Next Article in Journal
A Retrospective Review of Malignant Minor Salivary Gland Tumors and a Proposed Protocol for Future Care
Previous Article in Journal
Treatment of Palatal Fractures by Osteosynthesis with 2.0-mm Locking Plates as External Fixator
 
 
Craniomaxillofacial Trauma & Reconstruction is published by MDPI from Volume 18 Issue 1 (2025). Previous articles were published by another publisher in Open Access under a CC-BY (or CC-BY-NC-ND) licence, and they are hosted by MDPI on mdpi.com as a courtesy and upon agreement with Sage.
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Subcranial Approach in Pediatric Craniofacial Surgery

by
Jorge Ciechomski
*,
Ruben Aufgang
,
Lucrecia Villanueva
and
Victoria Demarchi
Plastic Surgery Unit, Hospital de Niños “Ricardo Gutierrez”, Ciudad Autonoma de Buenos Aires, Gallo 1330, Ciudad Autonoma de Buenos Aires, Argentina
*
Author to whom correspondence should be addressed.
Craniomaxillofac. Trauma Reconstr. 2010, 3(4), 231-235; https://doi.org/10.1055/s-0030-1268521
Submission received: 8 June 2010 / Revised: 14 August 2010 / Accepted: 14 August 2010 / Published: 10 November 2010

Abstract

:
We report our experience with the subcranial approach, developed at the Plastic Surgery Unit of Hospital “Ricardo Gutie’rrez”, for the treatment of injuries in the frontoethmoidal orbital region in pediatric patients. The subcranial approach was described by Raveh et al. for the treatment of fractures in the frontoethmoidal area. The subcranial approach was used later for surgery of tumors and deformities of the frontoethmoidal region. We have used this approach in nine cases of nontraumatic injuries (one meningioma, one orbital bone fibrous dysplasia, one vascular malformation, five nasal dermoid cysts, and one fronto-orbital mucocele). One patient with vascular malformation died of a stroke 10 days after surgery. The patient with the meningioma had a recurrence. Another patient developed an infection that needed surgical resolution and hardware removal. A third patient suffered a mild infection that receded with medication. No other complications were registered. The surgical exposure obtained through this approach was always excellent and left no cosmetic defects. There was no evidence of facial growth disturbance in this group of patients, except in one patient who received radiotherapy after surgery. Operative time and hospitalization were lower in this group than in patients with conventional frontal craniotomy.

The traditional approach for injuries of the skull base in the frontoethmoidal area has been frontal craniotomy with retraction of the frontal lobe. To decrease the morbidity of this technique, Raveh et al. described the subcranial approach for the treatment of nasoethmoidal trauma [1,2]. The subcranial approach was used later by the same authors for the treatment of the anterior base cranial deformities [3] and tumors [4,5]. In the medical literature, there are few publications on this approach in pediatric patients [6,7,8].
From January 1996 to October 2008 in the Plastic and Reconstructive Surgery Unit at a Children Hospital of Buenos Aires, we used the subcranial approach in a limited number of pediatric patients with nontraumatic pathology. The purpose of this article is to communicate this experience.

Methods

We retrospectively analyzed the medical records of nine patients treated in the Plastic and Reconstructive Surgery Unit at a Children Hospital of Buenos Aires from January 1996 to October 2008, with subcranial approach technique. This technique consisted of:
  • Bicoronal incision, elevation of the frontal flap up to the nasal dorsum, with visualization of the lower edge of the nasal bones, and release of the supraorbital nerves
  • Bone carving of a plaque that includes the central region of the frontal bone, with its external limits in the supraorbital nerves (Figure 1)
  • Lifting bone plaque, leaving, if possible, the periostium attached to the lower end of nasal bone (Figure 2)
  • Treatment of tumor/trauma and eventual reconstruction of the orbital wall or floor of the anterior cranial fossa with a bone graft (Figure 3)
  • Sealing of the surgical area with galea flap and fibrin glue (Figure 4)
  • Repositioning and fixation of the bone plaque (we preferred bioabsorbable mesh) ( Figure 5 )
  • Repositioning and closure of the frontal flap
Nine patients were operated on using this procedure (six females, three males), with an age range from 10 months to 14 years and an average of 5 years and 3 months. Pathology results are detailed in Table 1.
The average follow-up was 3 years and 3 months. Two patients with dermoid cysts dropped out during the first and second year after operation, respectively. At that time, there were no signs of disease recurrence.
One patient died at 10 days postsurgery due to a thrombotic stroke. She had been operated on for a vascular tumor of the ethmoidal region.
Another patient had recurrence of an orbital meningioma, which was reoperated on and irradiated. The patient remains with no disease progression 12 years after treatment. At present, the patient shows slight changes in the frontal boundary (Figure 6). One patient had local infection and required a new surgery to remove the mesh of absorbable osteosynthesis (Figure 7), and another one with nasal pus discharge had spontaneous drainage, which resolved with medical treatment.
The other patients had no complications.

