This document discusses various surgical approaches and osteotomies for accessing lesions in the skull base and deep neck spaces. It begins with an introduction and history of access osteotomy. It then discusses the indications, classifications, advantages/disadvantages of different approaches like Lefort I/II osteotomies, zygomatic osteotomies, and transpalatal approaches. Specific approaches like fronto-orbitozygomatic and transnaso-orbitomaxillary are also summarized. The goal of these osteotomies is to provide direct surgical access while minimizing trauma.

1. Access Osteotomy
Presented by Dr Rayan
Moderator Dr Archana

2. Contents
• Introduction
• History
• Indications
• Surgical approaches
• Classification
• Advantages and disadvantages
• Access to cranial base (ant, middle, c-spine)
• Access to infra temporal region
• Access to naso pharynx
• Access to base of tongue and oropharynx
• Access to Parapharyngeal spaces
• Rhinotomy approaches
• Post op care
• Complications
• Summary

3. Introduction
• A plethora of various pathologies occur in the skull base and deep spaces
of the neck.
• The surgical resection of these hidden lesions often pose a great surgical
challenge owing to the anatomical complexity, difficulty in accessibility and
proximity of vital structures.
• A multidisciplinary approach is often required in these situations
• Various approaches have been devised for their better exposure to provide
surgical access by transmaxillary, transzygomatic and transmandibular
approaches

4. The choice and type of access osteotomy to these hidden lesions of the
cranial base like Infratemporal fossa/ Sphenopalatine fossa and /or deep
spaces of neck is most often based on :
• The anatomic extent of the lesion,
• Vascularity of the lesion and
• Involvement of neurovascular structures in and around it.

5. History
• Access osteotomy was first introduced in 1836 by Roux to improve access in floor of
mouth and base of tongue of tongue surgeries.
• It was repeated in 1959 by Head and neck oncology group of Sloan- Kettering Cancer
Hospital.
• 1859 - Von Langenbeck performed a horizontal osteotomy in the maxilla, later described
as Le Fort I level for the removal of a benign nasopharyngeal polyp
• In 1981, Spiro et al proposed the translabial access with mandibulotomy.
• In 1984, Attia et al described translabial access with mandibular osteotomy anterior to
mental foramen.
• Tessier described the techniques of transposition and relocation of middle third of
facial skeleton for cranio facial synostosis.
• Curioni, Clauser and Janecka introduced the concept of craniofacial dismantling and
reassembly in the management of skull base tumors.

6. • Barbosa (1961) mobilized the zygomatic complex and sectioning the
mandibular ramus to gain access to the infratemporal fossa.
• Crockett (1963) advocated a similar approach but limited his mandibular
resection to the coronoid process.
• Dingman and Conley (1970) suggested a lip-splitting incision after
sectioning the mandible and rotating or removing it from the surgical field.
• Atten (1980) described a approach where only the arch of the zygoma and
the coronoid process were removed.
• Obwegeser (1985), mobilized the entire zygomatic complex and sectioning
the ramus horizontally in order that the superior ramal segment may be
mobilized.

7. Indications
It is mainly indicated in areas with benign or malignant lesions of
• Posterior floor of mouth
• Base of tongue
• Paranasal sinus
• Nasopharynx
• Oropharynx
• Parapharyngeal space
• Infratemporal space
• Skull base
• Cervical spine

10. • Lefort 1 with or without mid palatal split – clivus and upper cervical region for
angiofibromas, clivus tumors and the tumors of the nasopharynx, nasal septum
and nasal cavity.
• Zygomatico temporal osteotomy - infratemporal fossa and multiple regions of
skull base.
• Zygomatic arch osteotomy can be combined with vertical ramus osteotomy of
mandible with median or paramedian mandibulotomy - the inferior extent of the
lesion in the infratemporal space.
• Zygomatic arch osteotomy in combination with fronto temporal craniotomy -
intracranial tumors with middle cranial fossa.
• Transfacial lateral rotation technique - the retro maxillary area.

