- Email: [email protected]
The use of the facial translocation technique in the management of tumors of the paranasal sinuses and skull base
The use of the facial translocation technique in the management of tumors of the paranasal sinuses and skull base SHENG-PO HAO,
MD,
WHEI-LIN PAN,
DDS,
CHEN-NEN CHANG,
OBJECTIVE: We sought to assess the efficacy of facial translocation in the management of tumors of the skull base and paranasal sinuses. STUDY DESIGN AND SETTING: From July 1993 to December 1999, 75 patients, aged 3 to 102 years old, underwent facial translocation. Thirty-three (44%) patients also underwent a combined neurosurgical procedure. Nineteen (25%) had previous surgery. These patients were followed up to 6 years. RESULTS: There were 21 benign and 54 malignant tumors. There were no perioperative deaths. The morbidity rate was 31%. Of the 54 patients with malignant tumors, the actuarial 3-year survival rate was 59%, whereas the local control rate was 54%. CONCLUSION: The facial translocation technique offers favorable exposure of the critical zones of the anterior and middle cranial base, thus facilitating extensive resection and reconstruction. SIGNIFICANCE: This study demonstrates that facial translocation is one of the best surgical approaches to the skull base. (Otolaryngol Head Neck Surg 2003;128:571-5.)
T he basic principles of skull base surgery have been established as the following: wide exposure, protection of vital structures, oncologically complete resection, restoration of critical barriers, and functional and aesthetic reconstruction.1 A multidirectional approach is preferred, not only for exposure but also for oncologically complete resection and protection of vital structures. Facial translocation, a concept that originated from facial From the Departments of Otolaryngology, Dentistry, Neurosurgery, and Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University, China. Presented at the 5th International Conference on Head and Neck Cancer, San Francisco, CA, July 29 through August 2, 2000. Reprint requests: Sheng-Po Hao, MD, 14F, No. 16, Alley 4, Lane 137, Sec 5, Ming-Sheng E Rd, Taipei, Taiwan, China; e-mail, [email protected]. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/mhn.2003.121
MD,
and YUNG-SHIN HSU,
MD
compartment disassembly, is a valuable approach to the skull base.1,2 It provides the most direct approach to the central skull base and offers generous exposure to facilitate extensive tumor resection with preservation and restoration of critical structures. The facial translocation approach combined with elective craniofacial osteotomies and, optionally, with neurosurgical subfrontal or subtemporal approaches can offer the exposure of almost the entire anterior and middle cranial base.1,2 In addition to tumors of the skull base, this technique has been found useful in the management of tumors of the paranasal sinuses and orbit. The same concept has also been applied in the mandibular swing approach to tumors of the oropharyngeal and parapharyngeal spaces. Here, we report our results of the facial translocation approach for tumors of the paranasal sinuses and skull base. MATERIALS AND METHODS From July 1993 to December 1999, 75 consecutive patients with tumors of the paranasal sinuses and skull base underwent surgical resection via the facial translocation approach. Fifty-five patients were male, and 20 patients were female (age rang, 3 to 102 years; follow-up in clinic, up to 6 years). Thirty-three patients (44%), 28 with malignancies and 5 with benign tumors, also underwent a combined neurosurgical approach. Thirty-two patients (43%) had postoperative radiation therapy. Nineteen patients (25%) had had previous surgery elsewhere with primary recurrence and then underwent surgery in our hospital. Twenty-three patients (31%) had previous radiation therapy and had persistent or recurrent tumor and then underwent surgical resection. These tumors arose from various anatomic regions such as the orbit, paranasal sinuses, and skull base. We defined the origin of the tumors as best we could on the basis of preoperative radiologic images and intraoperative 571
572 HAO et al
findings. The origins of the tumors were nasopharynx (n ⫽ 28), nasal cavity (n ⫽ 12), cribriform plate area (n ⫽ 11), infratemporal fossa (n ⫽ 10), maxillary sinus (n ⫽ 5), ethmoid sinus (n ⫽ 4), sphenoid sinus (n ⫽ 2), frontal sinus (n ⫽ 1), clivus (n ⫽ 1), and orbit (n ⫽ 1). It was common to have tumors involving several different anatomic areas. Sixteen patients, 14 with malignant and 2 with benign tumors, had transcranial invasion. In 6 patients, part of the facial skeleton was involved by tumor and had to be removed with an additional 1-cm bone margin. The remaining facial skeleton was reimplanted, and the resulting defect was reconstructed with either the inner table of the frontal bone or free rib graft. Surgical Technique The basic surgical principles of facial translocation approach have been described elsewhere.2 However, over the years we have made some modifications to minimize surgical morbidity. Our modified procedures are described as follows. Facial Incision. A lateral rhinotomy incision joins a subciliary incision 1 cm lateral to the lateral fornix. The skin flap is elevated above the orbicularis oculi muscle to its lower margin, and then the muscle