Embouchure Dystonia - Trombone - "Losing the Lip" - Loss of Lip Control Wind Instruments -- Music and Medicine on MondayClick Here

Anterior Craniofacial Resection with Formal Anterior Bifrontal Craniotomy

last modified on: Tue, 08/29/2023 - 08:30

see also: Anterior Pericranial and Galeofrontalis-Pericranial FlapParanasal Sinus Surgery ProtocolsCranioplasty


  1. Note this approach is useful to consider but has been replaced in many cases by endoscopic approaches (Albonette-Felicio et al. 2020)

  2. Historical considerations no longer relevant include obtaining "plain skull film: Caldwell view at 6 ft, if planning subfrontal approach"

  3. Indications
    1. Tumors of the ethmoid sinus, frontal sinus, nasal cavity, orbits, and facial skin; ethmoid carcinoma, esthesioneuroblastoma, sinonasal undifferentiated carcinoma, melanoma, sarcoma
  4. Contraindications
    1. At times, a surgical exploration is the only way to evaluate the true extent of the tumor and its potential resectability
    2. Tumor extension into brain on MRI scan
    3. Tumor extension into cavernous sinus on MRI or CT
    4. Tumor extension into bony skull base in middle or posterior fossa


  1. Additional Preoperative Evaluations

    1. Recent MRI: axial, coronal and sagittal views, T1 with and without gadolinium and T2 weighted images
    2. Recent CT scan: axial and coronal with contrast, bone and soft tissue windows
    3. Consider PET imaging
    4. Plain skull film: Caldwell view at 6 ft, if planning subfrontal approach
    5. Confer with neurosurgery
    6. Confer with reconstructive team as to need for free tissue transfer
    7. Confer with oculoplastic surgery team as to plans for the eyes
      1. May admit the night prior to surgery
      2. Preoperative antibiotics, steroids, lumbar drain
      3. Preservation of pericranial flap
      4. Preservation of temporalis muscle, need for free flap reconstruction
      5. Level of craniotomy bone cut (supraorbital)
      6. Tracheostomy
        1. Decrease risk of pneumocephalus (to further separate air of sinonasal cavity from brain)
        2. For long cases and free flap repairs to facilitate airway management and pulmonary support
  2. Consent Inclusions
    1. Incision across scalp, shaving hair
    2. Facial incisions
    3. Exposure of the dura, brain, and cerebrospinal fluid (CSF) with risk of CSF leak, meningitis, brain abscess, brain injury (mental status changes, stroke, coma)
    4. Loss of sense of smell (lifelong)
    5. Nasal packing for up to one week
    6. Tracheotomy (possible)
    7. Blood loss (transfusion)
    8. Damage to adjacent structures
      1. Nasal crusting, nasal distortion, nasal obstruction, facial pain, facial numbness, epiphora, septal perforation, anosmia, blindness, diplopia
    9. Other depending on orbital status
      1. Blindness
      2. Eye removal
    10. Other depending on reconstruction (see Reconstructive protocols)
    11. Death


  1. Room Setup
    1. See Basic Soft Tissue Room Setup
      1. Back table x 2
      2. Mayo x 2
      3. Mayfield headrest
  2. Instrumentation and Equipment
    1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Fracture tray
      3. Sinus Tray
      4. Obwegeser Retractor Tray 2
      5. Obwegeser Retractor Tray 2
      6. Nasal Sharp Tray
      7. Nasal Prep Tray
      8. KLS Oto Trauma Implant - Instrument Tray
      9. KLS Free Flap Implant - Instrument Tray
    2. Special
      1. Tracheotomy Tray
      2. Midas Rex Drill Tray and burrs
      3. Bien Otologic Electric Drill Tray
      4. Neurosurgical cottonoids (1/2 x 3 in)
  3. Medications (specific to nursing)
    1. Antibiotic ointment
    2. 1% lidocaine with 1:100,000 epinephrine
    3. Oxymetazoline HCL nasal spray, 0.05%
    4. Surgicel
  4. Prep and Drape
    1. Standard prep, 10% providone iodine, 5% to periorbital areas
      1. Half strength betadine solution (saline dilution) prep to face
      2. Betadine soap prep to remainder of head and hair
      3. Prep for lateral thigh skin graft, fascia lata, and reconstructive needs
    2. Drape
      1. Drape under the head (the entire head and neck will be prepped in)
      2. Square off with towels around the neck and chest
      3. Split sheet
  5. Drains and Dressings
    1. Varidyne vacuum suction: 7 mm or 10 mm
    2. Xeroform gauze
    3. Iodoform gauze: 5%, 1/2 in x 5 yd coated with antibiotic ointment
    4. Craniotomy dressing: betadine ointment, Fluffs gauze, Kling gauze wrap, and Kerlix gauze wrap
    5. Nasal splint and gauze taped to bottom of nose
    6. Confer with Oculoplastic Surgery team for the eyes
  6. Special Considerations
    1. Lumbar drain placement.
    2. Anterior craniotomy is done in conjunction with this procedure and neurosurgical instrumentation is required.
    3. Skin graft and Fascia lata (see protocols) may also be necessary.
    4. The extent of the resection dictates the reconstruction needed, so there is a possibility of a Free Flap with this procedure (see free flap protocols).
    5. Tracheotomy may be done in conjunction with this procedure (see Tracheotomy protocol).
    6. Depending on the involvement of the eye, oculoplastic instrumentation may be needed.
    7. May place a tarsorrhaphy stitch (4-0 silk G-3) in the eyes to protect the cornea.
    8. Oxymetazoline HCL nasal spray, 0.05% on pledgets applied intranasally.
    9. 1% lidocaine with 1:100,000 epinephrine injection for nasofacial incision and buccal gingival sulcus incisions.


