Infratemporal fossa approach inversion of zygomatic complex tissue flap surgery

1. The maxillary sinus cancer invades the pterygopalatine fossa, the infraorbital fossa, and the middle skull base. 2. The upper alveolar and posterior buccal malignant tumors invade the infraorbital fossa. 3. The primary tumor of the infraorbital fossa. 4. Nasopharyngeal carcinoma invading the nasopharynx wall. 5. Benign tumors in the parasite and middle cranial fossa invade the middle skull base sphenoid ridge. Treatment of diseases: maxillary sinus cancer, nasopharyngeal carcinoma Indication 1. The maxillary sinus cancer invades the pterygopalatine fossa, the infraorbital fossa, and the middle skull base. 2. The upper alveolar and posterior buccal malignant tumors invade the infraorbital fossa. 3. The primary tumor of the infraorbital fossa. 4. Nasopharyngeal carcinoma invading the nasopharynx wall. 5. Benign tumors in the parasite and middle cranial fossa invade the middle skull base sphenoid ridge. Contraindications Malignant tumors invade the internal carotid artery, the sphenoid sinus wall, the cavernous sinus and other parts, and can not be completely removed. Preoperative preparation 1. Systemic and specialist examinations, including blood biochemistry, blood type, heart, lung, liver, kidney function, chest X-ray and paranasal sinus CT, MRI examination, if necessary, please consult the relevant departments, including neurosurgery, ophthalmology, etc. 2. Antibiotics were given 1 to 2 days before surgery and administered as required for general anesthesia. 3. Head preparation skin. Surgical procedure 1. Incision nasal incision, incision of the lower eyelid 0.5cm outside the internal iliac crest, and the conjunctiva was cut along the conjunctival sac, deep to the lower iliac bone surface, outward to the external wall of the iliac crest. In the outer iliac crest, a 0.5 cm full layer was cut open 0.4 cm below the upper eyelid, and the upper eyelid skin and the orbicularis oculi muscle were cut at a level of 0.4 cm from the gingival margin. The incision is inwardly to the midline of the upper incision, and the skin is cut into the bone surface in the forehead, and the hair is turned into a hairline 1 cm and then turned to the temporal side, and bent downward, and stopped at 5 cm on the ear. The frontotemporal and maxillary soft tissue flaps were opened on the periosteum to the outer edge of the ankle. The entire lower layer of the lower jaw is attached to the tissue flap: the upper septum plane is carefully separated, so that the orbicularis muscle and skin are attached to the tissue flap, and the 0.4 cm skin of the lower part of the palate and all the conjunctiva of the tarsal plate are retained in situ. The outer edge of the iliac crest and the humeral area are not separated. 2. Cut the skeletal connection to the ankle along the bone surface, down to the infraorbital fossa, insert the saw blade along the large wing of the sphenoid, and longitudinally saw the outer edge of the upper edge and the outer wall of the eyelid. Insert the saw blade into the infraorbital fossa along the outer wall of the upper jaw and saw the maxillary condyle forward. The specific location of the two sawing lines should be determined according to the specific lesion location and extent. In principle, there should be a certain safety margin from the tumor invasion site. In front of the zygomatic arch joint, the skin is incision 1 cm, and placed in the posterior part of the flat chisel. 3. Open the noodle composite tissue flap with a flat chisel along the sawing line, you can open the facial ridge and the iliac crest composite tissue flap together with the outer wall of the iliac crest and the humerus. If the posterior exposure is not enough, the mandibular condyles are sawn together and turned over. If there is a tumor invasion at the suspected condyle, it is cut off along with the condyle and the lower diaphragm. According to the difference between the lesion and the surgical field, it can be divided into the following three layers. 1 The sacral fossa in the lower fossa was initially revealed: after the frontotemporal complex tissue flap was turned backward and backward, the pterygopalatine, the internal iliac artery, the pterygoid muscle, the buccal nerve, and the part of the pterygoid muscle were all revealed. The ankle was drilled, the bone flap was opened, and the lateral part of the cranial fossa was revealed. 2 The inferior fossa of the lower fossa revealed deep excision: the internal maxillary artery, buccal nerve, pterygoid muscle, and pterygoid plate were removed, and the posterior wall of the maxillary sinus was partially removed, and the trunk of the trigeminal mandible and its branches and wings were revealed. Muscle, wing splitting, etc. The ankle bone window is enlarged, the bone of the lateral part of the middle skull base is worn away, and the cerebral palpebral leaves are pulled backwards. In the skull, the mandibular branch and the maxillary branch of the trigeminal nerve can be seen. Downward can be used to investigate the invading condition of the middle skull base plate; the front frontal area and the supraorbital sacral area can be explored forward; the sphenoidal winglet posterior sac area can be explored upwards. 