Discussion

The congenital diseases, trauma or tumors of the orbitonasoethmoidal region in pediatric patients have required traditionally a major approach, through a frontal craniotomy with frontal lobe displacement backward to treat the injury. This surgical approach had severe complications such as encephalomalacia, anosmia, olfactory nerve injury, and other serious cosmetic and functional changes [9,10], and there were problems sealing the dura. The reconstruction of the bone defect created aesthetic flaws of paranasal incisions, anosmia, and potential damage to the frontal lobe due to prolonged retraction. Raveh and Vuillelmin originally described a subcranial approach to treat fractures of the central region of the face. The easy implementation of this approach encouraged the authors to use it for tumor treatment, and other groups published several articles on the subject [11]. A combination of the subcranial approach with an intraoral approach of the maxillary region (a technique known as “facial degloving”) [12] or with approaches to the temporal fossa and the treatment of tumors of the frontal region has also been published [13]. Although the endoscopic technique has been proposed for resection of nasal dermoids in an attempt to minimize morbidity, the authors [14] only dealt with cases of small size and small intracranial communication. The use of endoscopic approaches in pediatrics is limited by the small diameter of the nasal cavity and the need of very narrow instruments.
Moore et al. [15], in a comparative analysis with traditional techniques, concluded that the operative time, need of intensive care, and hospital stay are significantly lower, without implying higher morbidity and mortality. In our patients, the average hospital stay was 3.5 postoperative days. Only the patient who suffered a stroke required intensive care.
Kellman et al. [6] in 2004 published their results of this approach in three patients with uncomplicated nasal dermoid cysts. In 2007, this group published another communication [7] and concluded that the technique is effective in younger patients, provides excellent exposure, minimizes frontal lobe retraction and cerebrospinal fluid fistulas, and has excellent cosmetic results. Follow-up of these patients showed that their facial growth was not impaired. This opinion is shared by Shlomi et al. [16] in the discussion of their population of adolescents.
In our series, only one patient, operated on due to an orbitoethmoidal meningioma (now 22 years old), had a slight alteration at the frontal region; but it should be noted that she is the only patient who had received local radiation therapy. In our follow-up, we have found no abnormalities of facial growth in patients who are still being followed.
We want to show our successful experience with the subcranial approach in pediatric patients. In a case of orbital bone fibrous dysplasia and meningioma, as well as in a frontal mucocele with involvement of the inner wall of the orbit, bone grafts taken from the outer table of the calvaria skull, already exposed by the approach, were used to repair the bone defects. It was also easy to repair the medial canthus under direct vision. The facts mentioned above are considered advantages for the subcranial approach.
Moreover, we highlight the ease of sealing the anterior cranial fossa with a galea flap or with bone grafts, or both. This is a point that we share with other authors [17,18,19,20].

Conclusions

Based on the above and in coincidence with other published work [21,22], we conclude that the subcranial approach in the pediatric population minimizes morbidity. Surgical exposure was excellent. Cosmetic results were excellent in all cases followed (Figure 8 and Figure 9). There was no evidence of facial growth disturbance (Figure 10 and Figure 11), but a longer follow-up and larger series of patients are necessary to confirm that. Operative time and hospitalization were lower in this group than in patients with conventional frontal craniotomy, which added to the above-mentioned benefits.