is elevated to skeletonize the orbital rim. It is crucial to preserve the branch of the facial nerve that supplies the orbicularis oculi muscle. The infraorbital neurovascular bundle is transected. The cheek flap then can be elevated and reflected inferiorly to expose the facial bones. Alternatively, the cheek flap may be left attached to the underlying facial bones, and an infratemporal tunnel is created along the lateral surface of the maxilla. By doing so, a vascularized facial bone compartment can be created based on the soft tissue of the premaxilla. Facial Osteotomy. Most commonly, a nasoorbito-maxillary osteotomy is performed. The zygoma may be included in the translocated facial bone graft if exposure of the infratemporal fossa is necessary. The nasolacrimal apparatus can be skeletonized and preserved only by removing the orbital floor and lacrimal bone. The lower end of the nasolacrimal duct which usually needs to be transected is marsupialized. The lateral nasal wall, if not involved by tumor, can be preserved and at the end of the procedure, it can be transposed as a
Otolaryngology– Head and Neck Surgery April 2003
useful flap to cover the undersurface of the facial bone graft. Preauricular Infratemporal Approach3 (Optional). Approach to the temporal, infratem-
poral, or subtemporal areas can be accomplished by a hemicoronal incision down to the pretragus area. The frontal branch of the facial nerve is preserved by creating a plane beneath the temporal fascia and its fat pad. After skeletonization of the zygoma, an appropriate osteotomy of the zygoma is made and the temporalis muscle is detached from its temporal insertion and retracted down to expose the temporal bone and infratemporal fossa. Further lateral exposure of the infratemporal fossa can be achieved by cutting away the coronoid process of the mandible. A low temporal craniotomy is created to expose the subtemporal space, and the middle cranial base bone is rongeured away up to the foramen ovale. Further exposure of the petrous internal carotid artery, eustachian tube, and middle meningeal artery is optional. Exposure of the Paranasal Sinuses, Nasopharynx, Clivus, and Cribriform Plate Area.
By removing the medial wall and posterior wall of the maxillary sinus, the pterygopalatine fossa and nasopharynx can be exposed. By removing the lateral wall of the maxillary sinus, the medial infratemporal fossa is exposed and may meet the infratemporal fossa approach. Approach to the cribriform plate, orbital roof, and planum sphenoidale can be optionally provided by a neurosurgical subfrontal approach. Exposure. This facial translocation approach offers generous exposure of the entire anterior and middle cranial base from the contralateral fossa of Rosenmu¨ ller in the nasopharynx to the ipsilateral temporomandibular joint. Reconstruction. Temporalis muscle pedicled from deep temporal arteries can be transposed to cover the exposed subtemporal dura or to obliterate the paranasal sinuses. Galeopericranial flaps are used most of time in reconstruction of the anterior cranial base. In rare situations, a free flap is needed for reconstruction of the skull base. The translocated facial skeleton is then replaced and fixed with microplates in a 3-point fixation. The translocated bone is replaced only when the inner periosteum remains free of cancer. The inner table of the split frontal bone or a free rib graft is used
Otolaryngology– Head and Neck Surgery Volume 128 Number 4
HAO et al 573
Table 1. Pathology Malignant
Benign
Tumor type
No.
Nasopharyngeal carcinoma Squamous cell carcinoma Olfactory neuroblastoma Mucoepidermoid carcinoma Osteogenic sarcoma Malignant fibrous histiocytoma Malignant melanoma Adenocystic carcinoma Chordoma Chondrosarcoma Malignant mixed tumor Acinic cell tumor Undifferentiated carcinoma Adenocarcinoma Total
17 9 8 4 3 3 2 2 1 1 1 1 1 1 54
to reconstruct the facial skeleton if it is involved by tumor and has to be removed. RESULTS There were 21 benign and 54 malignant tumors. There were no surgical deaths, and the perioperative morbidity rate was 30.7%; this included necrosis of the bone graft (n ⫽ 12), epiphora (n ⫽ 4), postoperative bleeding (n ⫽ 4), cerebrospinal fluid leak (n ⫽ 2), meningitis (n ⫽ 1), and blindness (n ⫽ 1). Some patients had crust formation in the sinonasal cavity and required frequent self-cleansing. This situation was worse in the patients who underwent further postoperative radiotherapy. The pathology spectrum was very wide (Table 1). The most common malignant tumors in our series were nasopharyngeal carcinoma (NPC) (n ⫽ 17), squamous cell carcinoma (n ⫽ 9), and olfactory neuroblastoma (n ⫽ 8). The most common benign tumors were inverted papilloma (n ⫽ 9), nasopharyngeal angiofibroma (n ⫽ 4), and aggressive polyposis (n ⫽ 3). Of the 54 malignant tumors, the local control rate was 54% and the actuarial 3-year survival rate was 59%. Of the 17 cases with primary recurrence of NPC, the local control rate was 78% and the actuarial 3-year survival rate was 71% with a median follow-up time of 19 months. Of the 21 patients with benign tumors, only 1 patient with a neurofibroma in the infratemporal fossa had recurrent disease 3 months after initial operation, and the other 18
Tumor type
Inverted papilloma Angiofibroma Aggressive polyposis Neurofibroma Mucopyocele Cyst Total
No.