  1. General Anesthesia
    1. Tube position: curved tube preferred, secured in midline, or tracheotomy
    2. Paralysis
    3. Lumbar drain: test function after final position
  2. Systemic Medication
    1. Antibiotics (see Antibiotic Prophylaxis in Head and Neck Surgery protocol)
    2. Steroids: 10 mg dexamethasone IV
  3. Positioning
    1. Supine
    2. Mayfield headrest
  4. Estimated Blood Loss
    1. 1500 cc (1000 to 3000)


  1. Anterior Craniotomy
    1. Standard neurosurgical anterior craniotomy except for:
      1. Extension of the pericranial flap 2 to 3 cm beyond the coronal suture line
      2. Elevation of the pericranial flap separate from the skin flap, extended to the supraorbital vessels
      3. Craniotomy inferior bone cuts at the level of the brow may cross the frontal sinus
      4. The low opening of the dura and transection of the superior sagittal sinus
      5. Brain retraction, exposure of the floor of the anterior cranial fossa, possible brain biopsy
      6. Section of the olfactory trach for pathology review
      7. Transection of the dura over the ethmoids, orbits, and nasal vault extending to sphenoid sinus
      8. Closure requires a pericranial patch to replace the resected dura
      9. Pericranial flap pedicled anteriorly and sutured posteriorly along the sphenoid roof, separating the nasal cavity from the cranial fossa
      10. The bone flap must have all sinus mucosa removed with a drill
      11. Dural tack-up sutures are placed
      12. The bone flap is replaced and secured with miniplates and burr hole covers. Large metal plates should be avoided in patients who will receive postoperative radiation therapy. However, open burr holes below the hairline will be seen and felt by the patient.
  2. Subfrontal Approach
    1. This approach is the same as steps "1" and "2" above, except that exposure is extended into the orbits bilaterally and over the nasal dorsum.
    2. The supraorbital neurovascular pedicles are released from their ostium by opening the ostium into the orbit with a 2 mm straight bone chisel.
    3. In patients with well-pneumatized frontal sinuses, the superior bone cuts are made at the superior extent of the sinus using a sagittal saw beveled at a 45° angle to the skull bone to enter the sinus and then extended around the lateral aspect of the sinus down to the orbits.
    4. In patients with small frontal sinuses, two low burr holes are made approximately 3 to 4 cm above the midorbits, followed by a low craniotomy usually extending into the frontal sinus and down to the orbits.
    5. Bone cuts are made from the frontal sinus into the orbits just medial to the neurovascular pedicles.
    6. A bone cut is made across the superior nasal bone above the medial canthal tendons.
    7. The superior and medial orbital bone cuts are connected across the orbital roof into the frontal sinus.
    8. The bone flap is removed with chisel cuts through bony intrasinus septa and/or with careful elevation of the frontal lobe dura.
    9. The posterior wall of the sinus is then removed using a diamond drill, elevators, and rongeurs.
    10. The dural opening, tumor resection, and closure is similar to the steps "4" to "12" above.
  3. Facial Approach
    1. In many cases, the entire tumor can be removed from the craniotomy approach alone.
    2. A standard lateral rhinotomy with medial maxillectomy may be required (see Maxillectomy protocol).
    3. A standard total maxillectomy with or without orbital exenteration may be required (see Maxillectomy protocol).
    4. See Facial Degloving Approach protocol.
  4. Intranasal Closure
    1. Skin grafting: A skin graft is placed on the nasal surface of the pericranial flap and along the orbit if periorbital or orbital bone is exposed.
    2. Packing: Xeroform gauze is packed in the nasal cavity to support the skin graft and protect the dural repair. Packing must end at nasal vestibule to aid in removal.
  5. Dressing
    1. Standard neurosurgical dressing


  1. Postoperative Monitoring
    1. Admit to ICU setting for postoperative monitoring
    2. Transfer to ward once neurologically and medically stable
    3. Watch for postoperative CSF leaks
    4. Watch for postoperative mental status changes
    5. Watch for postoperative diabetes insipidus
  2. Dressings
    1. Remove on postoperative day 2
  3. Packing
    1. Remove on postoperative day 5 to 7
    2. Antibiotics continued until nasal packing is removed


Ketcham AS, Wilkins RH, Van Buren JM, Smith R. A combined intracranial facial approach to the paranasal sinuses. Am J Surg. 1963;106:698.

Traynelis VC, McCulloch TM, Hoffman HT. Craniofacial resection of the anterior skull base. Neurosurgical Operative Atlas. Vol 5. 3rd ed. 1993:329-340.

Albonette-Felicio T, Rangel GG, Martinéz-Pérez R, Hardesty DA, Carrau RL, Prevedello DM. Surgical management of anterior skull-base malignancies (endoscopic vs. craniofacial resection). J Neurooncol. 2020 Dec;150(3):429-436. doi: 10.1007/s11060-020-03413-y. Epub 2020 Feb 4. PMID: 32020395.

Mehta GU, Passer JZ, Raza SM, Kim BYS, Su SY, Kupferman ME, Hanna EY, DeMonte F. The neurosurgical management of sinonasal malignancies involving the anterior skull base: a 28-year experience at The MD Anderson Cancer Center. J Neurosurg. 2021 Oct 8;136(6):1583-1591. doi: 10.3171/2021.5.JNS21772. PMID: 34624857.

Giurintano J, McDermott MW, El-Sayed IH. Vascularized Pericranial Flap for Endonasal Anterior Skull Base Reconstruction. J Neurol Surg B Skull Base. 2021 Feb 18;83(2):133-136. doi: 10.1055/s-0040-1721816. PMID: 35433180; PMCID: PMC9010135.