11. Surgical Approaches
Lateral Rhinotomy Incision
Weber-Fergusson Incision

12. Lynch Incision
Midfacial Degloving incision
Bi coronal Incision
Hemi coronal Incision

13. Classification of facial translocation approach to
the skull base
• Mini facial translocation-central is
designed to reach the medial orbit,
sphenoid and ethmoid sinus, and
the inferior clivus.
• Mini facial translocation-lateral -
opens the infratemporal fossa.
Classification of facial translocation approach to the skull base IVO P.JANECKA, MD, FACS,
[OTOLARYNGOL HEAD NECK SURG 1995;I 12:579-85.

14. • Standard facial translocation
achieves surgical access to the
anterolateral skull base.
• Extended facial translocation—
medial incorporates the standard
translocation unit plus the nose
and the medial one half of the
opposite face

15. • Extended facial translocation-medial and
inferior
• Extended facial translocation posterior –
incorporates the ear temporal bone and
posterior fossa into surgical access
• Bilateral facial translocation – combines
the right & left translocation units.
• Palatal split permits to reach C2 and
C3, if mandible is split, C4

16. A Classification Scheme to Midline Skull Base
Lesions
• A variety of transfacial surgical approaches to midline skull base lesions
can be organized in a simple classification scheme of six techniques or
levels.
• Three intracranial approaches use a subfrontal trajectory and variable
amounts of transfacial exposure through the nasal and orbital bones.
• supraorbial bar (level 1),
• supraorbitonasal bar (level II), and
• orbitonasal bar (level III)
Micheal Lawton et al. The transfacial approaches to midline skull base lesions: A classification scheme.
Operative Techniques in Neurosurgery Volume 2, Issue 4, December 1999, Pages 201–217

17. • Three extracranial approaches use a more inferior trajectory and
variable amounts of transfacial exposure through the maxilla.
• The transnasomaxillary approach (level IV) requires a Le Fort II
osteotomy with splitting of the maxillary fragment.
• The transmaxillary approach (level V) requires a Le Fort l osteotomy
with splitting of the palate.
• The transpalatal approach (level VI) requires circumferential osteotomy
and removal of the hard palate

18. A Classification Scheme to Midline Skull Base
Lesions
Level I: Transfrontal Approach
Indications - The transfrontal approach is used to access tumors of the anterior
cranial fossa and those that extend into the superior orbital region

19. • Bi coronal approach.
• Scalp is raised a separate flap
and pericranium separate.
• Bi frontal craniotomy is
performed.
• Supra-orbital bar is created
• Osteotomy cuts are made irt
infero lateral frontal bone
then forward above the FZ &
continued into the roof of the
orbit.
• Bi lateral cuts are connected
irt nasion above fronto nasal
suture.

20. Level II: Transfrontonasal Approach
• Removal of the nasal complex provides wide access to the nasopharynx, the
ethmoid and sphenoid sinuses, and the clivus.
• A level II exposure also is useful for exposing tumors that extend into the
superior, medial, and posterior aspects of the orbit.

21. • A bifrontal craniotomy and dural
dissection are performed
• The cuts across the lateral orbital walls
and roofs are the same for the level I
• The nasal cuts are made across the
nasal process of the maxilla, anterior
and medial to the nasolacrimal ducts.
• Then posteriorly along the medial
orbital wall.
• This cut is approximately 1 cm in front
of the optic canal.
• This medial orbital cut intersects with
the orbital roof osteotomies.
•
• An osteotomy across the frontal crest
anterior to the crista galli then releases
the supraorbitonasal bar

22. Level III: Transfrontonaso-Orbital Approach
• Large anterior cranial fossa lesions, nasopharyngeal lesions, and clival
lesions with anterior extension can be accessed through a level III exposure.
• This approach is similar to the level II approach but is augmented by
including the lateral orbital wall on the frontonasal fragment

23. • Dissection is identical to that used in
the level II approach.
• osteotomy crosses the lateral orbit
above the level of the superior margin
of the zygomatic arch, extending to the
inferior orbital fissure in the region of
the inferolateral orbital floor.
• level III frontonaso-orbital bar includes
the lateral orbital wall from the level of
the infraorbital fissure.
• The globes can then be retracted
laterally with ease to widen the
horizontal exposure.
• Most of the superior orbital roof also is
also included in the fragment to
facilitate the lateral retraction of the
globes.
• The cuts in the nasal bones are identical
to those described with the level II
approach.