References

  1. Raveh, J.; Redli, M.; Markwalder, T.M. Operative management of 194 cases of combined maxillofacial-frontobasal fractures: Principles and surgical modifications. J. Oral. Maxillofac. Surg. 1984, 42, 555–564. [Google Scholar] [PubMed]
  2. Raveh, J.; Vuillemin, T. The surgical one-stage management of combined cranio-maxillo-facial and frontobasal fractures. Advantages of the subcranial approach in 374 cases. J. Craniomaxillofac. Surg. 1988, 16, 160–172. [Google Scholar] [CrossRef] [PubMed]
  3. Raveh, J.; Vuillemin, T. Subcranial-supraorbital and temporal approach for tumor resection. J. Craniofacial Surg. 1990, 1, 53–59. [Google Scholar]
  4. Raveh, J.; Vuillemin, T. Advantages of an additional subcranial approach in the correction of craniofacial deformities. J. Craniomaxillofac. Surg. 1988, 16, 350–358. [Google Scholar]
  5. Raveh, J.; Laedrach, K.; Speiser, M.; Chen, J.; Vuillemin, T.; Seiler, R.; Ebeling, U. The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch. Otolaryngol. Head Neck Surg. 1993, 119, 385–393. [Google Scholar]
  6. Kellman, R.M.; Goyal, P.; Rodziewicz, G.S. The transglabellar subcranial approach for nasal dermoids with intracranial extension. Laryngoscope 2004, 114, 1368–1372. [Google Scholar] [CrossRef]
  7. Goyal, P.; Kellman, R.M.; Tatum, S.A., III. Transglabellar subcranial approach for the management of nasal masses with intracranial extension in pediatric patients. Arch. Facial Plast. Surg. 2007, 9, 314–317. [Google Scholar] [CrossRef]
  8. Gil, Z.; Constantini, S.; Spektor, S.; Abergel, A.; Khafif, A.; Beni-Adani, L.; Leonor, T.-L.; DeRowe, A.; Fliss, D.M. Skull base approaches in the pediatric population. Head Neck 2005, 27, 682–689. [Google Scholar]
  9. Jung, T.M.; TerKonda, R.P.; Haines, S.J.; Strome, S.; Marentette, L.J. Outcome analysis of the transglabellar/subcranial approach for lesions of the anterior cranial fossa: A comparison with the classic craniotomy approach. Otolaryngol. Head Neck Surg. 1997, 116 Pt 1, 642–646. [Google Scholar] [CrossRef]
  10. Kellman, R.M.; Marentette, L. The transglabellar/subcranial approach to the anterior skull base: A review of 72 cases. Arch. Otolaryngol. Head Neck Surg. 2001, 127, 687–690. [Google Scholar] [CrossRef]
  11. Raveh, J.; Vuillelmin, T. Advantages of the subcranial approach in craniofacial surgery. In Rigid Fixation of the Craniofacial Skeleton; Yaremchuk, M., Gruss, J., Manson, P., Eds.; Butterworth-Heinemann: Boston, MA, USA, 1992; p. 56. [Google Scholar]
  12. Fliss, D.M.; Zucker, G.; Amir, A.; Gatot, A. The combined subcranial and midfacial degloving technique for tumor resection: Report of three cases. J. Oral. Maxillofac. Surg. 2000, 58, 106–110. [Google Scholar] [CrossRef] [PubMed]
  13. Fliss, D.M.; Abergel, A.; Cavel, O.; Margalit, N.; Gil, Z. Combined subcranial approaches for excision of complex anterior skull base tumors. Arch. Otolaryngol. Head Neck Surg. 2007, 133, 888–896. [Google Scholar]
  14. Weiss, D.D.; Robson, C.D.; Mulliken, J.B. Transnasal endoscopic excision of midline nasal dermoid from the anterior cranial base. Plast. Reconstr. Surg. 1998, 102, 2119–2123. [Google Scholar] [PubMed]
  15. Moore, C.E.; Ross, D.A.; Marentette, L.J. Subcranial approach to tumors of the anterior cranial base: Analysis of current and traditional surgical techniques. Otolaryngol. Head Neck Surg. 1999, 120, 387–390. [Google Scholar] [PubMed]
  16. Shlomi, B.; Chaushu, S.; Gil, Z.; Chaushu, G.; Fliss, D.M. Effects of the subcranial approach on facial growth and development. Otolaryngol. Head Neck Surg. 2007, 136, 27–32. [Google Scholar]
  17. Fliss, D.M.; Zucker, G.; Amir, A.; Gatot, A.; Cohen, J.T.; Spektor, S. The subcranial approach for anterior skull base tumors. Oper. Tech. Otolaryngol. Head Neck Surg. 2000, 11, 238–253. [Google Scholar]
  18. Fliss, D.M.; Gil, Z.; Spektor, S.; Leider-Trejo, L.; Abergel, A.; Khafif, A.; Amir, A.; Gur, E.; Cohen, J.T. Skull base reconstruction after anterior subcranial tumor resection. Neurosurg. Focus. 2002, 12, e10. [Google Scholar]
  19. To, E.W.; Pang, P.C.; Chan, D.T.; Lam, J.M. Subcranial anterior skull base dural repair with galeal frontalis flap. Br. J. Plast. Surg. 2001, 54, 457–460. [Google Scholar]