9 4 3 2 2 1 21
patients remained free of disease while 2 patients died of other causes. Five of 21 patients with benign tumors required a combined craniofacial approach. The surgical morbidity in the group of benign tumors was low; only 1 patient had partial necrosis of the bone graft, which required sequestrectomy. In the 6 patients who had involvement of the facial bone by cancer, the facial skeleton had to be removed, and there was no evidence of recurrence in the remaining replaced facial bone. No patient in this series showed local recurrence in the translocated bone. DISCUSSION Over the years, the management of tumors of the skull base has remained a formidable challenge for head and neck surgeons. However, with the marked advancement in imaging and especially the development of magnetic resonance imaging, the local anatomy and patterns of spread of skull base tumors are better understood and we are more confident in approaching these tumors. There are various important surgical approaches to the skull base, such as infratemporal fossa approach,4 maxillary swing,5 subtotal maxillotomy approach,6 Le Fort I osteotomy approach,7 and facial translocation approach.1,2 All of these are sound surgical approaches, but facial translocation approach or facial bone disassembly approach has been appraised as the best surgical approach to the
574 HAO et al
middle central skull base.6 The basic principle of facial translocation approach is to temporarily remove the facial bone unit and to reimplant and fix it after the tumor is resected.2 Specifically, in facial translocation approach, the facial osteotomy can be electively carried out according to the anatomic location of the tumor.8 The facial translocation approach may also be combined with a subfrontal approach for anterior cranial base tumors or combined with a subtemporal approach for tumors of the middle cranial base and infratemporal fossa. We found the facial translocation invaluable for tumors involving the nasopharyngeal or paranasopharyngeal spaces. The usual tumor arising from the nasopharyngeal space is NPC, a common cancer in southern parts of China, Hong Kong, and Taiwan. Originating from the fossa of Rosenmu¨ ller, NPC is notorious for submucosal spread and commonly extends out of the nasopharyngeal space to the parapharyngeal space via a natural anatomic pathway in which the eustachian tube and tensor veli palatini muscle are located. Superior extension of the tumor to the skull base by directly destroying the base of the pterygoid plate is also common, and from here, NPC can invade the cavernous sinus superiorly and the foramen ovale laterally. Other tumors, such as those arising from minor salivary glands, may not be as aggressive as NPC; however, they may also follow the pattern of natural extension of NPC. It is crucial to realize that we seldom deal with a tumor solely occupying the nasopharyngeal space. Unexpected extension to the peritubal or parapharyngeal space is common, and the surgical approach should be modified according to the preoperative magnetic resonance imaging findings and the intraoperative findings. The facial translocation approach, with elective osteotomies, can flexibly fulfill the above requirements.8 To its full extent, a unilateral facial translocation approach can offer exposure from the contralateral Rosenmu¨ ller fossa to the ipsilateral glenoid fossa. Combined with a subfrontal approach, anterior cranial base extensions of NPCs can be resected. When combined with a subtemporal approach, lateral extension of NPCs to the sphenoid ridge and foramen ovale area can be resected.
