A new surgical approach to extensive tumors in the pterygomaxillary fossa and the skull base

Objective. The article describes a new surgical approach to extensive tumors in the pterygomaxillary fossa and the middle skull base. Methods. The first incision divides the upper lip in the midline, passes under the nasal pyramid, and extends laterally, reaching the level of the temporamandibular joint, at which point it exits to meet the vertical coronal/preauricular incision. An incision is then made along the maxillary buccogingival fold on the involved side, running from the midline to the retromolar area. Another incision is made along the mandibular buccogingival fold on the involved side, running from canine to retromolar area. The cheek flap is reflected inferiorly to the level of the angle of mandible after the elevation of the maxillary and mandibular periosteum and the messeteric fascia in a downward fashion. The frontotemporal scalp is reflected toward the midline after completion of the coronal and transtemporal incision and an appropriate undermining. The craniofacial skeleton is exposed from the midline. After osteotomies of the orbitomaxillary skeleton and a horizontal subperiosteal osteotomy at the angle of the mandible are completed, a frontotemporal craniotomy is performed, and the foramina spinosum, ovale, and rotundum, as well as the superior orbital fissure, are identified. The tumor is exposed in the surgical field; after the tumor is resected, the orbitomaxillary skeleton and the mandibular namus, removed during the approach phase, are replaced and affixed by miniplate. The external soft tissues, including the skin, are then reapproximated along the preoperative markings. Results. The surgical field obtained at the skull base extends from the contralateral eustachian tube to ipsilateral geniculate ganglion. It includes the nasopharynx, clivus, sphenoid, cavernous sinus, and the entire infratemporal fossa, as well as superior orbital fissure and the pterygopalatine fossa. This approach was used in 5 patients. All patients healed per primum. Conclusion. This technique is especially useful for excising tumors in the nasopharynx, clivus, superior orbital fissure-cavernous sinus, and infratemporal and pterygopalatine fossa.