Transzygomatic approach plus mini-peeling of middle fossa for devascularization of sphenoid wing meningiomas. Technical note
- Department of Neurosurgery, Hospital Padilla, Tucuman, Argentina
- Universidad Nacional de Tucuman, Argentina
- Department of Neurosurgery, Hospital Civil de Guadalajara, Mexico
- Department of Neurosurgery, Hospital Italiano de Buenos Aires, Argentina
- Department of Neurosurgery, Hospital Metropolitano Oesta Pelópidas Silveira, Recife, Brasil
Department of Neurosurgery, Hospital Metropolitano Oesta Pelópidas Silveira, Recife, Brasil
DOI:10.4103/sni.sni_135_18Copyright: © 2018 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Alvaro Campero, Juan F. Villalonga, Ramiro Lopez Elizalde, Pablo Ajler, Carolina Martins. Transzygomatic approach plus mini-peeling of middle fossa for devascularization of sphenoid wing meningiomas. Technical note. 24-Jul-2018;9:140
How to cite this URL: Alvaro Campero, Juan F. Villalonga, Ramiro Lopez Elizalde, Pablo Ajler, Carolina Martins. Transzygomatic approach plus mini-peeling of middle fossa for devascularization of sphenoid wing meningiomas. Technical note. 24-Jul-2018;9:140. Available from: http://surgicalneurologyint.com/surgicalint-articles/transzygomatic-approach-plus-mini%e2%80%91peeling-of-middle-fossa-for-devascularization-of-sphenoid-wing-meningiomas-technical-note/
Background:Sphenoid wing meningiomas account for 20% of supratentorial meningiomas. The main supply of these tumors is provided by branches of the middle and accessory meningeal arteries. Surgical resection of meningiomas requires early tumor devascularization. Our objective is to present the role of transzygomatic approach plus mini-peeling of the anterior third of the middle fossa in the extradural identification and coagulation of branches of middle and accessory meningeal arteries involved in tumor supply.
Methods:Ten formalin-fixed, silicone-injected cadaveric heads were used. On each side a transzygomatic approach plus mini-peeling of the anterior third of the middle fossa was performed. Between 2005 and 2017, the authors applied this technique for the resection of sphenoid wing meningiomas in 28 patients.
Results:The mean age of patients was 54 years. Thirteen tumors could be classified as medial-third type, 6 as middle-third type, and 4 tumors were lateral-third type. Five tumors represented combined types. Of these, 3 tumors involved the medial and middle-third of the sphenoid wing and 2 involved the entire wing. Surgical resection was classified as Simpson I/II in 24 patients (86%). There were no permanent deficits or postoperative mortality.
Conclusions:The transzygomatic approach combined with mini-peeling of the anterior third of the middle fossa is effective in allowing early devascularization of sphenoid wing meningiomas. These maneuvers are particularly important during resection of large tumors.
Keywords: Meningiomas, middle fossa, sphenoid wing, transzygomatic approach
Sphenoid wing meningiomas (SWM) comprise 20% of supratentorial meningiomas.[
One of the most important steps in surgical removal of a meningioma is its early devascularization.[
Ten formalin-fixed, silicone-injected cadaveric heads were used. On each side, a transzygomatic approach[
Between 2005 and 2017, the authors applied this technique for the resection of SWM in 28 patients with SWM. No en plaque tumors were included in this group. Age, gender, SWM classification, preoperative symptoms, resection grade according to Simpson classification, and postoperative complications were recorded.
The maxillary artery, through its middle and accessory meningeal arteries, provides almost all the supply to the dura over the convexity and important contributions to the supply of the basal dura.[
Middle fossa anatomy. (a and b) Meningeal arteries in the middle fossa. (c) Duramater of the middle fossa. (d and e) lateral wall of the cavernous sinus. III CN, III cranial nerve; ON: optic nerve; Car. A, carotid artery; V1: ophthalmic nerve of Willis; V2: upper maxillary nerve; V3: lower maxillary nerve; For. Spinosum, foramen spinosum; Mid. Men. A., middle meningeal artery; Ant. Div., anterior division; Post. Div., posterior division; Med. Br., medial branch; Lat. Br., lateral branch
The accessory meningeal artery, also called the lesser or small meningeal artery, may arise from the maxillary or middle meningeal arteries. In 78% of the cases, the accessory meningeal artery enters the cranium through the foramen ovale. In the remaining 22% of the cases, it passes through the emissary sphenoid foramen (foramen of Vesalius). The intracranial territory of the accessory meningeal artery includes the gasserian ganglion and the adjacent middle fossa dura. The caliber of the accessory meningeal artery is approximately 1/3 to 1/2 of the middle meningeal artery.[
The middle fossa of the skull extends from the posterior border of the lesser sphenoid wing and chiasmatic sulcus anteriorly to the petrous ridge of the temporal bone and dorsum sellae of the sphenoid body posteriorly.[
The cavernous sinuses are paired structures located alongside the sella, hypophysis, and sphenoid sinus. Each cavernous sinus extends from the superior orbital fissure anteriorly to the dorsum sellae posteriorly. The cavernous sinus inferior limit approximates a line passing along the upper margin of V2. Each cavernous sinus has four dural walls – lateral, medial, superior, and posterior.[
Head positioning and incision planning
The patient lies in a supine position, head turned 30° to the contralateral side of the approach. Head is extended and lateralized, away from the shoulder. The skin incision starts at the lower margin of the zygomatic arch, 5 mm anterior to tragus and extends, behind the hair line, to the contralateral midpupillary line [
