Anterolateral Routes to the Skull Base—The Frontotemporal Approaches and Exposure of the Sellar and Parasellar Regions

• Published in: World neurosurgery 2023-04, Vol.172, p.131-145
• Main Authors: Bernardo, Antonio, Evins, Alexander I.
• Format: Article
• Language: English
• Subjects: Anterolateral; Cavernous sinus; Fronto-orbitozygomatic; Humans; Orbit - surgery; Osteotomy - methods; Pericavernous; Periclinoid; Skull base; Skull Base - surgery; Technique; Zygoma - surgery
• ISSN: 1878-8750; 1878-8769
• DOI: 10.1016/j.wneu.2022.11.055

Surgical approaches to the sellar and parasellar regions are highly challenging due to the densely packed nature of the traversing neurovasculature. The frontotemporal-orbitozygomatic approach offers a wide angle of exposure for the management of lesions involving the cavernous sinus, parasellar region, upper clivus, and adjacent neurovascular structures. It combines the pterional approach with different osteotomies that remove the superior and lateral walls of the orbit and zygomatic arch. Extradural exposure and preparation of the periclinoid region, whether as initial preparation for a combined intraextradural approach to deep-seated skull base targets or as the main avenue of surgical exposure, can substantially enlarge surgical corridors and minimize the need for brain retraction in this very confined microsurgical space. We provide a stepwise description of how we perform the fronto-orbitozygomatic approach and an associated series of surgical maneuvers and techniques that can be utilized in a variety of anterior and anterolateral approaches, either alone or in combination, to tailor exposure to a given lesion. These techniques are not limited to traditional skull base approaches and represent a valuable addition to every neurosurgeon's armamentarium as enhancements to common surgical approaches.