The Orbitozygomatic Craniotomy and Its Judicious Use: Neurosurgical Atlas Series
The Orbitozygomatic Craniotomy and Its Judicious Use: Neurosurgical Atlas Series
T
Accepted, May 31, 2019.
Published Online, August 29, 2019. he orbitozygomatic craniotomy (OZ) orbital roof and rim as well as the frontal process
(Video) involves an expansion of the of the zygoma.
Copyright "
C 2019 by the
pterional approach through osteotomy of In the 1-piece osteotomy (Figure 1), the
Congress of Neurological Surgeons
various sections of the superior/lateral orbital frontotemporal craniotomy and supraorbital
rim/roof and zygoma. This additional bone osteotomy are completed in 1 bone flap. In
removal broadens the subfrontal trajectory and the 2-piece osteotomy, a traditional pterional
can minimize the need for brain retraction to craniotomy is first elevated, and then the
access the floor of the anterior and middle supraorbital osteotomy is performed. The
skull base and the parasellar and interpeduncular 1-piece frontotemporal craniotomy and supraor-
spaces.1-6 It also allows for an enhanced inferior- bital osteotomy (referred to as modified OZ) is
to-superior operative trajectory and working the least disruptive and most efficient alternative
angles with flexible maneuverability and multi- and provides most of the advantages of all the
directional degrees of operative freedom. Its other OZ variations; this approach, referred to
judicious and selective or discriminate use is simply as OZ, is the topic of discussion here
important for justifying the potential risk of (Model).
cosmetic deformity and additional operative time The patient provided written informed
associated with this skull base osteotomy. consent for the surgery shown in Video and
Multiple variations of the OZ involving Figures 6 and 9. Institutional review board/ethics
different amounts of bone work have been committee approval was neither sought nor
described7-42 and the discussion below is an required for the data presented here.
efficient technique. The most widely used and
practical modifications are the “1-piece” and
“2-piece” supraorbital osteotomies, which Indications for the Modified OZ
include limited resection of the zygoma. These Modifications of the OZ have been widely
modified variations involve mobilization of the used for both vascular and neoplastic lesions
within the orbital apex, paraclinoid and
parasellar regions, cavernous sinus, and the
interpeduncular and upper paraclival terri-
ABBREVIATIONS: CT, Computed tomography; 3D,
3-dimensional; OZ, orbitozygomatic craniotomy
tories.1-6 Paramedian cranial base masses with
tremendous superior extension can benefit from
FIGURE 1. Shown are fundamental osteotomy locations for the 1-piece modified OZ. The first osteotomy A cuts across the orbital rim. The second osteotomy B
disconnects the frontal process of the zygoma, and the last cut C is made across the roof of the orbit through an expanded keyhole. The “key” location of the keyhole for
exposing the orbit and frontal dura is important for planning subsequent osteotomies. These bony cuts lead to disarticulation of the orbital rim, zygoma, and orbital
roof. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
MODIFIED ORBITOZYGOMATIC
CRANIOTOMY/OSTEOTOMY
The steps for completing an OZ osteotomy are summarized
in Figures 5-15. The subfacial technique is applied for protection
of the facial nerve branches. The superficial temporalis fascia is
incised and reflected along with the fat pad.
Usually, 2 to 3 cm of dissection over the periorbita is suffi-
cient in expectation of the osteotomy along the orbital roof. If the
periorbita is disrupted, intraorbital fat that herniates through the
defect can be shrunken using bipolar electrocautery. Disruption
of the periorbita leads to more pronounced postoperative perior-
bital edema and bruising.
Once the supraorbital nerve is released, it can be easily reflected
inferiorly along with the pericranial flap and periorbita. The
small osteotomy around the nerve can also be used as the exit
point for the footplate of the craniotome at the time of the
craniotomy.
MODEL. A, (https://sketchfab.com/3d-models/orbitozygomatic-7c9363672e604 This retrograde muscle dissection may permit better preser-
c1a9c51bc84c2b1f244): The outline of osteotomies for the OZ are shown. B, vation of the subperiosteal layer containing the deep temporal
(https://sketchfab.com/3d-models/orbitozygomatic-craniotomy-03c574c2f33a4
arteries and nerves that nourish the muscle, which could minimize
efd864423e6df2cab3c?cursor=cD0yMDE4LTEwLTE2KzIwJTNBMTglM0Ew
NS4xMDExMTU%3D) The completed osteotomy lines are shown. C, (https://
postoperative atrophy. The muscle is then retracted inferiorly, not
sketchfab.com/3d-models/orbitozygomatic-craniotomy-extent-of-exposure-eecf227 anteriorly, to maximize its mobilization away from the subfrontal
153354b979dfd70a4e20e1bcc) The osteotomies and extent of exposure for the working zone.
OZ are shown in 3-dimensional (3D) space. The neural structures within the The closure is conducted using standard cranial plates; the
operative corridor are highlighted. The instructions for use of this model are as zygomatic arch is plated, and major defects in the bone in the
follows: please use the full-screen function for optimal visualization [by clicking areas anterior to the hairline are filled with cranioplasty material.
on the arrows on the right lower corner of the model]. To move the model in
In cases of intraosseous pathology and significant bone resection,
3D space, use your mouse’s left-click and drag; to enlarge or decrease the size
of the object, use the mouse’s wheel. The right-click and drag function moves titanium mesh can be used for minimizing the risk of cosmetic
the model across the plane. With permission from The Neurosurgical Atlas by deformity. The roof of the orbit is not routinely constructed; we
Aaron Cohen-Gadol. have not observed any incidence of enophthalmos with such a
strategy.