Middle fossa mini-peeling in a laboratory dissection. (a-h) Cadaveric dissection simulating a transzygomatic approach. Temp. Musc., temporal muscle; Fr.-Zyg. Sut., Fronto-Zygomatic suture; Zyg. Arch.: Zygomatic arch; V1: Oftalmic nerve of Willis; V2: Upper maxillary nerve; V3: Lower maxillary nerve
Skin incision and soft tissue dissection
Skin incision is performed using number 24 surgical blade. If needed, the preauricular segment of the skin incision may safely extend inferior to the lower margin of the zygomatic arch up to, on average, 26 mm.[
The soft skin incision starts with a subgaleal dissection, which exposes the temporalis muscle up to its anterior one-fourth where fatty tissue can be seeing through the fascial layers covering the muscle. At this level, a number 11 blade is used to deepen the incision through the external layer of the superficial temporal fascia, which is elevated with interfascial fat to protect the frontal branch of the facial nerve. In this space, one finds the small interfascial vein, perpendicular to the fascial incision, indicating that the adequate stratum has been followed. The interfascial vein should be coagulated and cut.[
Zygomatic arch osteotomies
Two vertically-oriented bone cuts are performed across the zygomatic arch. The first posterior most cut is located immediately anterior to the zygomatic tubercle. The second anterior most cut is located at the zygomatic angle, where the zygomatic arch meets the frontal process of the zygomatic bone [
Temporalis muscle: Detachment and retraction
The temporal muscle is retrograde-dissected to prevent postop atrophy.[
A fronto-temporo-sphenoidal craniotomy is performed [
Mini-peeling of the anterior third of middle fossa
A number 11 blade is used to perform the initial incision at the level of the lateral most end of the superior orbital fissure. This cut is no more than a release incision that allows reaching the cleavage plane between the dural layers in this area and might be repeated at the level of foramen rotundum. Once the cleavage plane between the lateral and medial layers is found, blunt separation of the two dural layers along the middle fossa starts. This “peeling” is undertaken from anterior to posterior using a dissector. During this stage, coagulation of the dural arteries coursing along the lateral layer and comprising the anterior branch of the middle and accessory meningeal arteries is undertaken, devascularizing the tumor from its meningeal supply. The mini-peeling is carried up to the level of foramen spinosum and V3 at foramen ovale [
Dural incision and tumor resection
The dural incision follows frontal and temporal extensions, allowing direct access to the tumor and complete resection. Tumor debulking becomes simpler as its vascular supply has been dealt with the mini-peeling.
Bony flap removed is replaced following dural closure. The temporal muscle is securely reattached to the superior temporal line. The zygomatic arch is restored to its anatomical location and fixed.
Twenty-eight patients with SWM were treated during this period. Seventeen were women. Age of the patients at surgery was on average 54 years (range: 28–82 years).
Clinical symptoms included headache (12 patients), visual deficit (5), seizures (3), intracranial hypertension (3), aphasia (1), frontal syndrome (1), hemiparesis (1), oculomotor palsy (1), and abducens palsy (1 patient).
Thirteen tumors were classified as medial-third type, 6 as middle-third type, and 4 tumors were lateral-third type. Five tumors represented combined types. Of these, 3 tumors involved the medial and middle-thirds of the sphenoid wing and 2 involved the entire wing.
Resection was classified as Simpson grade I in 12 patients, II in 12, III in 3, and grade IV in 1 patient. Surgical resection was classified as Simpson I/II in 24 patients (86%). No patient required red cell transfusion. Postoperative complications included transitory aphasia (1), transitory oculomotor nerve palsy (1), transitory abducens nerve palsy (1), CSF fistula that required transitory lumbar drainage (1), and wound dehiscence (1 patient). No permanent pain or masticatory disfunction were registered. There were no deaths related to treatment. We include a case example in Figure
The traditional approach to SWM has been pterional.[
In dealing with meningiomas, an essential maneuver, prior to dural opening, is maximal devascularization of the lesion. This can be accomplished by microsurgical coagulation or preoperative embolization of meningeal branches.[
Preoperative embolization can be an attractive adjunct to resection. However, it must be total to decrease operative blood loss; and an aggressive embolization can generate permanent postprocedural neurological deficits.[
This paper provides the description of a straightforward surgical option to deal with SWM, namely the transzygomatic approach plus mini-peeling of the middle fossa. This choice of approach provides for a simpler bony work, which can be accomplished by neurosurgeons working in all kinds of neurosurgical scenarios without straining the technological arsenal available. It also offers the possibility of early tumor devascularization, which enables safer and expedient resection. To adequately perform the transzygomatic approach plus mini-peeling of the middle fossa two maneuvers are key – (a) the zygomatic osteotomy,[
Other potential advantages of this approach, not directly evaluated in this study might involve the findings of Ouyang et al.,[
We recommend the transzygomatic approach plus mini-peeling of the middle fossa to become a part of the surgical armamentarium of neurosurgeons dealing with SWM.
The transzygomatic approach plus mini-peeling of the middle fossa are two surgical maneuvers that allow for effective devascularization and dealing with SWM. They are particularly important when large tumors are considered.
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Conflicts of interest
There are no conflicts of interest.
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