24. Cribriform Plate Preservation
• When performing a level II or III approach to a tumor that does not involve
the cribriform plate, the integrity of the cribriform plate and olfactory
nerves can be preserved.
• A circumferential cribriform plate osteotomy completely frees this portion
of the anterior cranial floor and enables its upward mobilization.
• permits greater posterior exposure beyond the cribriform plate onto the
planum sphenoidale.
• Reduces the risk of CSF leak, and preserves olfaction.

25. • Under direct vision, an osteotomy
is performed posterior to the
cribriform plate through the
planum sphenoidale.
• Typically, ' this osteomy is made
with two cuts, one from each
side.
• The final cut is through the
perpendicular plate of the
ethmoid bone and nasal mucosa.
• Care is taken to preserve a
generous cuff of nasal mucosa
attached inferiorly to the
cribriform plate

26. Level IV: Transnasomaxillary Approach
• Indications - Wide exposure of the entire central skull base region can be achieved,
which is produced with a Le Fort II osteotomy.
• Used for large nasopharyngeal and clival lesions, particularly those that extend
anteriorly, posteriorly, inferiorly, superiorly.
• Additional exposure is achieved by down-fracturing, bipartitioning, and winging out
the maxillary bone, but a price must be paid with a facial incision

27. • Modified Weber-Ferguson incision
is extended across the radix and
along the subciliary margin on the
lower lid on the opposite side. A
bilateral buccal sulcus incision is
also made.
• The piriform aperture and nasal
floor are exposed and stripped of
their mucosa. The orbital floors,
infraorbital nerves, and
nasolacrimal ducts are dissected.
• Le fort II osteotomy cuts are made.
• The nasal fragment is divided at the
nasal process of the maxilla on one
side, and the hard and soft palates
are divided at the midline, yielding
two fragments

28. Level V: Transmaxillary Approach
• Indicationa - Small clival lesions with superior, posterior, and
inferior extensions and small-to-moderate nasopharyngeal lesions
can be accessed.
• This is accomplished through a Le Fort I osteotomy with or without
a palatal split.
• The exposure of the level V approach is less than that of the level IV
but has a better cosmetic result.

29. • Vestibular incision.
• Standard le fort I cuts are made.
• In case of children the cuts need
to be made higher up to avoid
developing tooth buds.
• In case more exposure is needed
palate can be split.
• After tumor resection, reassembly
is performed with prepared
interdental splints and
preregistered fixation plates

30. Level VI: Transpalatal Approach
• Indications - The transpalatal approach exposes the lower clival and upper
cervical region for resection of small tumors by removing the hard palate and
splitting the soft palate.
• The approach is essentially an extended transoral approach, with additional
superior exposure gained by palatal resection.
• Level VI approach is the least invasive of the six levels, requiring minimal
facial disassembly and no facial incision.

31. • The palate is approached through the nasal floor and oral mucosa. An upper buccal sulcus
incision is made, and the nasal floor is exposed extramucosally.
• incision is made through the palatal mucosa and through the soft palate to one side of the
uvula
• saw is used to cut around the margin of the palate against the alveolar edge just medial to the
greater palatine foramen and greater palatine arteries
• The septum is separated from the nasal groove along the nasal floor.
• Cuts are also made in the lateral nasal wall into the antra with osteotomes.
• The bony palate is lifted out and the soft tissue portions are retracted.
• The vomer and perpendicular plate of the ethmoid are removed with a rongeur for further
exposure

32. The ideal surgical approach should:
• Provide increased and more direct exposure of the pathology and
the adjacent neuro vasculature with:
– a short straight line between the surgeon and the pathology
– a wide arc of exposure in three dimensions.
• Be extensile, i.e. capable of being extended perioperatively.
• Minimize brain retraction where exposure of the intracranial
contents is required.
• Have minimal morbidity functionally or cosmetically.
• Result in minimal increase in overall operating time.
• Avoid facial skin incisions.

33. Advantages
1.Presenting optimal lines of "separation" of facial units for a surgical
approach, permitting the least traumatic displacement.
2.The primary blood supply to the "facial units" is through the external carotid
system, which also has a lateral-to-medial direction of flow, thus ensuring
viability of displaced surgical units.
3.The midface contains multiple "hollow" anatomic spaces facilitate the
relative ease of surgical access to the central skull base.
Classification of facial translocation approach to the skull base IVO P.JANECKA, MD, FACS, [OTOLARYNGOL
HEAD NECK SURG 1995;I 12:579-85.