Otolaryngology– Head and Neck Surgery April 2003
In our department, the facial translocation approach was the surgical approach of choice for recurrent NPCs. The indications for nasopharyngectomy included not only nasopharyngeal mucosa disease but also parapharyngeal space invasion or transcranial invasion. In our series, of the 17 patients with local recurrent NPC who underwent nasopharyngectomy via the facial translocation approach, the local control rate was 78% and the actuarial 3-year survival rate was 71%. Another concern about the facial translocation approach is the propriety of the reimplanted facial skeleton when tumor had involved the facial bones. Currently, we would not consider replanting the facial bones that were definitely involved with cancer; however, the periosteum is a good barrier against cancer and the facial bone can be replaced as long as the periosteum is free of cancer by frozen section diagnosis. If the facial bone is focally involved by cancer, the involved bone should be removed with an additional 1-cm bone margin while the remaining facial skeleton is replaced. The resulting defect can then be reconstructed with a bone graft either from the inner table of the frontal bone or from the rib. In our series, no recurrence in the translocated bone was ever detected. In our previous article, we described the harmful effect of radiotherapy on the transplanted facial bone graft.9 We now apply only the free facial bone graft technique to those in whom no previous or further radiotherapy would be administered. In patients who will have postoperative radiotherapy, a vascularized facial bone graft technique, as described previously,9 is to be used. In our series, the major complication of the facial translocation approach was necrosis of the facial bone graft, which was most commonly caused by failure of the bone graft to be revascularized by the free facial bone graft technique. Over the years, several technical modifications of the facial translocation approach to further avoid bone graft necrosis have been designed in our department. First, 3-point fixation is crucial to secure and immobilize the facial bone graft otherwise the microtrauma would interfere with bone union.9 Second, the facial bone unit is secured to the facial soft tissue by suturing the cheek soft tissue flap to the drilling holes of the facial bone
Otolaryngology– Head and Neck Surgery Volume 128 Number 4
unit. Third, the lateral nasal wall can be preserved and transposed to resurface the inner aspect of the translocated facial bone unit if it is far away from the tumor and remains free of disease. In our series, the patients were also required to follow a self-cleansing program of the paranasal sinus area with warm saline daily. These measures can effectively decrease the rate of bone graft necrosis. If there was exposed subtemporal dura, a temporalis muscle flap was transposed to cover the dura and to obliterate the paranasal sinus cavity. This maneuver is crucial to prevent postoperative ascending infections. However, because the transposed temporalis muscle flap might hinder the early detection of local recurrence, it is important to have a postoperative imaging study as a baseline for comparison because later recurrence is possible. The facial translocation approach can also be a valuable approach to paranasal and orbital tumors. In the conventional lateral rhinotomy approach, part of the maxilla bone is removed and the resulting bone defect is not reconstructed, thus resulting in a notable paranasal depression while the skin incision heals perfectly. By replacing the bone to its original place, the facial translation approach avoids this problem. In addition, the facial translocation may provide a much more generous exposure of all the paranasal sinuses and infratemporal fossa than traditional lateral rhinotomy can offer. This is especially valuable when dealing with an easily recurrent tumor such as inverted papilloma of the paranasal sinuses or nasopharyngeal angiofibromas with infratemporal fossa extension. For other tumors that have multiple sinuses involved, the excellent exposure of-
HAO et al 575
fered by the facial translocation approach would further facilitate radical excision. In conclusion, the facial translocation approach provides the most direct approach to the central skull base; provides the possibility of intracranial excision by combining a neurosurgical approach, thus generating greater exposure; facilitates oncologically sound radical excision; and maintains an acceptable morbidity and cosmetic result. Facial translocation is truly a most valuable approach to the paranasal sinuses, nasopharynx, clivus, and infratemporal fossa. REFERENCES
1. Nuss DW, Janecka IP, Sekhar LN, et al. Craniofacial disassembly in the management of skull base tumors. Otolaryngol Clin North Am 1991;24:1465-97. 2. Janecka IP, Sen CN, Sekhar LN, et al. Facial translocation: a new approach to the cranial base. Otolaryngol Head Neck Surg 1990;103:413-9. 3. Sekhar L, Schramm V, Jones N. Subtemporal preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 1987;67:488-99. 4. Fisch U. Infratemporal fossa approach to tumors of the temporal bone and base of skull. J Laryngol Otol 1978; 92:949-67. 5. Wei WI, Lam KH, Sham JST. New approach to the nasopharynx, the maxillary swing approach. Head Neck 1991;13:200-7. 6. Catalano PJ, Biller HF. Extended osteoplastic maxillotomy, a versatile new procedure for wide access to the central skull base and infratemporal fossa. Arch Otolaryngol Head Neck Surg 1993;119:394-401. 7. Williams WG, Lo LJ, Chen YR. The Le Fort I-palatal split approach for skull base tumors: efficacy, complications, and outcome. Plast Reconstr Surg 1998;102:2310-9. 8. Janecka IP. Classification of facial translocation approach to the skull base. Otolaryngol Head Neck Surg 1995;112: 579-85. 9. Hao SP. Facial translocation approach to skull base–the viability of translocated facial bone graft. Otolaryngol Head Neck Surg 2001;124:292-6.