  20. Laedrach, K.; Lukes, A.; Raveh, J. Reconstruction of skull base and fronto-orbital defects following tumor resection. Skull Base 2007, 17, 59–72. [Google Scholar]
  21. Fliss, D.M.; Zucker, G.; Cohen, A.; Amir, A.; Sagi, A.; Rosenberg, L.; Leiberman, A.; Gatot, A.; Reichenthal, E. Early outcome and complications of the extended subcranial approach to the anterior skull base. Laryngoscope 1999, 109, 153–160. [Google Scholar]
  22. Shohet, M.R.; Laedrach, K.; Guzman, R.; Raveh, J. Advances in approaches to the cranial base: Minimizing morbidity. Facial Plast. Surg. 2008, 24, 129–134. [Google Scholar] [CrossRef] [PubMed]
Figure 1. Dissection of the frontal flap up to the nasal dorsum. Carving a plaque that includes the frontal bone with outermost limits in the supraorbital nerve.
Figure 1. Dissection of the frontal flap up to the nasal dorsum. Carving a plaque that includes the frontal bone with outermost limits in the supraorbital nerve.
Cmtr 03 00029 g001
Figure 2. Lifting of the frontonasal plaque leaving, if possible, soft tissues adhered to the nasal bone.
Figure 2. Lifting of the frontonasal plaque leaving, if possible, soft tissues adhered to the nasal bone.
Cmtr 03 00029 g002
Figure 3. Treatment of the pathology and eventual reconstruction of the orbital wall or floor of the anterior cranial fossa with bone graft harvested from calvaria.
Figure 3. Treatment of the pathology and eventual reconstruction of the orbital wall or floor of the anterior cranial fossa with bone graft harvested from calvaria.
Cmtr 03 00029 g003
Figure 4. Sealing the area with galea flap and fibrin glue.
Figure 4. Sealing the area with galea flap and fibrin glue.
Cmtr 03 00029 g004
Figure 5. Repositioning and fixation of bone plaque.
Figure 5. Repositioning and fixation of bone plaque.
Cmtr 03 00029 g005
Figure 6. Recurrent meningioma sequel. The patient received radiotherapy.
Figure 6. Recurrent meningioma sequel. The patient received radiotherapy.
Cmtr 03 00029 g006
Figure 7. Local infection. The patient needed reoperation to remove the reabsorbable mesh.
Figure 7. Local infection. The patient needed reoperation to remove the reabsorbable mesh.
Cmtr 03 00029 g007
Figure 8. Fibrous dysplasia. Presurgical appearance.
Figure 8. Fibrous dysplasia. Presurgical appearance.
Cmtr 03 00029 g008
Figure 9. Fibrous dysplasia. Two years after surgery.
Figure 9. Fibrous dysplasia. Two years after surgery.
Cmtr 03 00029 g009
Figure 10. Nasal dermoid cyst. Presurgical appearance.
Figure 10. Nasal dermoid cyst. Presurgical appearance.
Cmtr 03 00029 g010
Figure 11. Nasal dermoid cyst. Four years after surgery.
Figure 11. Nasal dermoid cyst. Four years after surgery.
Cmtr 03 00029 g011
Table 1. Cases.
Table 1. Cases.
DiagnosisAgeSexFollow-up (y)Complications
Naso-orbital meningioma7 yF12Orbital recurrence; frontal alteration
Nasal dermoid cyst3 y, 6 moF3No complications
Nasal dermoid cyst2 y, 3 moF2No complications
Nasal dermoid cyst4 yM3Local infection; reoperation
Nasal dermoid cyst4 y, 2 moM1No complications
Vascular tumor (nonspecific)9 yFDeath at 10 d postsurgery (stroke)
Nasal dermoid cyst20 mF5Nasal discharge; medical treatment
Orbital fibrous dysplasia3 y, 5 moF3No complications
Frontal mucocele14 yM8No complications
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Ciechomski, J.; Aufgang, R.; Villanueva, L.; Demarchi, V. Subcranial Approach in Pediatric Craniofacial Surgery. Craniomaxillofac. Trauma Reconstr. 2010, 3, 231-235. https://doi.org/10.1055/s-0030-1268521

AMA Style

Ciechomski J, Aufgang R, Villanueva L, Demarchi V. Subcranial Approach in Pediatric Craniofacial Surgery. Craniomaxillofacial Trauma & Reconstruction. 2010; 3(4):231-235. https://doi.org/10.1055/s-0030-1268521

Chicago/Turabian Style

Ciechomski, Jorge, Ruben Aufgang, Lucrecia Villanueva, and Victoria Demarchi. 2010. "Subcranial Approach in Pediatric Craniofacial Surgery" Craniomaxillofacial Trauma & Reconstruction 3, no. 4: 231-235. https://doi.org/10.1055/s-0030-1268521

APA Style

Ciechomski, J., Aufgang, R., Villanueva, L., & Demarchi, V. (2010). Subcranial Approach in Pediatric Craniofacial Surgery. Craniomaxillofacial Trauma & Reconstruction, 3(4), 231-235. https://doi.org/10.1055/s-0030-1268521

Article Metrics

Back to TopTop