34. 4. Displacement of facial units for an approach to the cranial base offers much greater
tolerance to postoperative surgical swelling, as opposed to similar displacement of
the content of the neurocranium.
5. Reestablishment of the normal anatomy, after repositioning of the facial units
during the reconstructive phase of surgery, provides a high degree of functional and
esthetic achievement.

35. Disadvantages
1. Contamination of the surgical wound with oropharyngeal bacterial flora.
2. The need for facial incisions with subsequent scar development.
3.Emotional considerations for the patient related to "surgical
facial disassembly."
4. The potential need for supplementary airway management (postoperative
endotracheal intubation,temporary tracheostomy).

36. Skull base approachanteriorlyand laterally
• Anterior skull base approaches include: Fronto- naso – orbital osteotomy,
Trans nasal, orbitozygomatic osteotomy, naso frontal osteotomy.
• These osteotomies are done to have a straight line access to remove
intracranial lesions.
• S.M. Raza et al reported that Frontal–nasal– orbital craniotomy provides
access to the floor of the anterior and middle cranial fossa while avoiding
excessive brain retraction and oedema.
• A lower incidence of postoperative complications, such as Cerebrospinal
Fluid leak and infection.

37. Fronto- orbitozygomaticosteotomy
• The orbitozygomatic approach provides wide,
multidirectional access to the anterior and middle
cranial fossae, as well as to the upper third of the
posterior fossa and clivus
• Incision – hemicoronal or pre auricular.
• The first cut is made across the root of the
zygomatic process obliquely.
• Second and third cuts divide the zygomatic bone
just above the level of the malar eminence.
• The fourth cut divides the superior orbital rim and
roof.

38. • The next two cuts free
the lateral orbital wall by
connecting the inferior
and superior orbital
fissures
• The sixth and final cut
extends from the lateral
margin of the superior
orbital fissure to join the
fifth cut from the inferior
orbital fissure
• Modification:
• Osteotomy including
maxilla

39. The trans naso-orbitomaxillaryapproach to
the anteriorand middle skull base
• He describes the trans naso-orbito-maxillary
approach for the management of extensive
anterior skull base tumours
• A modified Weber-Ferguson incision is used.
The lip splitting and lateral nasal component of
the incision are placed opposite the side to
which the nose is to be transposed .
• Osteotomy cuts are made so that the piriform
aperture margins are included as a rigid base for
the transposed nose, which also widens the area
of exposure for the transnasal exploration.
Salins P C The trans naso-orbitomaxillary approach to the anterior and middle
skull base Int. ,L Oral Maxillofac. Surg. 1998; 27:53 57

40. • The lateral nasal osteotomy cuts are made at right
angles to the bone surface
• Further osteotomy cuts, to permit the
mobilization of the anterior wall of the maxillary
sinus and part of the inferior orbital rim
• A Le Fort I level horizontal cut, which
communicates with both the lateral nasal and
zygoma
• The orbital floor osteotomy is joined medially to the
lateral nasal osteotomy
• The entire segment is mobilized, pedicled on the
cheek and hinged on the zygomatic bone.
• Modification: associated with lefort 1 /
mandibulotomy

41. Middle cranial base approaches
• Include Le Fort I maxillary downfracture osteotomy, sometimes combined
with median or paramedian mandibulotomy and Fronto-Naso-Orbital
osteotomy.
• When compared with other popular approaches, Lefort I osteotomy
provides excellent exposure for angiofibromas, clivus tumors, and the
tumors of the nasopharynx, nasal septum, and nasalcavity.
• In 1988 Belmont et al performed a midsagittal osteotomy and divided the
segment in two halves so as to obtain better access to the pituitary gland in
middle cranial fossa.

