presented with cadaveric photos, illustrations, and a video.

Section snippets

Materials and Methods

Orbitozygomatic craniotomies were performed on 20 sides of 11 formalin-fixed cadaveric heads. The most difficult step was the final cut of the posterolateral wall of the orbit from the inferior orbital fissure (IOF) to the superior orbital fissure (SOF). We identified the tip of this osteotomy, which could shorten the length and time for cutting from the IOF to SOF, through cadaveric dissections and measured the shortest distance from the IOF to SOF on each side. This technique was applied to

Results

The average of the shortest distance from the lateral edge of the IOF to SOF was 21.3 mm (range, 19–23 mm) on 20 sides of the 11 cadaveric heads after sufficient resection of the bony prominence of the greater sphenoid wing with rongeurs and making it flat (Figure 4B). This orbitozygomatic craniotomy was applied to 13 clinical cases (Tables 1 and 2). The cases comprised 10 women and 3 men with an average age of 55.8 years (range, 26–78 years). The average follow-up period was 39.3 months

Discussion

The orbitozygomatic approach provides surgeons with a wide operative space and short distance and facilitates minimal brain retraction and avoiding brain contusion and other neurovascular complications to treat neoplastic or vascular lesions deeply located around the temporal base, parasellar region, premesencephalic region including basilar bifurcation, mesial temporal lobe, cavernous sinus, and orbital apex.1, 2, 3, 4, 5, 12, 13 Some anatomic studies demonstrated that an orbitozygomatic

Conclusions

We developed a modified technique of Zabramski's orbitozygomatic craniotomy through cadaveric dissections. In our modification, the final orbital cut between IOF and SOF, the most difficult step of Zabramski's osteotomy, was simplified, as follows: 1) the bone structure between IOF and SOF was flattered before the orbitotomy; 2) the final cut between IOF and SOF was single and linear with the shortest distance; and 3) the final cut was made only with a rongeur macroscopically. With this

Acknowledgment

The authors are grateful to Mr. Hiroyuki Nakade for his support in the cadaveric dissections, to Mr. Tatsuji Hishima and Mr. Takayoshi Asahi for their technical assistance in preparing the figures, and to Ms. Yuka Itakura and Ms. Saki Emori for their secretarial assistance.

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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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