Operative Techniques in Otolaryngology (2010) 21, 39-43

A panoramic approach to the anterior skull base—The

combined subfrontal/subcranial and Le Fort I approach
Terry Y. Shibuya, MD, FACS,a Randall Schoeman, MD, DDS,a Sooho Choi, MDb

From the aDepartment of Head and Neck Surgery and the

b
Department of Neurosurgery, Southern California Permanente Medical Group, Anaheim, California.

KEYWORDS Surgical exposure for massive tumor of the anterior skull base can be difficult. We have combined two
Subfrontal; surgical approaches, the subfrontal/subcranial approach and the Le Fort I osteotomy approach, to
Subcranial; provide panoramic accesses to the anterior skull base. Via this combination of exposures, we have
Le Fort I; easily accessed and resected tumors extending from the cribiform plate all the way down to the level
Advanced head and of the upper cervical spine. Additionally, we have used the nasal endoscope and microscope to assist
neck tumors; in our resection. This approach has several advantages, which include ease of post-resection skull base
Anterior skull base reconstruction and excellent cosmetic results by avoiding anterior facial incisions. We believe this
tumors approach should be in the armamentarium of any surgeon resecting massive anterior skull base tumor.
© 2010 Elsevier Inc. All rights reserved.

Panoramic access to the anterior skull base is frequently
required for massive tumors that traverse the anterior skull
base and span multiple regions. Very few approaches pro-
vide wide surgical exposure that spans from the anterior
cribiform plate to the upper cervical spine. Over the past 8
years, we have combined the subfrontal/subcranial ap-
proach with the Le Fort I approach simultaneously. This
combination has provided a panoramic exposure of the
entire anterior skull base, from cribiform to upper cervical
spine. Both are easy to perform and hide all surgical inci-
sions in the scalp and sublabial regions, thereby avoiding
any facial scars. We have found that, for selectively large
tumors, this combination of approaches provides excellent
tumor access, hidden facial incisions, and easy reconstruc-
tive options.
Raveh, in 1978, pioneered the subfrontal approach to the
anterior skull base for the repair of high-velocity skull base
trauma and congenital anomalies.1,2 This approach provides
vertical access from the anterior ethmoid roof down to the
superior clivus and horizontal access across both orbital roofs,
extending toward the temporal bones laterally (Figure 1). Vi-
Address reprint requests and correspondence: Terry Y. Shibuya,
MD, FACS, Department of Head and Neck Surgery, Southern California
Permanente Medical Group, 3460 La Palma Ave, Anaheim, CA 92806.
E-mail address: terryshibuya@yahoo.com.
1043-1810/$ -see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.otot.2010.03.007
sualization of the nasal cavity and maxillary sinuses is possible
as well. The subfrontal exposure allows for intra- and extra-
dural tumor resection with minimal frontal lobe retraction. To
enhance visualization of the entire clivus and upper cervical
spine inferiorly, a transmaxillary or Le Fort I approach is
added3 (Figure 2). In addition, the septum is mobilized in a
fashion similar to a transeptal/transnasal pituitary approach
after mobilizing the lower maxilla inferiorly via a Le Fort I
osteotomy. This combination of techniques allows a pan-
oramic approach to the anterior skull base.
Technique
The subfrontal approach is briefly reviewed.
1. The subfrontal approach begins with a coronal incision
performed from preauricular crease to preauricular crease.
2. A pericranial flap is preserved and based on the su-
pratrochlear and supraorbital arteries for later use in
reconstruction of the anterior skull base defect. The flap
is carried down to the frontozygomatic suture line later-
ally and to the rhinion and piriform aperture medially.
3. The orbit is accessed and the periorbita elevated off the
medial, superior, and lateral orbital walls (Figure 3A).
The anterior ethmoidal artery is ligated.
40 Operative Techniques in Otolaryngology, Vol 21, No 1, March 2010
