The Transzygomatic Transmandibular Approach: A Step-By-Step Cadaveric Study and Review of the Literature

Introduction: The trans-zygomatic trans-mandibular approach allows access to the infratemporal fossa and parapharyngeal space. It has been described with different adaptations based on the lesion’s extension and each surgeon’s technique. Relatively common, it has been described in conjunction with a frontotemporal craniotomy, allowing for dissection and control at the middle cranial fossa. With the inception of endoscopic skull base surgery, the indications for this approach are now limited; yet, with the ample range of maneuverability it offers, it should be considered for large lesions that cannot be handled within the restrictions of the endoscopic corridor.

Method: Using an embalmed human cadaveric specimen, a step-by-step dissection of the trans-zygomatic trans-mandibular approach was performed. Additionally, a systematic review was conducted using the search terms “Zygomatic transmandibular approach” AND “Infratemporal fossa” in PubMed, Google Scholar, and Cochrane. Articles published until 2024 were screened based on the following criteria: (1) contains a description of the surgical approach and (2) presents at least one clinical case with a description of the lesion’s extension and histology. From the included articles, surgical approach, combination of techniques, and postoperative morbidity variables were assessed.

Results: A step-by-step dissection of the zygomatic trans-mandibular approach was performed through the following sequence: mobilization of the parotid gland with exposure of the facial nerve trunk, zygomatic process downward retraction, mandibular osteotomy, pterional craniotomy, orbitotomy, and infratemporal fossa and middle fossa dissection. A total of 63 articles were encountered through the search. Of these, 16 articles were reviewed following the abstract screening. After full-text analysis, 5 articles met the inclusion criteria. Pathologies surgically managed through this procedure commonly included clivus chordoma, meningiomas, and trigeminal schwannomas. Postoperative morbidity was related to trigeminal and facial nerve dysfunction in addition to mastication complications.

Conclusion: The trans-zygomatic trans-mandibular approach allows resection of large lesions with parapharyngeal and infratemporal fossa extension, including clivus chordomas, cutaneous malignancies, parotid tumors, and juvenile angiofibromas. This approach offers a visual and operative trajectory that improves vascular control. In addition, it allows the management of dumbbell-like lesions that occupy both the middle cranial fossa and infratemporal fossa, as is the case of some trigeminal schwannomas.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
07 February 2025