Facial Translocation Approach Research Articles

Open nasopharyngectomy—Facial translocation approach

Salvage nasopharyngectomy has become the mainstay of treatment after radiotherapy failure for nasopharyngeal carcinoma. However, surgical access to the nasopharynx has always been a challenge to head and neck surgeons. Various surgical approaches to the nasopharynx includes transpalatal, transmaxillary, midline mandibulotomy, transpterygoid, facial translocation, and infratemporal fossa approaches. The facial translocation approach is based on the principle of disassembling of vascularized midfacial composite units, permitting wide access for the treatment of tumors at nasopharynx, anterior skull base, paranasal sinuses, pterygomaxillary and infratemporal fossa, and the orbit. The facial translocation approach offers previously unavailable wide and direct exposure and allows extensive resection of tumors in the above areas. Facial translocation also preserves critical structures through approximation and fixation of the facial fragments after the operation, with a potential for immediate reconstruction of the complex region of the nasopharynx and cranial base.

Combined Minimally Invasive Supraciliary and Transfacial Approach for Large Tumors with Skull Base and Sinonasal Involvement.

Tumors invading both the anterior skull base and the sinonasal area have traditionally been accessed via largely invasive open craniofacial approaches. Minimally invasive extended endoscopic endonasal approaches have recently become increasingly available but have anatomical limitations and require incremental experience and thus high patient volume. Our objective was to assess the applicability of a novel combination of the minimally invasive supraciliary incision and the limited maxillofacial osteotomy as a combined surgical approach for large tumors invading both the anterior skull base and the sinonasal area. The well-established technique of supraciliary incision with a 2.5× 3.0-cm craniotomy was combined for the first time with limited facial translocation approach. This series involves 11 cases (female/male ratio 4:7; ranging in age from 6 to 61 years). Intracranial tumor propagation with intranasal and ethmoidal extension was detected in all patients. The pathologic diagnoses included adenocarcinomas, esthesioneuroblastoma, rhabdomyosarcoma, sinonasal papilloma, meningioma, and neurofibroma. The postoperative approach-related mortality rate was zero. No case of cerebrospinal fluid leak was detected. The 3-year survival rate was 70%. The limited transfacial approach in combination with a supraciliary extension is associated with minimal mortality and morbidity and facilitates gross total tumor removal. We highly recommend this approach for the surgical treatment of large tumors invading both the anterior skull base and the sinonasal area, especially for those being out of indication for extended endoscopic endonasal surgery.

Morbidity Profile and Functional Outcome of Modified Facial Translocation Approaches for Skull Base Tumors

The primary objective of this study was to evaluate morbidity associated with facial translocation approaches for skull base and results of various technical modifications. Forty consecutive patients who underwent facial translocation approaches for accessing skull base tumors from July 2005 to June 2010 were included in this study. There were 25 patients who underwent standard facial translocation, 4 patients medial mini, and 11 patients underwent extended facial translocation. Thirteen patients had benign disease and 27 patients had malignant disease. Resection was R0 in 36 and R1 in 4 patients. Most patients had acceptable cosmetic results. None of the patients had problems related to occlusion or speech and swallowing. The commonest complication observed was nasal crusting in 16 patients. Grade 2 trismus and exposure of mini plate was seen in three patients. Two patients developed necrosis of translocated bone. Three patients developed palatal fistula before modification of palatal incision. Facial translocation provides a satisfactory access for adequate clearance of skull base tumors with satisfactory aesthetic and functional results. With modifications of the surgical technique and implementation of new surgical tools, the morbidity of facial translocation approaches will continue to decrease.

Anterior skull base surgery

The basic principle of anterior skull base surgery is to provide adequate exposure to enable three dimensional resection of skull base tumors. Negative surgical margins, which is within the control of surgeon, is the principle prognostic factor in anterior skull base tumors. Open skull base approaches is the standard of care for malignant anterior skull base tumors. Benign lesions may be resected by alternate minimally invasive approaches. Advances in anterior skull base surgery, in particular the facial translocation approaches allows wide exposure of the tumors with minimal retraction of the brain. The outcome of anterior skull base tumors have steadily increased over the years with disease free survival comparable to other malignant neoplasm of the head and neck region. This review described various surgical approaches and pertaining anatomy and pathology of anterior skull base tumors.