Figure 1 The subfrontal or subcranial approach to the skull
base. The arrow indicates the improved view with the subfrontal
extension.
4. Osteotomies are marked out, and the size of frontal bone
flap removed is dependent on the size of tumor being
access/resected. Osteotomies are usually performed as
follows: superior osteotomy—placed across the frontal
bone in a horizontal plane; lateral osteotomies— cut
from the superior osteotomy ends inferiorly down and
thru the superior orbital rims bilaterally; orbital osteoto-
mies—placed from the superior orbital rim cut 1 cm
posterior into the superior orbital roof, then cut 90°
medially to the medial orbital wall, then cut inferiorly
down the medial orbital wall to the level of the nasolac-
rimal duct, then cut anteriorly and out the medial orbital
wall; anterior osteotomy—placed along the nasomaxillary
groove horizontally just anterior to the lacrimal duct and
connected with the opposite side (Figure 3B). A final ver-
tical osteotomy is performed anterior to the crista galli
detaching the frontonasal segment. The orbit and dura are
protected at all times with ribbon retractors (Figure 4A).
5. There are variations in the size of bone flap removed (Fig-
ure 4). A Raveh type I approach removes the frontonasal
segment while preserving the posterior wall of the frontal
sinus. The posterior wall is removed in a second step and is
indicated when tumor abuts this region. A Raveh type II
approach removes the frontonasal segment, which includes
the posterior wall of the frontal sinus. This is performed
when tumor involves the posterior wall or broader intracra-
nial exposure is needed to access the tumor. Visualization
and removal of tumor extending to the sphenoid sinus and
clivus is easily achieved.
For sinonasal tumors extending through the olfactory groove,
the olfactory cleft may be easily keyholed and dropped infe-
riorly into the sinus cavity for an en bloc resection. If tumor
only involves one side of the olfactory groove, the involved
side may be easily visualized and resected while preserving the
opposite side.
Le Fort I approach
The Le Fort I approach is briefly reviewed.
1. A sublabial incision is performed in the gingival-buccal
sulcus, leaving a 5- to 7-mm cuff of mucosa for closure
of the wound postoperatively.
2. The cheek is elevated off bilateral anterior maxillary sinus
walls to the level of the nasal aperture and superiorly both
medial and lateral to the inferior orbital nerve exiting its
foramen on the anterior maxillary wall (Figure 5).
3. Next, the mucosa of the inferior nasal floor is elevated
bilaterally, and the mucosa is elevated off the lower nasal
septum bilaterally. This can be done via the sublabial
incision or performed via a hemitransfixation incision in
the right nostril (similar to performing a septoplasty).
When doing this, we elevate the mucosa off the septum
completely on one side and on the remaining side only
elevated to 3-5 mm above the maxillary crest/cartilaginous
septal junction. This will preserve the septal mucosal at-
tachment on one side, ensuring a cartilage/mucosa vascu-
lar blood supply to one side.
4. Next, osteotomies are performed along the anterior,
medial, and lateral maxillary sinus walls using an os-
cillating saw (Figure 6).
5. After performing the osteotomies, 1.5-mm titanium
midface plates are bent, drilled, and fixed into position.
This will allow for correct anatomic positioning of the
maxilla prior to fracturing. The plates are then saved in
cups marked with the correct anatomical position for
reconstruction post tumor resection (Figure 7).
6. Next, a curved osteotome is placed in the pterygomax-
illary fissure, and an osteotomy is performed on the left
and right sides.
7. After this, two small self-retaining retractors are placed
between the anterior maxillary osteotomies on the left
Figure 2 The transmaxillary with the Le Fort I osteotomy ap-
proach to the skull base. Lines indicate the extent of exposure.
Shibuya et al Combined Subfrontal/Subcranial and Le Fort I Approach 41

Figure 3 The subfrontal approach. (A) Subcranial access viewed from above. (B) Osteotomies performed. FS, frontal sinus.