3 The lower cranial fossa is closer to the midline. The trigeminal mandibular branch is cut at the foramen ovale. The pterygoid muscle is cut and the sacral muscle is cut. The eustachian tube, the sacral muscle, and the pharyngeal muscle can be exposed. Outside the pharyngeal recess. Separate and cut the posterior junction of the eustachian tube, cut off the cartilage-like tissue, and open the internal carotid artery to expose the horizontal section of the internal carotid artery. The inward can be traced to the upper part of the fracture hole. In the skull, the trigeminal semilunar ganglion and the saddle cavernous sinus region can be reached. Grinding the bones next to the saddle enters the sphenoid sinus. 4. The surgical procedure and scope of resection of the tumor are determined according to the nature of the lesion, the location and extent of the lesion. Primary in the posterior region of the buccal sac and posterior maxillary sinus, invading the pterygopalatine region and the infraorbital fossa, mainly to remove the anterior inferior fossa, the buccal region, the posterior maxillary, the pterygoid, the lower part of the sphenoid wing, and the wing Radial root, part of the cranial fossa plate. After the initial infraorbital fossa was exposed, the skull was drilled into the lower part of the scapular scale and the lower part of the sphenoid wing. The mid-cranial base dura was separated and the intracranial involvement was investigated. The internal maxillary artery was ligated at the pterygoid muscle, and the venous plexus was sutured and ligated, and the electric muscle knife was used to cut the wing muscle. Separate and probe the tip of the sputum and cut the bone according to the condition. The cheek area and the anterior and posterior maxillary area were incisioned according to conventional surgical methods. The mandibular condyle, the anterior ascending branch, and part of the diaphragm are often removed together. If it is a nasopharyngeal tumor, after the initial infraorbital fossa is exposed, the internal maxillary artery is first ligated, and the medial end of the pterygoid muscle is cut and pulled downward. Open the ankle bone flap, enter the middle cranial fossa, separate the mid-cranial base dura, cut the mandibular nerve, and pull the cerebral temporal lobe back. Behind the joint of the rock butterfly is the anterior superior wall of the internal carotid artery. The spine can indicate the posterior inner part of the internal carotid artery. The internal carotid artery is opened from the anterior and the artery is exposed to the rupture hole. The lower wall of the bone can be cut open. Cut off the eustachian tube, the lateral attachment of the Zhangye sail muscle, cut the root of the pterygos just below the bone surface of the saddle, and then enter the sphenoid sinus, pay attention to protect the internal carotid artery and cavernous sinus. The midline was separated back along the pharyngeal contraction muscle. In this way, the nasopharyngeal tumor can be removed substantially in bulk. Tumor in the parasagittal area: After the initial infraorbital fossa was exposed, the external pterygoid muscle was cut downward and the anterior craniotomy was performed. Mainly remove the anterior inner part of the sphenoidal wing, bite the outer wall of the iliac crest to reach the tip of the iliac crest, completely open the supracondylar sulcus, remove the root of the pterygoid, cut off the maxillary nerve, and the saddle can be revealed. 5. Repair the defect in the operation area, close the operation cavity to make the diaphragm and fascia flap, cover the dura mater and wound surface of the skull base. Part of the residual defect area can be opened to the nasopharynx or mouth, filled with gelatin sponge and iodoform gauze. The ankle bone flap was restored and the facial palpebral composite tissue flap was repositioned. The wire was fixed at the osteotomy, and the incision was layered and sutured. complication If it is a paranasal sinus tumor, the lesion is easily invaded to the tip of the sacrum, near the saddle, close to the internal carotid artery. If the blood vessel ruptures, fatal bleeding can occur. This is the most serious complication of the operation. Be careful. Pay attention to the depth of the operation and the direction of the instrument operation, do not over-detect. Benign tumors in this area may be separated and resected; if it is a malignant tumor, it can only be stopped. Blood vessels that have been invaded by tumors, that is, detected using blunt instruments, may also have the possibility of breaking through blood vessels. In the event of a ruptured internal carotid artery, local compression and tamponade will not help, and the internal carotid artery can only be ligated quickly in the neck. Other complications refer to anterior skull base surgery and Holliday surgery.