42. LeFort I osteotomy approach
Contraindications
1. Anticipation of large dural defect post resection
2. Dural involvement
3. Neoplasm at the level of the osteotomy
4. Anterior ethmoidal or high nasal vault disease
5. Unerupted permanent dentition
Anatomic boundaries/surgical exposure
• Superior extent: sella turcica, cribiform plate.
• Inferior extent: C1 (possibly C2).
• Lateral extent: pterygoid and temporalis muscle.
• Posterior extent: Clivus, posterior wall of sphenoid
sinus, greater wing of sphenoid bone

44. Modification in lefort1
Le Fort Maxillary Swing Procedure for Posterior Maxilla Tumor Extirpation Deepak
Kademani, DMD, MD*J Oral Maxillofac Surg 65:1055-1058, 2007
Le Fort Maxillary Swing Procedure
• Intra oral vestibular incision.
• Le Fort I level osteotomy was performed
• Nasal crest of the maxilla was separated from
the vomer and perpendicular plate of the
palatine bone.
• Laterally, the lateral nasal walls were
osteotomized.
• Left pterygomaxillary dysjunction was
performed; this allowed the maxilla to be
gently mobilized.
• As the maxilla was brought inferiorly, the
tumor mass was visualized in the right
maxillary sinus

45. • tumor was freed from the orbital floor and
lateral nasal wall
• superior and lateral surface of the maxilla, an
osteotomy was performed isolating the tumor
mass.
• The left portion of the maxilla was then
lateralized
• Entire tumour was resected in toto.
• The remaining maxilla was then repositioned
using the miniplates & fixed.
• split thickness skin graft was harvested and
used for intraoral reconstruction with a
bolster dressing and prefabricated surgical
stent.

46. Maxillary removal and reinsertion
• Favorable surgical technique for the
treatment of anterior cranial base
(ACB) tumors in adults and even in
children.
• Intra oral vestibular approach.
• Improves operative morbidity by
preserving both function and form of
the maxillary region and gives
excellent exposure to ACB.
Maxillary removal and reinsertion: A favorableapproach for
extensive anterior cranial base tumorsOtolaryngology–Head and
Neck Surgery (2010) 142, 322-326

47. • Modification: two piece lefort 1
• The Le Fort I osteotomy as a maxillotomy,
with midline split of the hard and soft palate,
can be used safely in certain clinical
situations for lesions of the nasal cavity,
nasopharynx, upper anterior cervical spine
and base of skull, for which direct
visualization is required
Sidney B. Eisig, Joseph Feghali, Craig Hall, James T. Goodrich, The 2-Piece Le Fort I Osteotomy
for Cranial Base Access, J Oral Maxillofac Surg 58:482-486, 2000

48. • After an extended facial de-gloving to
allow exposure of the midface, titanium
craniofacial plates are planned and
shaped before making the bone cuts.
. After completion of the osteotomies, the
corresponding maxillary bone is removed
and after wide exposure to the ACB is
obtained, the tumour can be removed

49. Approachesto infra temporalregion-
• Zygomatic arch osteotomy:
• Pre auricular or hemi coronal incision
• It include zygomatic arch osteotomy
with inferior orbital rim extensions,
pedicled or non pedicled and inverted L
Zygomatic bone osteotomy with or
without involvement of lateral orbital
rim.
Devireddy SK, Kishore K, Gali RS, Kanubaddy SR, Dasari MR, Akheel M. Access osteotomies
of maxillofacial region: A report of three cases. Arch Int Surg 2013;3:193-7.

50. • The osteotomised zygomatic arch with
the masseter muscle was reflected
inferiorly. In these cases, zygomatic
arch osteotomy is pedicled inferiorly
on masseter & was swung laterally &
inferiorly.
This permitted stripping temporalis
muscle from temporal bone &
swinging it latero-inferiorly thus
exposing infratemporal fossa & the
lesion

51. • Zygomatic arch osteotomy can be combined with vertical ramus
osteotomy of mandible with median or paramedian mandibulotomy
for better exposure of the inferior extent of the lesion in the
infratemporal space.
• Modification: along with coronoidectomy

52. Mandibulotomy Approach tothe
InfratemporalFossa
• Hidden lesions located at
parapharyngeal, lateral pharyngeal
spaces and deep spaces of neck,
posterior oral floor and
retromaxillary region can be
accessed by mandibular
osteotomies. They include median
or vertical
mandibular
or paramedian step
mandibulotomy with
swing approach.