MD,
WHEI-LIN PAN,
DDS,
CHEN-NEN CHANG,
OBJECTIVE: We sought to assess the efficacy of facial translocation in the management of tumors of the skull base and paranasal sinuses. STUDY DESIGN AND SETTING: From July 1993 to December 1999, 75 patients, aged 3 to 102 years old, underwent facial translocation. Thirty-three (44%) patients also underwent a combined neurosurgical procedure. Nineteen (25%) had previous surgery. These patients were followed up to 6 years. RESULTS: There were 21 benign and 54 malignant tumors. There were no perioperative deaths. The morbidity rate was 31%. Of the 54 patients with malignant tumors, the actuarial 3-year survival rate was 59%, whereas the local control rate was 54%. CONCLUSION: The facial translocation technique offers favorable exposure of the critical zones of the anterior and middle cranial base, thus facilitating extensive resection and reconstruction. SIGNIFICANCE: This study demonstrates that facial translocation is one of the best surgical approaches to the skull base. (Otolaryngol Head Neck Surg 2003;128:571-5.)
T he basic principles of skull base surgery have been established as the following: wide exposure, protection of vital structures, oncologically complete resection, restoration of critical barriers, and functional and aesthetic reconstruction.1 A multidirectional approach is preferred, not only for exposure but also for oncologically complete resection and protection of vital structures. Facial translocation, a concept that originated from facial From the Departments of Otolaryngology, Dentistry, Neurosurgery, and Neurosurgery, Chang Gung Memorial Hospital and Chang Gung University, China. Presented at the 5th International Conference on Head and Neck Cancer, San Francisco, CA, July 29 through August 2, 2000. Reprint requests: Sheng-Po Hao, MD, 14F, No. 16, Alley 4, Lane 137, Sec 5, Ming-Sheng E Rd, Taipei, Taiwan, China; e-mail, [email protected]. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/mhn.2003.121
MD,
and YUNG-SHIN HSU,
MD
compartment disassembly, is a valuable approach to the skull base.1,2 It provides the most direct approach to the central skull base and offers generous exposure to facilitate extensive tumor resection with preservation and restoration of critical structures. The facial translocation approach combined with elective craniofacial osteotomies and, optionally, with neurosurgical subfrontal or subtemporal approaches can offer the exposure of almost the entire anterior and middle cranial base.1,2 In addition to tumors of the skull base, this technique has been found useful in the management of tumors of the paranasal sinuses and orbit. The same concept has also been applied in the mandibular swing approach to tumors of the oropharyngeal and parapharyngeal spaces. Here, we report our results of the facial translocation approach for tumors of the paranasal sinuses and skull base. MATERIALS AND METHODS From July 1993 to December 1999, 75 consecutive patients with tumors of the paranasal sinuses and skull base underwent surgical resection via the facial translocation approach. Fifty-five patients were male, and 20 patients were female (age rang, 3 to 102 years; follow-up in clinic, up to 6 years). Thirty-three patients (44%), 28 with malignancies and 5 with benign tumors, also underwent a combined neurosurgical approach. Thirty-two patients (43%) had postoperative radiation therapy. Nineteen patients (25%) had had previous surgery elsewhere with primary recurrence and then underwent surgery in our hospital. Twenty-three patients (31%) had previous radiation therapy and had persistent or recurrent tumor and then underwent surgical resection. These tumors arose from various anatomic regions such as the orbit, paranasal sinuses, and skull base. We defined the origin of the tumors as best we could on the basis of preoperative radiologic images and intraoperative 571
572 HAO et al
findings. The origins of the tumors were nasopharynx (n ⫽ 28), nasal cavity (n ⫽ 12), cribriform plate area (n ⫽ 11), infratemporal fossa (n ⫽ 10), maxillary sinus (n ⫽ 5), ethmoid sinus (n ⫽ 4), sphenoid sinus (n ⫽ 2), frontal sinus (n ⫽ 1), clivus (n ⫽ 1), and orbit (n ⫽ 1). It was common to have tumors involving several different anatomic areas. Sixteen patients, 14 with malignant and 2 with benign tumors, had transcranial invasion. In 6 patients, part of the facial skeleton was involved by tumor and had to be removed with an additional 1-cm bone margin. The remaining facial skeleton was reimplanted, and the resulting defect was reconstructed with either the inner table of the frontal bone or free rib graft. Surgical Technique The basic surgical principles of facial translocation approach have been described elsewhere.2 However, over the years we have made some modifications to minimize surgical morbidity. Our modified procedures are described as follows. Facial Incision. A lateral rhinotomy incision joins a subciliary incision 1 cm lateral to the lateral fornix. The skin flap is elevated above the orbicularis oculi muscle to its lower margin, and then the muscle is elevated to skeletonize the orbital rim. It is crucial to preserve the branch of the facial nerve that supplies the orbicularis