and right sides (Figure 8). Each is then simultaneously
opened, similar to “opening a clam shell.”
8. At the base of the clam shell or posterior wall of the
maxilla, the pterygoid plates are then resected carefully
using Takahashi forceps, and the pterygoid muscles are
released from their insertion on the plates. As this
occurs, the maxilla will descend, and the self-retaining
retractor can be maximally opened.
9. The septum can now be pushed to one side, and a Hardy
pituitary retractor can be placed trans-septally to expose
the anterior wall of the sphenoid sinus. Because the cavity
is very large, the speculum lies at the level of the upper
cervical spine region. To enhance exposure, we usually
place two Hardy retractors on top of each other to provide
enhanced retraction and exposure (Figure 9).
10. At this point, surgical exposure will be visible from the
cribiform region all the way to the level of the upper
cervical spine. The endoscope or microscope or both can
be used to assist with tumor resection using this technique.
Reconstruction
Brief review of reconstruction option:
1. Once the tumor has been resected, there are several
options for reconstructing the anterior skull base. A large
pericranial flap that was previously harvested with the
subfrontal approach may be rotated into the defect. This

Figure 4 Raveh type 1 and 2 approaches. (A) The frontal bone flap created with the type 1 and 2 approaches. (B) Removal of the frontal
bone flap and view obtained.
42 Operative Techniques in Otolaryngology, Vol 21, No 1, March 2010
Figure 5 The facial degloving approach with exposure of the
anterior maxillary sinus wall.
can be used to seal the cribiform region and sphenoid
sinus and line the clivus and cervical spine.
2. If the flap is too short or inadequate in length to reach,
we routinely harvest tensor fascia lata from the thigh,
cutting it into strips of adequate length and width to
cover the defect. We routinely place three layers of
tensor over the defect in a layered fashion and use fibrin
glue to secure into position.
3. Next, the nasal mucosa is then repositioned to cover the
flap or tensor.
4. After this, the bone flaps are fixed back into position. For
the maxilla, the prebend plates and screws are fixed into
position. For the subfrontal area, the bone flap is stripped
of any mucosa, and a diamond bur is used to bur any
residual mucosa off the bone. The frontal sinus is crani-
alized, and the bone is secured into proper position with
microplates or titanium mesh.
5. The nose is then packed with either strip gauze coated
with bacitracin ointment or nasal tampons coated with
ointment.
6. The patient is then kept intubated overnight, but will
frequently have a tracheotomy placed to reduce the
Figure 6 Osteotomies of the anterior, lateral and medial maxilla,
prior to fracturing. (Color version of figure is available online.)
Figure 7 Plating the anterior maxilla, prior to mobilizing the
maxilla. (Color version of figure is available online.)
chance of airway obstruction and prevention of a tension
pneumocephalous. If there is a concern regarding a po-
tential cerebral spinal fluid (CSF) leak, we do not rou-
tinely place suction drain in the scalp. This is to reduce
the potential for the drain to create a suction fistula.
Complications
To prevent a CSF leak, meticulous dural reconstruction is
performed. Small dural defects are sutured shut, whereas
larger defects may be repaired using an anteriorly based
pericranial flap or a laterally based temporalis–pericranial
flap. Either flap is rotated into the defect and used to sepa-
rate the dura from the sinonasal cavity. Other options in-
clude using tensor fascia lata, temporalis fascia, lyophilized
dura, or bovine pericardium to separate the regions. For
large defects, a free or pedicled myocutaneous flap may be
used as well. To prevent herniation of the medial orbital
contents, temporalis fascia or tensor fascia lata may be used
to line the medial wall. Gel foam (Pfizer, New York, NY) is
then placed on top of the fascia, and xeroform gauze (Co-
vidien, Mansfield, MA) is used to line the cavity. Bacitra-
cin-impregnated packing is placed to hold the grafts in
position for 1 week and then removed. A triple layer of
tensor fascia lata has been used successfully and is very
Figure 8 Opening the maxilla with self-retaining retractors.