53. Types of lipsplitting
Oral Maxillofac Surg 59:1292-1296, 2001 *

54. • A standard paramedian mandibulotomy
is performed through a lower lip–
splitting midline incision on the lower
lip, chin, and the submental and
submandibular regions. A short cheek
flap is elevated, remaining anterior to the
mental foramen.
• An angled mandibular osteotomy is
placed between the lateral incisor and
the canine teeth. The mylohyoid muscle
is divided to allow lateral retraction of
the mandible

56. MandibulotomyApproach for a Tumor of the Lateral
Aspectof the InfratemporalFossa
• Benign and malignant tumors of the infratemporal
fossa located posterolateral to the maxillary antrum
but medial to the ascending ramus of the mandible
are best approached via a mandibulotomy approach.
• As the mandible is swung laterally, further wider
exposure is obtained by division of the lateral
pterygoid muscle inferior to the greater wing of the
sphenoid bone, exposing the lower end of the tumor.
S. Nabil, A. J. Nazimi, R. Nordin, F. Hariri, M. R. Mohamad Yunus, A. B. Zulkiflee Mandibulotomy:
an analysis of its morbidities Int. J. Oral Maxillofac. Surg. 2018; 47: 1511–1518

57. Approach for the nasopharynx
• Surgical access to the nasopharyngeal
and retromaxillary region is dictated by the
size and location of the tumor
• Small, centrally located tumors can be
approached through the palate. Larger and
lateral lesions may require a medial
maxillectomy or maxillary swing approach

58. Transpalatal approach

59. Medial MaxillectomyApproach
• A modified Weber-Ferguson incision
with a Lynch extension
• Care is taken, however, to prevent
injury to the infra-orbital nerve
• generous anterior wall antrotomy is
made
• The opening in the anterior wall is
extended up to the nasal process of
the maxilla

60. Accessto oropharynxand base of tongue:
• Median Labiomandibular Glossotomy
(Trotter’s Operation):
• Tumors located in the midline of the
oropharynx and the craniocervical
junction can be approached optimally
with a mandibulotomy and median
glossotomy.
Scott, N., Sudderick, R., & Bater, M. The Trotter procedure: a forgotten approach? Journal
of Surgical Case Reports, 2014(1), rjt134–rjt134.

61. • Splitting the tongue in the midline
through a relatively avascular plane
permits preservation of the lateral
neurovascular bundles to both halves
of the tongue and leaves the patient
with very little functional deficit.
• Modification: mandibulotomy with
paralingual extension and mandibular
swing

62. Access to para-pharyngealspaces
• The styloid process, the stylomandibular ligament and the mandible
impede access to parapharengeal region.
• Division of the mandible was first proposed by Ariel et al.
• The most important maneuvers and osteotomies that have been proposed
to improve surgical access to the parapharyngeal space

63. Double mandibular osteotomy with coronoidectomy for tumours in the parapharyngeal spaceN.
Lazaridis, ∗ K. Antoniades † British Journal of Oral and Maxillofacial Surgery (2003) 41, 142–146

65. Stylomandibulartenotomy
Stylomandibular tenotomy in the transcervical removal oflarge benign parapharyngeal tumoursBritish Journal of Oral
and Maxillofacial Surgery (2002) 40, 313–316
• Tumours present in the parapharengeal spaces
• An extra oral transcervical incision was placed.
• The angle of the mandible and the
stylomandibular ligament were identified
• The stylomandibular ligament was then divided
close to the mandible.
• The mandible was retracted forwards using
bicortical transmandibular stainless steel wire
• Extracapsular dissection of the tumour was done
• Stylomandibular ligament was not repaired
• Layered closure done

66. Attia’sAnterolateralapproach
• The Anterolateral approach for better exposure parapharyngeal space,
infratemporal space and pterygomaxillary space
• The approach described here results in a wide-field exposure of both the
pterygomaxillary and parapharyngeal spaces with no sacrifice of either
mandibular function or the sensory supply of the face or oral cavity.
• The parapharyngeal space is entered through a transcervical incision
Attia, E. L., Bentley, K. C., Head, T., & Mulder, D. (1984). A new external approach to the
pterygomaxillary fossa and parapharyngeal space. Head & Neck Surgery, 6(4), 884–891.