Morbidity Profile of Facial Translocation Approaches for Skull Base Tumors and a Technique to Reduce It

Morbidity Profile of Facial Translocation Approaches for Skull Base Tumors and a Technique to Reduce It

P2.34. Morbidity profile of facial translocation approaches for skull base tumors and techniques to reduce it

P2.34. Morbidity profile of facial translocation approaches for skull base tumors and techniques to reduce it

Quantitative Evaluation of Transtemporal and Facial Translocation Approaches to Infratemporal Fossa

To compare the extent of exposure and surgical maneuverability provided by facial translocation and transtemporal approaches for access to the infratemporal fossa and anterolateral skull base. Surgical procedures were performed on five fresh frozen adult cadavers (ten sides) with no known pathology. Facial transfacial approaches with and without a mandibulotomy and transtemporal approaches were evaluated. OBJECTIVE measures were (1) the distance from the surgical plane to designated anatomic landmarks and (2) the surgical angle of exposure. Distances from the surgical plane to the anatomic reference points were comparable for most of the access procedures (3 to 6 cm). The extended midfacial translocation and bilateral facial translocation approaches did, however, provide a shorter operative distance (1 to 3 cm) for access to the infratemporal fossa and contralateral structures, respectively. The transtemporal approaches facilitate a better angle of exposure (74 to 84 degrees) to the petrotemporal region, while the transfacial approaches were superior for access to the infratemporal structures. Based on the results, we propose a clinical algorithm for selecting a surgical approach based on the position and extent of an infratemporal or petrotemporal lesion.

Facial translocation approaches to skull base: indications, methods and morbidity profile

Introduction: The facial translocation approaches comprise of a series of transfacial approaches to the anterior and middle skull base. Facial translocation scores over traditional transcranial approaches in that brain retraction is minimized, thereby reducing the morbidity associated with the procedure. The facial skeleton is osteotomised along the planes of embryonic fusion with attention to the aesthetic units of the face, thereby providing a good cosmetic outcome. Principal complications of this procedure are bleeding, CSF leak, infection and delayed wound healing.

Facial translocation approach to infratemporal fossa and cranial base in extensive angiofibroma: A review of 7 cases

Angiofibroma extending to infratemporal fossa, orbit and middle cranial fossa is a difficult problem for a surgeon to tackle. Traditional extracranial excision with radiotherapy for the intracranial extension was practiced for a long time with variable results. Different approaches to remove such a tumour are described but most of them are not free from resultant morbidity in the form of facial asymmetry and incomplete tumour removal. Facial translocation approach facilitates complete tumour removal without cutting through the tumour thereby reducing per-operative blood loss. It also avoids facial asymmetry as the zygomatico-orbito-maxillary bony complex is replaced after the tumour removal. We present a review of seven cases with the results. The surgical steps, advantages, disadvantages and the complications are discussed.

Salvage surgery for locally recurrent nasopharyngeal carcinoma—A 10-year experience

Objective To evaluate the result of salvage surgery for patients with primary recurrence of nasopharyngeal carcinoma (NPC) after radiation therapy. Study design and setting Prospective cohort at a tertiary referral center. Patients and methods Thirty-eight consecutive patients with primary recurrence of NPC after radiation failure underwent salvage surgery for curative intention via the facial translocation approach from July 1993 to December 2002. The follow-up time ranged from 2 to 88 months. Twelve patients with intracranial and skull base invasion needed a combined neurosurgical approach. Eight patients had additional postoperative radiation therapy. Results The actuarial 3-year survival and local control rate was 60% and 72.8%, respectively. Ten (83.3%) of 12 patients with intracranial and skull base invasion achieved local control. There was no surgical mortality, and the morbidity rate was only 13.2%. Conclusion and significance The results of this study reveal better outcome of salvage surgery than that of most published literature of reirradiation for recurrent NPC. With the adequate exposure provided by the facial translocation approach, an integrated concept of skull base surgery, and the collaboration of neurosurgeons, we can extend our surgical indications of salvage surgery and resect many advanced lesions with acceptable mortality and morbidity.

Successful repair of CSF leak with a facial translocation approach after two failed endoscopic surgeries

Objectives: There has been an increased incidence of cerebrospinal fluid (CSF) leaks associated with greater numbers of sinus and anterior skull base surgeries. The leading causes of CSF leaks are iatrogenic injury and trauma. Over the past 20 years, CSF leak repairs via an endoscopic approach have been reported with success rates ranging from 83%-100%. Failed endoscopic repairs provide a challenge to the clinician. Methods: The case reported here is that of a 38-year-old female, who required nonendoscopic management of her middle cranial base CSF leak, after 2 failed attempts with endoscopic repair. The CSF leak occurred after resection of a pituitary adenoma via a transphenoidal approach. Results: The CSF leak recurred for the third time shortly after the second repair. The defect was then approached via a mini-facial translocation approach. A left lateral rhinotomy incision was made and the left nasal, frontal, and maxillary bones were exposed. After osteotomies were made, the maxillary sinus was rotated laterally exposing the sphenoid sinus. Rongeurs were used to open the sphenoid sinus and direct visualization of the CSF leak in the left lateral aspect of the sphenoid sinus was obtained. The leak was isolated and repaired with fat grafting, fibrin glue, and middle turbinate mucosa by neurosurgery. Conclusion: The patient has had an uneventful recovery with good cosmesis and no recurrence of the CSF leak.

