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CC BY-NC-ND 4.0 · J Neurol Surg B Skull Base 2022; 83(S 03): e646-e647
DOI: 10.1055/s-0041-1727125
Skull Base: Operative Videos

Anatomical Basis of the Zygomatic-Transmandibular Approach: Operative Video

Gerardo Guinto
1   Department of Neurosurgery, Centro Medico ABC, Mexico DF, Mexico
2   Department of Neurosurgery, Hospital Angeles del Pedregal, Mexico DF, Mexico
,
Eli Hernandez
2   Department of Neurosurgery, Hospital Angeles del Pedregal, Mexico DF, Mexico
,
David Gallardo-Ceja
2   Department of Neurosurgery, Hospital Angeles del Pedregal, Mexico DF, Mexico
,
Francisco Gallegos-Hernandez
3   Department of Head and Neck Surgery, Centro Medico ABC, Mexico DF, Mexico
,
Norma Arechiga
4   Department of Neurology, Centro Medico ABC, Mexico DF, Mexico
,
Gerardo Guinto-Nishimura
5   Department of Neurosurgery, Instituto Nacional de Neurologia y Neurocirugia Manuel Velasco Suarez, Mexico DF, Mexico
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Abstract

Tumor growth in infratemporal fossa (ITF) and parapharyngeal space (PPS) is generally slow and generates very few clinical manifestations, so it is not uncommon for tumors to reach large dimensions at the time of diagnosis, making necessary to perform ample approaches. In zygomatic-transmandibular approach (ZTMA), the access of the ITF and PPS is obtained by a combination of a pterional craniotomy plus a zygomatic-mandibular osteotomy. Tumor excision is achieved by its initial dissection from all of the neurovascular structures of the middle fossa by the neurosurgical team and the final resection by the head and neck team from below. In the first part of this video, we present a brief anatomical–surgical description of the ITF and PPS and in the second part, we show case of a trigeminal schwannoma that could be successfully removed through a ZTMA. Using this approach, an ample and safe exposure of the ITF and PPS is achieved, without affecting the chewing or facial nerve function and with excellent cosmetic results, so it can be considered as a reliable surgical option, particularly in cases of giant tumors that affect these regions ([Figs. 1] and [2]).

The link to the video can be found at: https://youtu.be/oxVFhzT8HsQ.


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Keywords

infratemporal fossa - parapharyngeal space - skull base surgery - trigeminal schwannoma - zygomatic-transmandibular approach
Zoom Image
Fig. 1 Contrast enhanced preoperative magnetic resonance imaging T1-weighted (left column), in axial (above) and coronal (below) view, compared with the postoperative result (right column) in the same axial (above) and coronal (below) views.
Zoom Image
Fig. 2 Basic steps of the zygomatic-transmandibular approach. (A) Exposure of the lateral craniofacial region. (B) Pterional craniotomy plus zygomatic osteotomy (which may or may not include the orbital rim) and a subsigmoid vertical mandibular osteotomy. (C) The posterior half of the ascending ramus of the mandible is rotated as a hinge, so that the tumor is released from the middle cranial fossa and extracted from below.

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Conflict of Interest

None declared.

Address for correspondence

Gerardo Guinto, MD
Department of Neurosurgery, Hospital Angeles del Pedregal
Mexico DF 10700
Mexico   

Publication History

Received: 11 September 2020

Accepted: 09 January 2021

Article published online:
03 May 2021

© 2021. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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Zoom Image
Fig. 1 Contrast enhanced preoperative magnetic resonance imaging T1-weighted (left column), in axial (above) and coronal (below) view, compared with the postoperative result (right column) in the same axial (above) and coronal (below) views.
Zoom Image
Fig. 2 Basic steps of the zygomatic-transmandibular approach. (A) Exposure of the lateral craniofacial region. (B) Pterional craniotomy plus zygomatic osteotomy (which may or may not include the orbital rim) and a subsigmoid vertical mandibular osteotomy. (C) The posterior half of the ascending ramus of the mandible is rotated as a hinge, so that the tumor is released from the middle cranial fossa and extracted from below.