67. • Incision - A curvilinear incision was
developed from the mastoid process to the
midline of the neck, extended anteriorly to
end in a lip split.
• Layered dissection to identify the carotid
system and ECA was liagated
• Intra oral incisions placed irt to buccal
aspect and lingual aspect and reflection
done to expose the entire body and ramus
of mandible.
• mandibular osteotomies are arranged to
spare the inferior dental nerve and vessels.
• Anterior osteotomy cut is made between
lateral incisor and canine
• After detaching muscles and ligaments
from the body and ramus and medializing
sub mandibular gland

68. • The osteotomized mandible was then
reflected superiorly to provide access
to the lateral pharyngeal region.
• After removing the tumor the
mandible was returned to its original
position.
• Fixation was done and IMF done

69. Modified attia approach for enormous pleomorphic adenoma of para-pharyngeal space with
all-embracing chondroid calcification Bansal V (2015- Volume 1(5): 141-145)

70. Rhinotomy
The lateral rhinotomy incision provides excellent exposure of
• Nasal cavity,
• Lateral nasal wall,
• Nasal septum,
• Nasal roof,
• Maxillary sinus,
• Pterygopalatine fossa,
• Pterygoid plates,
• Ethmoid sinuses,
• Medial and inferior orbital walls,
• Sphenoid sinus,
• Nasopharynx,
• Clivus,
• Medial aspect of the infratemporal fossa
Mann, W. J. (1985). Total rhinotomy for midline lesions of the ethmoids and the nose.
Journal of Maxillofacial Surgery, 13, 273–276.

71. • Superiorly the incision begins 5cm
beneath the medial aspect of the
eyebrow.
• continous over the nasal bone with a z-
plasty along the nasomaxillary groove
beneath the ala and the columella to be
continued symmetrically on the
opposite side.
• The incision is carried directly to bone
and into the vestibule with complete
release of the columella
• Low lateral osteotomies are completed
and transverse osteotomies are placed 3
mm. superior to the medial canthal
ligament, fracturing the bony nasal
pyramid.

72. • Leaving the mucosa attached, the
septum is dissected from the nasal spine
with subsequent detachment of the
perpendicular plate.
• The middle turbinates are then detached.
• Superiorly, the bone of the anterior
cranial base may be removed using
roungers
• The entire unit can be rotated superiorly
• After careful haemostasis, a light
packing is introduced into the nasal
cavity and the entire nose is rotated back
into its original position.
• Skin closure is done in two layers.

73. Wolf J. Mann, Total Rhinotomy for Midline Lesions of the Ethmoids and the Nose; J. max.-fac. Surg. 13 (1985) 273-276

74. Rhinotomy is limited to the nasal cavity, paranasal sinuses, nasopharynx,
and limited pterygopalatine fossa.
Contraindication
Small localized tumors centered in the nasal cavity, which can be easily
resected through the transnasal endoscopic technique or transpalatal
approach.
Massive lesions which are beyond the scope of this operation.
DENNIS LIM, JUVENILE ANGIOFIBROMA: TRANSMAXILLARY APPROACH VIA LATERAL RHINOTOMY; OPERATIVE
TECHNIQUES IN OTOLARYNGOLOGY--HEAD AND NECK SURGERY, VOL 10, NO 2 (JUN), 1999: PP 101-106

75. Postoperativecare
• Neuromonitoring – intensive care for first few days of surgery
• Airway
• For patients who have experienced disruption of the nasolacrimal
drainage system, appropriate eye care is necessary.
• When the nasolacrimal duct is resected, an indwelling nasolacrimal
stent is placed at the time of surgery to retain a natural draining passage
for tears and to reestablish epithelialization of a neonasolacrimal duct
tract

76. • Wound Care: extensive humidification of the air is necessary to reduce
dryness, crusting, and bleeding in case of surgery involved in nasal and
para nasal sinuses.
• Pulmonary care for prevention of pneumonia and routine prophylaxis for
deep vein thrombosis are used while the patient is still confined to bed and
early ambulation is not feasible.
• Once the patient is able to sit up, gradual progressive ambulation is
encouraged, with the goal of having the patient fully ambulatory by the
fifth to seventh postoperative day.

77. • When the surgical intervention involves the masticator space or TMJ, the
development of trismus is a risk.
• Initially trismus develops because of a spasm of the muscles of mastication
resulting from postoperative pain and discomfort, and later, trismus occurs
as a result of fibrosis around the TMJ and the masticator group of muscles.
• Therefore exercises of the jaw are initiated in the early postoperative
period, and the patient is instructed to self execute jaw exercises during the
recovery phase. Mechanical devices for prevention and/or improvement of
trismus are available and should be used when indicated.