Facial translocation approach in the management of central skull base and infratemporal tumors.

The objectives were to systematize the indications of various types of facial translocation and to present a technical modification to avoid some sequelae of this approach. Retrospective analysis was made of patients treated with different types of facial translocation approach to resect nasopharyngeal, infratemporal, and sinonasal tumors. Thirty-nine patients underwent facial translocation approaches for neoplasms originally involving the nasopharynx (27) infratemporal fossa (7), and nasal cavity (5). Of the 21 malignant tumors, 2 were stage T2, 5 were stage T3, and 14 were stage T4. From the entire series of patients, 10 received a unilateral medial translocation, 3 a bilateral medial translocation, 25 a standard facial translocation, and 1 an extended medial facial translocation. Fifteen patients (38%) developed some kind of complication, such as wound infection (nine cases) and osteomyelitis and cerebrospinal fluid leak (five cases each). Two patients died as a result of postoperative complications (5.2%). Overall 5-year survival for malignant tumors was 43%. Neither the histological appearance of the tumor nor the T stage influenced the survival of patients. Survival of patients with intracranial involvement was significantly decreased compared with patients with involvement of other areas (P =.0003). The facial translocation approach offers an excellent exposure in tumors with large degree of involvement of the nasopharynx, infratemporal fossa, nasal cavity, and maxillary sinus. More limited osteotomies are indicated in smaller tumors. The use of midfacial degloving minimizes the number of sequelae of these approaches.

Lateral nasal wall mucoperiosteal flap: a versatile new reconstruction of the inner defect of translocated facial bone segments.

From July 1998 to December 2002, 42 patients (including 29 patients who had undergone radiation therapy) underwent a newly designed lateral nasal wall mucoperiosteal flap pedicled anteriorly on the lateral nasal artery of the angular artery to resurface a translocated facial bone segment during a facial translocation approach to the skull base to prevent its avascular necrosis. Of the 42 patients studied, 1 patient had full-thickness flap loss that resulted in bone graft necrosis. Another patient had marginal necrosis. The average length, width, and surface area of the flap was 30 mm, 45 mm, and 1350 mm measured on 5 patients. The mucoperiosteal flap tolerated radiation therapy well. The lateral nasal wall mucoperiosteal flap is a simple, reliable flap that provides ample vascularized tissue to resurface the nude translocated facial bone segment during a facial translocation approach to the skull base. It thus prevents its avascular necrosis even after radiation therapy.

안면전위 접근법 및 두개안면 절제술을 통해 제거한 비강신경교세포종 1예

안면전위 접근법 및 두개안면 절제술을 통해 제거한 비강신경교세포종 1예

Modified facial translocation technique to prevent necrosis of bone graft.

To assess the efficacy of a modified facial translocation technique in preventing translocated facial bone graft from necrosis, which is the most common complication of facial translocation. Prospective. A lateral nasal flap was preserved and transposed to resurface the inner surface of the translocated facial bone graft in a facial translocation approach to skull base tumors in 35 patients including 24 patients with radiation therapy between July 1998 and December 2000. Only one patient had bone graft necrosis. Thirty-four (97%) of 35 patients had intact mucosa covering the inner surface of the translocated facial bone graft. The outcome was not affected by preoperative or postoperative radiation therapy. A modified facial translocation technique using a lateral nasal flap to resurface the inner defect of the translocated facial bone graft significantly improved the viability of the translocated facial bone graft, especially in patients who underwent radiation therapy. The use of a lateral nasal flap does not interfere with the detection of early local recurrence.

Salvage surgery for recurrent nasopharyngeal carcinoma.

To evaluate the results of salvage surgery for patients with primary recurrence of nasopharyngeal carcinoma after radiotherapy. Cohort study. Academic tertiary referral center. Eighteen consecutive patients with primary recurrence of nasopharyngeal carcinoma after radiation failure underwent nasopharyngectomy for cure via a facial translocation approach from July 1, 1993, to December 31, 1999. Follow-up ranged from 3 to 71 months. Five patients with skull base invasion required a combined neurosurgical approach to treatment. Seven patients had additional postoperative radiotherapy. The actuarial 3-year survival was 57%, while the local control was 78%. Four of 5 patients who had skull base invasion achieved local control. There was no surgical mortality, and the morbidity was 22%. Advances in skull base surgery make possible the effective control of primary recurrence of nasopharyngeal carcinoma, with acceptable mortality and morbidity.

