subcranial approach

This procedure was first introduced by Ravch et al. in 1993. They initially used this procedure to treat skull base trauma and craniofacial deformities. The following description is slightly different from the original method. Treatment of diseases: eyelid meninges - brain swelling Indication According to the extent and location of the lesion, different subcranial approaches are divided into three types of surgery. 1.lateral fronto-orbital osteotomy is applied to the treatment of the lateral anterior skull base and supraorbital skull base lesions, including frontal sinus, ethmoid sinus, upper orbital malignant tumor, traumatic and Malformation, meningeal bulging, etc., but does not include lesions with apical and intracranial involvement. 2. Subcranial extended fronto-nasao-orbital exposure can be further divided into unilateral frontal-nasal-sacral and medial temporal osteotomy (unilateral fronto-naso- Suprarorbital and medial orbital wall osteotomy and bilateral fronto-naso-orbital osteotomy, which is suitable for one or both sides of the axillary lesions, including the medial and lateral iliac wall, The apex of the sac and the frontal and posterior wall of the frontal sinus, the lesion of the ethmoid sinus, and the lesion in the central or paramedian region of the skull base, posterior to the sphenoidal sphenoidale, sphenoid sinus, sphenoid sinus, slope, etc., including the nasal cavity Upward, the olfactory sulcus, the cockscomb and the intracranial dura mater can be exposed to the front, middle and back of the skull base. 3.Connected subcranial transfrontal procedure This procedure is suitable for a wide range of intracranial invasions. It is actually a combined cranio-nasal approach. The difference is that the surgical incision and the surgical field are in the same area. The bottom is separated to the eyelids to reveal the dome. Contraindications Because this surgical approach is mainly applied to the upper and lower part of the skull base plate and the lesions from the anterior to the anterior and posterior, the lesion extends outward to the maxillary sinus and the pterygopalatine fossa is difficult to handle, so the operation expands outward. The treatment of lesions is limited and should be noted when selecting cases. Preoperative preparation 1. The same nasal "H" incision surgery, including preoperative antibiotics and preoperative preparation of general anesthesia. 2. Should be prepared for the forehead scalp, shaved hair, eyebrows. 3. The imaging examination should have a brain MRI to understand the lesions in the brain. 4. Consultation with relevant departments to assess the effects of lesions and surgery on the optic nerve and important intracranial blood vessels. Surgical procedure Incision In the forehead hairline, the bilateral incision of the bilateral iliac crest is deep, and the superficial aponeurosis is shallow, and the deep soft tissue is preserved. It can be used as a pedicled aponeurotic periosteal flap to repair the meningeal defect. 2. Separation Separate the superficial skin, subcutaneous tissue and superficial fascia of the cap-like aponeurosis to the plane of the eyebrow arch, and then cut the aponeurosis and periosteum of the cap, and use the periosteal stripper to separate along the bone surface until the upper edge of the iliac crest and separate the periosteum of the apical wall; If it is a single side, only one side of the dome wall can be separated, and if it is on both sides, the double-sided dome wall should be separated. 3. Cut the skull The first type of surgery only needs to cut the extra iliac crest on the lateral wall. On the outside of the glabella, the second type of bone is cut more outward, including the frontal condyle or the superior iliac crest and the lower part of the frontal and middle The frontal nose, the third type, in addition to the above different bone incision methods, also need to open a bone window in the middle of the frontal bone to treat the lesions invading the meninges and brain tissue of the forehead. 4. Sinus treatment Excision of the medial mucosa of the frontal sinus floor, enlargement of its opening; ethmoid sinus resection, including middle turbinate if necessary, open anterior wall of the sphenoid sinus. The sinus mucosa can be removed as needed. 5. Meningeal repair If there is involvement of the meninges or brain tissue, it should be repaired after the lesion is removed. The forehead cap aponeurosis (with pedicle or free) can be used. The fascia is usually placed under the dura mater, partially overlapping (2.0mm), then The suture is sutured in a continuous blanket, so that when the brain tissue is restored, the fascia can be implanted and pressed, and the dura mater is attached and closed, which is beneficial to healing. 6. Skull reduction After the lesion is removed, the skull is removed and the skull can be removed and fixed with steel wire or micro-shaped titanium plate. 7. Nasal packing After the operation chamber was rinsed with physiological saline and antibiotic solution, the nasal cavity was filled with iodoform gauze. 8. Stitching and dressing wounds The forehead incision was sutured in full layers, and a rubber drainage strip was placed on the surface of the skull, one on each side, and the bandage was pressure-wrapped with two bandages. complication 1. Cerebrospinal fluid leakage: After repairing the dural defect, short-term cerebrospinal fluid may occur after surgery, and if there is improper repair, continuous leakage may occur. 2. Local or intracranial infection: Because the operation is connected with the nasal cavity or sinus, postoperative infection is easy, including sputum cellulitis, frontal osteomyelitis and meningitis. Therefore, postoperative care should be taken to prevent infection. 3. Olfactory loss: This surgical approach is prone to damage one or both sides of the olfactory tissue or the olfactory fossa resulting in postoperative olfactory impairment or loss.