Anterior Craniofacial Resection

Even though anecdotal examples of operative techniques anticipating the concept of anterior craniofacial resection were published in the 1940s (Dandy 1941) and 1950s (Malecki 1959), Ketcham et al. (1963) must be credited with the first results on a group of 19 patients with malignant tumors, most originating from the sinonasal tract, who had received anterior craniofacial resection. This surgical technique can be considered the major innovative procedure among the external approaches of the last four decades, since it has markedly contributed to improving the prognosis of malignant tumors encroaching the anterior skull base. The basic concept of the operation is to obtain additional exposure of the tumor from above and to ensure even superiorly a free margin of resection. This is usually achieved through a coronal incision and a frontal craniotomy, which, accoording to Raveh et al. (1993), is harvested as low as possible to obtain a good view on the anterior skull base without undue retraction of the frontal lobes (Fig. 5.21). A midfacial degloving, a lateral rhinotomy approach, or even in selected cases a transnasal microendoscopic approach (Thaler et al. 1999) is associated to perform the dissection of the inferior part of the surgical specimen.

Whenever the lesion is in close contact with the skull base, but there are no radiologic and intraoperative signs of bony involvement, the procedure can be carried out extradurally and the dissection superiorly includes the cribriform plate and the fovea ethmoida-lis. Those lesions eroding the skull base and possibly infiltrating the dura dictate instead a wide resection of the dura. The ablative part of the operation must be further extended to include a variable amount of brain parenchyma when the lesion is clearly in contact or even infiltrates the frontal lobe(s). Dura defects require multiple-layer duraplasty which can be performed with different autologous and/or homologous materials. An anteriorly-pedicled pericranium flap down-folded and fixed posteriorly to the planum sphe-noidale is commonly used to reinforce the duraplasty and to offer a nicely vascularized barrier, which divides the sinonasal tract from the cranium.

Anterior Craniofacial Resection
Fig. 5.21. a Access to the anterior cranial fossa through a coronal incision (red line, frontal craniotomy). b Posteriorly the resection reaches the planum sphenoidale

References

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Draf W (1991) Endonasal micro-endoscopic frontal sinus surgery, the Fulda concept. Op Tech Otolaryngol Head Neck Surg 2:234-240

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