(Color version of figure is available online.)
Shibuya et al Combined Subfrontal/Subcranial and Le Fort I Approach
Figure 9 Placement of two Hardy retractors trans-septally,
stacked on top of each other with the maxilla pushed inferiorly for
improved exposure of the skull base. (Color version of figure is
available online.)
effective at preventing leaks or infections. Free bone grafts
to reconstruct the medial orbital wall are rarely performed.
If used, they must be completely surrounded by vascular-
ized tissue or there will be a high risk of failure. This is
especially true in a previously irradiated tissue bed. The use
of alloplastic materials or titanium mesh in irradiated tissue
beds or soon-to-be-radiated beds is not routinely recom-
mended due to infectious complications and extrusion of
alloplastic material over time.
Discussion
Panoramic exposure of the anterior skull base from cribi-
form to upper cervical spine is occasionally required for
advanced skull base tumors. Over the past decade, we have
combined two individual approaches, the subfrontal/subcra-
nial approach with the Le Fort I approach, to provide pan-
oramic exposure. With this combination we have been able
to surgically resect a variety of very extensive tumors. We
have also added the assistance of the nasal endoscope and
microscope to further enhance our visualization, dissection,
resection, and reconstruction. The broader exposure has
allowed the surgeon to use a two-handed surgical approach
while operating along the anterior skull base. Additionally,
43
the sublabial incision and coronal incision have prevented
anterior facial scars and enhanced cosmetic outcome.
Reconstruction of defects along this region can be quite
extensive, especially if the clivus is resected and the only
remaining barrier between the nasopharynx/sinus region is
the dura covering the brainstem. In such instances, we have
used a large pericranial flap rotated into the defect from
above or used a triple layering of tensor fascia lata covering
the dura. Overlying this, we rotate nasal/septal mucosa
provided it is available and has not been resected. After this
is completed, gel foam impregnated with bacitracin oint-
ment is placed on top of the grafts/flap; finally, xeroform
gauze with strip gauze is packed against the gel foam to
hold everything in place. This is kept in position for 7 days
and then removed in the office or under sedation if the
patient is not cooperative or there is concern a dehiscence is
present. Radiation for malignant tumor may be necessary,
and it is very important that the wound has healed prior to
radiation. We routinely wait 6 weeks prior to initiating this.
Patient postoperative care is very important to prevent
infections. Patients will frequently develop very large crusts
that need to be removed. Patients are instructed to flush their
nasal passage/douche with saline four to six times a day for
about a week after the packing is removed. They will need
to be seen on a regular basis for nasal debridement while the
cavity is maturing. At times the crusting can be very adher-
ent to the lateral nasal walls and posterior nasopharynx/
clival wall. It is not recommended to be overly vigorous in
removing the posterior wall crusts, especially if the poste-
rior bony wall has been completely removed. With time the
crust will mature and soften and can be gently removed in
the office. Flushing with saline is an important adjunct to
loosing the scabs/crust, helping to facilitate the cavity’s
maturation.
In conclusion, we have found the combination of the
subfrontal/subcranial approach with the Le Fort I osteotomy
approach to be a very effective exposure to massive tumors
extending along the anterior cranial base. The access has
been panoramic in nature, allowing for excellent visualiza-
tion for resection and reconstruction, while providing ex-
cellent cosmesis.
References
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fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol
Head Neck Surg 119:385-393, 1993
2. Shibuya TY, Armstrong WB, Shohet J: Skull base surgery, in Ensley JF,
Gutkind SJ, Jacobs JR, Lippman SM (eds): Head and Neck Cancers.
San Diego, CA, Academic Press, 2003, pp 339-357
3. Brown H: The Le Fort I maxillary osteotomy. J Maxillofac Surg 14:
112-119, 1986