Original ArticleOrbitozygomatic Craniotomy with Modified Zabramski's Technique: A Technical Note and Anatomic and Clinical Findings
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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Cited by (6)
Three-Piece Orbitozygomatic Craniotomy: Anatomical and Clinical Findings
2019, World NeurosurgeryCitation Excerpt :As noted by Kodera et al.,6 the greater wing of the sphenoid bone is prominent, making the osteotomy from the inferior orbital fissure to the lateral edge of the superior orbital fissure difficult. As described previously,6,8 flattening the prominence located between the superior orbital fissure and inferior orbital fissure makes the osteotomy safe and simple to perform. The lateral wall of the orbit is extremely thin; therefore, careful drilling should be performed to avoid damaging the periorbita.
The orbitozygomatic approach. History, technique, and modifications
2019, Zhurnal Voprosy Nejrokhirurgii Imeni N.N. BurdenkoAnatomical Description and Variations of the Anterior Arterial Brain Circulation in Colombian Cadaveric Specimens
2021, International Journal of Morphology
Supplementary digital content available online.
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.