oculi muscle. The infraorbital neurovascular bundle is transected. The cheek flap then can be elevated and reflected inferiorly to expose the facial bones. Alternatively, the cheek flap may be left attached to the underlying facial bones, and an infratemporal tunnel is created along the lateral surface of the maxilla. By doing so, a vascularized facial bone compartment can be created based on the soft tissue of the premaxilla. Facial Osteotomy. Most commonly, a nasoorbito-maxillary osteotomy is performed. The zygoma may be included in the translocated facial bone graft if exposure of the infratemporal fossa is necessary. The nasolacrimal apparatus can be skeletonized and preserved only by removing the orbital floor and lacrimal bone. The lower end of the nasolacrimal duct which usually needs to be transected is marsupialized. The lateral nasal wall, if not involved by tumor, can be preserved and at the end of the procedure, it can be transposed as a
Otolaryngology– Head and Neck Surgery April 2003
useful flap to cover the undersurface of the facial bone graft. Preauricular Infratemporal Approach3 (Optional). Approach to the temporal, infratem-
poral, or subtemporal areas can be accomplished by a hemicoronal incision down to the pretragus area. The frontal branch of the facial nerve is preserved by creating a plane beneath the temporal fascia and its fat pad. After skeletonization of the zygoma, an appropriate osteotomy of the zygoma is made and the temporalis muscle is detached from its temporal insertion and retracted down to expose the temporal bone and infratemporal fossa. Further lateral exposure of the infratemporal fossa can be achieved by cutting away the coronoid process of the mandible. A low temporal craniotomy is created to expose the subtemporal space, and the middle cranial base bone is rongeured away up to the foramen ovale. Further exposure of the petrous internal carotid artery, eustachian tube, and middle meningeal artery is optional. Exposure of the Paranasal Sinuses, Nasopharynx, Clivus, and Cribriform Plate Area.
By removing the medial wall and posterior wall of the maxillary sinus, the pterygopalatine fossa and nasopharynx can be exposed. By removing the lateral wall of the maxillary sinus, the medial infratemporal fossa is exposed and may meet the infratemporal fossa approach. Approach to the cribriform plate, orbital roof, and planum sphenoidale can be optionally provided by a neurosurgical subfrontal approach. Exposure. This facial translocation approach offers generous exposure of the entire anterior and middle cranial base from the contralateral fossa of Rosenmu¨ ller in the nasopharynx to the ipsilateral temporomandibular joint. Reconstruction. Temporalis muscle pedicled from deep temporal arteries can be transposed to cover the exposed subtemporal dura or to obliterate the paranasal sinuses. Galeopericranial flaps are used most of time in reconstruction of the anterior cranial base. In rare situations, a free flap is needed for reconstruction of the skull base. The translocated facial skeleton is then replaced and fixed with microplates in a 3-point fixation. The translocated bone is replaced only when the inner periosteum remains free of cancer. The inner table of the split frontal bone or a free rib graft is used
Otolaryngology– Head and Neck Surgery Volume 128 Number 4
HAO et al 573
Table 1. Pathology Malignant
Benign
Tumor type
No.
Nasopharyngeal carcinoma Squamous cell carcinoma Olfactory neuroblastoma Mucoepidermoid carcinoma Osteogenic sarcoma Malignant fibrous histiocytoma Malignant melanoma Adenocystic carcinoma Chordoma Chondrosarcoma Malignant mixed tumor Acinic cell tumor Undifferentiated carcinoma Adenocarcinoma Total
17 9 8 4 3 3 2 2 1 1 1 1 1 1 54
to reconstruct the facial skeleton if it is involved by tumor and has to be removed. RESULTS There were 21 benign and 54 malignant tumors. There were no surgical deaths, and the perioperative morbidity rate was 30.7%; this included necrosis of the bone graft (n ⫽ 12), epiphora (n ⫽ 4), postoperative bleeding (n ⫽ 4), cerebrospinal fluid leak (n ⫽ 2), meningitis (n ⫽ 1), and blindness (n ⫽ 1). Some patients had crust formation in the sinonasal cavity and required frequent self-cleansing. This situation was worse in the patients who underwent further postoperative radiotherapy. The pathology spectrum was very wide (Table 1). The most common malignant tumors in our series were nasopharyngeal carcinoma (NPC) (n ⫽ 17), squamous cell carcinoma (n ⫽ 9), and olfactory neuroblastoma (n ⫽ 8). The most common benign tumors were inverted papilloma (n ⫽ 9), nasopharyngeal angiofibroma (n ⫽ 4), and aggressive polyposis (n ⫽ 3). Of the 54 malignant tumors, the local control rate was 54% and the actuarial 3-year survival rate was 59%. Of the 17 cases with primary recurrence of NPC, the local control rate was 78% and the actuarial 3-year survival rate was 71% with a median follow-up time of 19 months. Of the 21 patients with benign tumors, only 1 patient with a neurofibroma in the infratemporal fossa had recurrent disease 3 months after initial operation, and the other 18
Tumor type
Inverted papilloma Angiofibroma Aggressive polyposis Neurofibroma Mucopyocele Cyst Total
No.