FIGURE 5. The plane between the galea and the pericranium is developed in case a vascularized pericranial flap is needed
at the time of closure. The scalp flap is reflected anteriorly and separated from the temporalis fascia. The belly of the no.
10 scalpel blade can be used to separate the pericranium from the galea. A, The fat pad is exposed. B, The plane between
the galea and the pericranium is developed anteriorly until the subgaleal fat pad containing the frontotemporal (frontalis)
branches of the facial nerve becomes visible. These branches are located in the superficial fascia of the fat pad, not within
the fat pad itself. Therefore, one of two techniques for reflecting the fat pad without injuring these branches can be used:
(1) the interfascial technique, in which the superficial temporal fascia is reflected anteriorly along with the fat pad via
dissection underneath the fat pad but superficial to the deep temporal fascia; or (2) the subfascial technique, in which the
superficial temporal fascia is reflected anteriorly along with the fat pad and the deep temporal fascia, all as one layer (this
is my preferred method because it offers maximal protection for the facial nerve branches). This fat pad is usually located
2.5 to 3 cm posterior to the frontal process of the zygoma and the orbital rim. Bovie electrocautery is used to cut the deep
temporal fascia and reflect the fat pad in the subfascial manner (see Video). With permission from The Neurosurgical Atlas
by Aaron Cohen-Gadol.
FIGURE 6. Subfascial technique. A, The 2 layers of the temporal fascia encasing the fat pad are incised to the level of the muscle fibers and parallel
FIGURE 7. A, The superiosteal or subpericranial dissection is carried around the orbital rim and underneath the anterior
roof of the orbit. Beyond the rim, the periosteum of the zygomatic and frontal bones blends into the periorbita. Blunt
dissection is used to free the periorbita from the orbital rim lateral to the supraorbital notch. The periorbita is often
adherent at the frontozygomatic suture. This attachment is dissected first, and then a blunt dissector is used to sweep over
the periorbita from the inferior orbital fissure toward the supraorbital notch until the subperiosteal plane is well defined.
B, The supraorbital nerve is often embedded within its notch but can be mobilized out of its groove with gentle blunt
dissection. However, the nerve rarely owns its own foramen. If such a foramen is present, a straight small-caliber side-
cutting drill bit is used to cut a halo of the orbital rim around the supraorbital nerve to allow for anterior mobilization of
the nerve with its foramen without injury to the nerve (inset). With permission from The Neurosurgical Atlas by Aaron
Cohen-Gadol.
FIGURE 9. A, It is imperative to place the keyhole at the appropriate location and drill at the correct angle to expose both the periorbital and
frontal dura through the expanded burr hole. Accurate creation of the keyhole facilitates execution of the 1-piece orbitozygomatic craniotomy and
prevents excessive bone loss in the keyhole region and resultant cosmetic deformity. The keyhole is made approximately 7 mm superior and 5 mm
posterior to the frontozygomatic suture (yellow arrow).6 The shaft of the drill is held at a 45-degree angle measured from the plane of the temporal
bone. B, The supraposterior half of this burr hole exposes the dura of the anterior fossa, and the anteroinferior part exposes the periorbita (inset).
C, The roof of the orbit divides these 2 compartments within the keyhole. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
FIGURE 11. The footplate attachment is also used to create the inferior portion of the craniotomy. A, Starting at the
temporal burr hole, the craniotome is directed inferiorly and then anteriorly until the progress of the footplate is stopped by
the sphenoid wing. At this point, the drill is “turned around on itself ” (steps 1 and 2) to expand the last few millimeters
of the bony cut, creating enough space so that the footplate can be removed from the epidural space (step 3). B, Next, the
footplate is replaced with a straight side-cutting B1 drill bit and the first orbital osteotomy is performed. This cut involves
connecting the orbital portion of the keyhole to the previous exit point of the craniotome via an osteotomy along the lateral
wall of the orbit and sphenoid wing. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
FIGURE 13. A, A thin small osteotome is used to perform the final osteotomy along the orbital roof from the medial-to-
lateral direction, starting at the osteotomy that was used to release the supraorbital nerve. The bone of the orbital roof can
be very thin, and excessive force while using the mallet should be avoided. B, An alternative and preferred method for
completing the orbital roof osteotomy involves the use of a small thin osteotome to cut across the roof of the orbit through
the keyhole. Two cotton patties can be used to protect the frontal dura posteriorly and the periorbita inferiorly from the
osteotome. It is important that the osteotome is angled toward the exit point of the supraorbital nerve. With permission
from The Neurosurgical Atlas by Aaron Cohen-Gadol.
FIGURE 15. Once the cranio-orbital bone flap is elevated, additional bone from the anterolateral aspect of the orbital
roof is removed, and the lesser sphenoid wing is reduced further; a straight side-cutting B1 drill bit is used for this purpose.
The orbital contents are protected. This small piece of orbital roof might not need to be replaced during closure A and B.
Additional bony removal along the subfrontal corridor can be tailored on the basis of the location of the target lesion. An
extradural clinoidectomy might be necessary for lesions around the proximal internal carotid artery along the skull base.
The clinoidectomy provides an early decompression of the optic nerve at its foramen before the adjacent compressive tumor
is manipulated. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
Disclosures 22. Honeybul S, Neil-Dwyer G, Lees PD, Evans BT, Lang DA. The orbitozygomatic
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The author has no personal, financial, or institutional interest in any of the
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aneurysms. Neurosurgery. 2005;56(1 suppl):172-177.
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