No-Drill Single-Piece Fronto-Orbito-Zygomatic Craniotomy: Surgical Technique and Preliminary Results from an African Developing Country

Background: Fronto-orbito-zygomatic (FOZ) craniotomy is a work-horse skull base surgical technique performed as a single-piece or multi-piece approach. Powered surgical drills and other technological adjuncts deployed in Western skull base surgery units for these sophisticated surgical dissections are logistically unavailable in the developing countries.

Materials and Methods: Here we present an annotated description of our no-drill surgical technique of single-piece FOZ craniotomy in a low-resource African neurosurgery practice. The tools we use are all manual, including the Hudson brace and Cushing’s skull perforator blades for cranial trepanations; the Gigli saws for skull bone cuts, and osteotomes/mallets plus the Leksell rongeurs for osteotomies/bone excisions. The critical steps in this technique include an orbital roof osteotomy to achieve the cranio-orbital convexital bone cuts; the intraorbital-to-extraorbital passage of the Gigli saw past the lateral orbitotomy out into the temporal fossa and then under the zygomatic process to engage the orbital floor and thus obtain an orbitozygomatic bone cut that preserves the zygomatic process on the fronto-temporal-orbital convexity bone flap, thereby achieving the FOZ craniotomy as a single-piece bone flap.

Results: Since the evolution of this surgical technique in our practice, we have used the approach successfully in 12 patients (6 males:6 females) to treat anterolateral and middle-fossa skull base lesions, including 4 sphenoorbital meningiomas, 4 giant pituitary adenomas, 1 craniopharyngioma, 2 nasopharyngeal carcinomas, and 1 thalamopeduncular astrocytomas. At the end of intracranial dissections, cranial reconstruction was achieved with the use of cranioFixR (B Braun, Aesculap), a simple low-profile titanium cranial fixation-plate system. To minimize postoperative neurological deficits, near-total tumor excision was the intraoperative goal and was achieved in 8/12 cases, and subtotal in the remaining 4/12. Postoperative complications included transient ptosis, periorbital ecchymosis and enophthalmos, and limited hemorrhages at the operative sites. There were no permanent postoperative deficits following this procedure, and excellent wound healing/cosmesis was achieved.

Conclusions: We have used our training in advanced clinical skull base microsurgery to devise an effective, evidence-based low-cost surgical technique for executing the highly technical single-piece FOZ craniotomy in an African developing country notwithstanding the severe logistic constraints in our practice. This approach was accomplished without power drills and good outcomes were achieved.

Publication History

Article published online:
05 February 2024