9 4 3 2 2 1 21
patients remained free of disease while 2 patients died of other causes. Five of 21 patients with benign tumors required a combined craniofacial approach. The surgical morbidity in the group of benign tumors was low; only 1 patient had partial necrosis of the bone graft, which required sequestrectomy. In the 6 patients who had involvement of the facial bone by cancer, the facial skeleton had to be removed, and there was no evidence of recurrence in the remaining replaced facial bone. No patient in this series showed local recurrence in the translocated bone. DISCUSSION Over the years, the management of tumors of the skull base has remained a formidable challenge for head and neck surgeons. However, with the marked advancement in imaging and especially the development of magnetic resonance imaging, the local anatomy and patterns of spread of skull base tumors are better understood and we are more confident in approaching these tumors. There are various important surgical approaches to the skull base, such as infratemporal fossa approach,4 maxillary swing,5 subtotal maxillotomy approach,6 Le Fort I osteotomy approach,7 and facial translocation approach.1,2 All of these are sound surgical approaches, but facial translocation approach or facial bone disassembly approach has been appraised as the best surgical approach to the
574 HAO et al
middle central skull base.6 The basic principle of facial translocation approach is to temporarily remove the facial bone unit and to reimplant and fix it after the tumor is resected.2 Specifically, in facial translocation approach, the facial osteotomy can be electively carried out according to the anatomic location of the tumor.8 The facial translocation approach may also be combined with a subfrontal approach for anterior cranial base tumors or combined with a subtemporal approach for tumors of the middle cranial base and infratemporal fossa. We found the facial translocation invaluable for tumors involving the nasopharyngeal or paranasopharyngeal spaces. The usual tumor arising from the nasopharyngeal space is NPC, a common cancer in southern parts of China, Hong Kong, and Taiwan. Originating from the fossa of Rosenmu¨ ller, NPC is notorious for submucosal spread and commonly extends out of the nasopharyngeal space to the parapharyngeal space via a natural anatomic pathway in which the eustachian tube and tensor veli palatini muscle are located. Superior extension of the tumor to the skull base by directly destroying the base of the pterygoid plate is also common, and from here, NPC can invade the cavernous sinus superiorly and the foramen ovale laterally. Other tumors, such as those arising from minor salivary glands, may not be as aggressive as NPC; however, they may also follow the pattern of natural extension of NPC. It is crucial to realize that we seldom deal with a tumor solely occupying the nasopharyngeal space. Unexpected extension to the peritubal or parapharyngeal space is common, and the surgical approach should be modified according to the preoperative magnetic resonance imaging findings and the intraoperative findings. The facial translocation approach, with elective osteotomies, can flexibly fulfill the above requirements.8 To its full extent, a unilateral facial translocation approach can offer exposure from the contralateral Rosenmu¨ ller fossa to the ipsilateral glenoid fossa. Combined with a subfrontal approach, anterior cranial base extensions of NPCs can be resected. When combined with a subtemporal approach, lateral extension of NPCs to the sphenoid ridge and foramen ovale area can be resected.