Facial translocation approach to the skull base: The viability of translocated facial bone graft

Objectives: A retrospective review of 56 patients who were operated through a facial translocation approach was carried out to assess the viability of the translocated facial bone segment. Methods: Eleven patients had preoperative radiotherapy, and 26 had postoperative radiotherapy. In 14 patients the translocated bone segment was kept attached to the anterior cheek, and in 42 patients the bone segment was detached and then implanted. A vascularized flap was used to obliterate the defect in the paranasal sinuses in 15 patients. Results: Twelve (21.4%) patients had devitalized bone segment and required sequestrectomy. The incidence of devitalized bone segment was higher in the patients who received postoperative radiotherapy ( P = 0.04) and lower in the patients in whom the defect in the paranasal sinuses was reconstructed with a vascularized flap ( P = 0.006). Conclusions: The translocated facial bone segment should be kept attached to the cheek soft tissue when possible, or the defect in the paranasal sinuses should be reconstructed with a vascularized flap. (Otolaryngol Head Neck Surg 2001;124:292-6.)

Salvage Surgery for Recurrent Nasopharyngeal Carcinoma

To evaluate the efficacy of salvage surgery in the treatment of recurrent nasopharyngeal carcinoma (NPC) at the primary site. A retrospective investigation of the outcome of salvage surgery for 28 patients with recurrent NPC after definite radiation therapy. The nasopharynx was approached anteroposteriorly by the transmaxillary approach (maxillary swing, maxillectomy) or inferior approach (midline mandibulotomy or median labiomandibular glossotomy), or laterally by modified facial translocation or transpterygoid approach; intentional ligation of the internal carotid artery was performed after establishment of extracranial-intracranial (EC-IC) bypass in one patient; postoperative irradiation was given to the patients with positive pathological margins. Nine patients lived without disease for 20 to 93 months (mean interval, 52 mo) after surgery; among them, eight patients had T1 tumors that were resected totally by surgery via anteroposterior approaches and the other patient had postoperative irradiation to control the disease. Seven patients had local recurrence 8 to 21 months after treatment. Four patients developed distant metastases, including one patient with a T2b tumor that was totally resected through modified facial translocation approach with ligation of internal carotid artery. Eight patients died of other causes; internal carotid artery blowout was the cause of death in four of these eight patients. In most cases of recurrence, T1 nasopharyngeal tumors can be resected totally by anteroposterior approaches; for T2 or larger tumors, postoperative irradiation is usually necessary. Otherwise, facial translocation offers a better chance to completely resect the tumors. Internal carotid artery is better ligated if patients have received greater than 70 Gy irradiation or if the artery must be exposed during the surgery. We suggest that EC-IC bypass be used to avoid the possible complications (or cerebral ischemic stroke) caused by ligation of internal carotid artery. The transmaxillary approach is favored in the management of nasopharyngeal tumor recurrence with nasal cavity extension, and midline mandibulotomy is more suitable for resection of posterior margin of nasopharyngeal tumor recurrence. Facial translocation offers the widest operative field and is the most versatile approach for radical resection of nasopharyngeal tumor recurrence, but the surgeon should be skilled in the management of the facial nerves to reduce morbidity.

Classification of facial translocation approach to the skull base

To categorize a surgical approach to the skull base. Retrospective assessment of an evolving concept pertaining to the facial translocation procedure. Schematic/conceptual. To allow favorable surgical reach of the essential anatomy at the cranial base with the potential for functional and esthetic reconstruction. Systematic craniofacial disassembly. The facial translocation technique of modular craniofacial disassembly of facial units permits a satisfactory match between a skull base tumor and a selected surgical approach. Individual units have a complementary relationship to one another, allowing an expansion of the surgical approach as needed.

Classification of facial translocation approach to the skull base

OBJECTIVE: To categorize a surgical approach to the skull base. DESIGN: Retrospective assessment of an evolving concept pertaining to the facial translocation procedure. SETTING: Schematic/conceptual. MAIN OUTCOME MEASURES: To allow favorable surgical reach of the essential anatomy at the cranial base with the potential for functional and esthetic reconstruction. INTERVENTION: Systematic craniofacial disassembly. RESULTS: The facial translocation technique of modular craniofacial disassembly of facial units permits a satisfactory match between a skull base tumor and a selected surgical approach. Individual units have a complementary relationship to one another, allowing an expansion of the surgical approach as needed. (OTOLARYNGOL HEAD NECK SURG 1995;112:579-85.)