78. Complication
• Complications related to the branches of internal carotid artery can be of
sudden onset and are most serious. They include vasospasm, thrombosis,
and hemorrhage.
• Alterations in cerebrospinal fluid dynamics may lead to postoperative
leakage of cerebrospinal fluid, pseudomeningocele, and hydrocephalus.
Acute hydrocephalus that develops postoperatively is usually obstructive
because of mass effect (edema, hemorrhage). In contrast, delayed
hydrocephalus is typically communicating and related to poor absorption of
the cerebrospinal fluid or scarring of the basal cisterns.

79. • The substantial risk of injury to the cranial nerves, facial nerve weakness
• tongue dysfunction
• TMJ dysfunction
• Mal alignment of dentition
• Malunion
• Scaring , lower eye lid retraction
• epiphora
• Infection , oral contamination
• Problems with swallowing and loss of sensation in the palate
• Need for tracheostomy to maintain airway post operatively

80. Summary
• Many craniofacial techniques have been in use to improve access to the skull
base, infra temporal , para/ lateral pharyngeal region
• varying degrees of mobilisation have been described in literatures however, the
primary objectives are similar.
• Improved access to the pathology should be achieved with minimal brain
retraction.
• The procedure should facilitate protection of the brain and adjacent
neurovascular structure
• The surgery of access should have minimal morbidity and introduce minimal
additional operating time.
• Patient specific osteotomy approach need to be carried out based on the site,
size, type of tumour, adjacent anatomical structure, anticipated complication

81. References
• 1.Head and neck oncology Jatin P Shah
• 2. Operative oral and maxillofacial surgery- Langdon patel
• 3.. The transfacial approaches to midline skull base lesions: A classification
scheme. Operative Techniques in Neurosurgery Volume 2, Issue 4,
December 1999, Pages 201–217
• 4. The Le Fort I osteotomy as a surgical approach for removal of tumours
of the Midface Hermann F. Sailer, Piet E. Haers, Klaus W. Grfitz Journal of
Cranio-MaxillofaciaI Surgery (1999) 27, 1~
• 5. Oral Maxillofac Surg 59:1292-1296, 2001 Functional and Aesthetic
Results of Various Lip-Splitting Incisions: A Clinical Analysis of 60 Cases
Alexander D. Rapidis, MD, DDS, Dr Dent, Oral Maxillofac Surg 59:1292-
1296, 2001 *
• 6. CRANIOFACIAL OSTEOTOMIES FOR HIDDEN HEAD & NECKLESIONS
• Mohammad Akheel, Suryapratap Singh Tomar2 Craniofacial osteotomies
for hidden head & neck lesions, Journal of Head & Neck physicians and
surgeons, 2013;1(1):1-3
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82. • 7. Classification of facial translocation approach to the skull base IVO P.
JANECKA, MD, FACS, Pittsburgh, Pennsylvania OTOLARYNGOL HEAD NECK
SURG 1995;I 12:579-85.
• 8. Journal of Cranio-Maxillofacial Surgetlv (1997) 25, 285-293 Craniofacial
access to the anterior and middle cranial fossae and skull base G. Lello 1, R
Statham 2, J. Steers 2, M. McGurk 3 . Journal of Cranio-Maxillofacial
Surgetlv (1997) 25, 285-293
• 9. G. K. B. Sandor, D. A. Charles, V. G. Lawson, C. H. Tator: Trans oral
approach to the nasopharynx and clivus using the Le Fort I osteotomy with
midpalatal split. Int. J. Oral MaxiIlofac. Surg. 1990; 19:352 355.
• 10. A new external approach to the pterygomaxillary fossa and
parapharyngeal space. Attia EL, Bentley KC, Head T, Mulder D. Head Neck
Surg. 1984 Mar-Apr;6(4):884-91.
• 11. Maxillary-fronto-temporal approach for removal of recurrent
malignant infratemporal fossa tumors: Anatomical and clinical study Yuxing
Guo, Chuanbin Guo* Journal of Cranio-Maxillo-Facial Surgery 42 (2014)
206e212
• 12. Double mandibular osteotomy with coronoidectomy for tumours in the
parapharyngeal space N. Lazaridis, ∗ K. AntoniadesBritish Journal of Oral
and Maxillofacial Surgery (2003) 41, 142–146

83. Thankyou…