Otolaryngology– Head and Neck Surgery April 2003
In our department, the facial translocation approach was the surgical approach of choice for recurrent NPCs. The indications for nasopharyngectomy included not only nasopharyngeal mucosa disease but also parapharyngeal space invasion or transcranial invasion. In our series, of the 17 patients with local recurrent NPC who underwent nasopharyngectomy via the facial translocation approach, the local control rate was 78% and the actuarial 3-year survival rate was 71%. Another concern about the facial translocation approach is the propriety of the reimplanted facial skeleton when tumor had involved the facial bones. Currently, we would not consider replanting the facial bones that were definitely involved with cancer; however, the periosteum is a good barrier against cancer and the facial bone can be replaced as long as the periosteum is free of cancer by frozen section diagnosis. If the facial bone is focally involved by cancer, the involved bone should be removed with an additional 1-cm bone margin while the remaining facial skeleton is replaced. The resulting defect can then be reconstructed with a bone graft either from the inner table of the frontal bone or from the rib. In our series, no recurrence in the translocated bone was ever detected. In our previous article, we described the harmful effect of radiotherapy on the transplanted facial bone graft.9 We now apply only the free facial bone graft technique to those in whom no previous or further radiotherapy would be administered. In patients who will have postoperative radiotherapy, a vascularized facial bone graft technique, as described previously,9 is to be used. In our series, the major complication of the facial translocation approach was necrosis of the facial bone graft, which was most commonly caused by failure of the bone graft to be revascularized by the free facial bone graft technique. Over the years, several technical modifications of the facial translocation approach to further avoid bone graft necrosis have been designed in our department. First, 3-point fixation is crucial to secure and immobilize the facial bone graft otherwise the microtrauma would interfere with bone union.9 Second, the facial bone unit is secured to the facial soft tissue by suturing the cheek soft tissue flap to the drilling holes of the facial bone
Otolaryngology– Head and Neck Surgery Volume 128 Number 4
unit. Third, the lateral nasal wall can be preserved and transposed to resurface the inner aspect of the translocated facial bone unit if it is far away from the tumor and remains free of disease. In our series, the patients were also required to follow a self-cleansing program of the paranasal sinus area with warm saline daily. These measures can effectively decrease the rate of bone graft necrosis. If there was exposed subtemporal dura, a temporalis muscle flap was transposed to cover the dura and to obliterate the paranasal sinus cavity. This maneuver is crucial to prevent postoperative ascending infections. However, because the transposed temporalis muscle flap might hinder the early detection of local recurrence, it is important to have a postoperative imaging study as a baseline for comparison because later recurrence is possible. The facial translocation approach can also be a valuable approach to paranasal and orbital tumors. In the conventional lateral rhinotomy approach, part of the maxilla bone is removed and the resulting bone defect is not reconstructed, thus resulting in a notable paranasal depression while the skin incision heals perfectly. By replacing the bone to its original place, the facial translation approach avoids this problem. In addition, the facial translocation may provide a much more generous exposure of all the paranasal sinuses and infratemporal fossa than traditional lateral rhinotomy can offer. This is especially valuable when dealing with an easily recurrent tumor such as inverted papilloma of the paranasal sinuses or nasopharyngeal angiofibromas with infratemporal fossa extension. For other tumors that have multiple sinuses involved, the excellent exposure of-
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fered by the facial translocation approach would further facilitate radical excision. In conclusion, the facial translocation approach provides the most direct approach to the central skull base; provides the possibility of intracranial excision by combining a neurosurgical approach, thus generating greater exposure; facilitates oncologically sound radical excision; and maintains an acceptable morbidity and cosmetic result. Facial translocation is truly a most valuable approach to the paranasal sinuses, nasopharynx, clivus, and infratemporal fossa. REFERENCES
1. Nuss DW, Janecka IP, Sekhar LN, et al. Craniofacial disassembly in the management of skull base tumors. Otolaryngol Clin North Am 1991;24:1465-97. 2. Janecka IP, Sen CN, Sekhar LN, et al. Facial translocation: a new approach to the cranial base. Otolaryngol Head Neck Surg 1990;103:413-9. 3. Sekhar L, Schramm V, Jones N. Subtemporal preauricular infratemporal fossa approach to large lateral and posterior cranial base neoplasms. J Neurosurg 1987;67:488-99. 4. Fisch U. Infratemporal fossa approach to tumors of the temporal bone and base of skull. J Laryngol Otol 1978; 92:949-67. 5. Wei WI, Lam KH, Sham JST. New approach to the nasopharynx, the maxillary swing approach. Head Neck 1991;13:200-7. 6. Catalano PJ, Biller HF. Extended osteoplastic maxillotomy, a versatile new procedure for wide access to the central skull base and infratemporal fossa. Arch Otolaryngol Head Neck Surg 1993;119:394-401. 7. Williams WG, Lo LJ, Chen YR. The Le Fort I-palatal split approach for skull base tumors: efficacy, complications, and outcome. Plast Reconstr Surg 1998;102:2310-9. 8. Janecka IP. Classification of facial translocation approach to the skull base. Otolaryngol Head Neck Surg 1995;112: 579-85. 9. Hao SP. Facial translocation approach to skull base–the viability of translocated facial bone graft. Otolaryngol Head Neck Surg 2001;124:292-6.