Anteriolateral Craniotomy: A Technique for Improved Aesthetic Outcome

Introduction: Frontotemporal craniotomies may result in cosmetic defects such as brow drop, temporal depression, or visible grooves and excavations caused by denervation and devascularization, bone loss, and tissue migration. We will present our techniques for aesthetically-oriented pterional, fronto-orbital (FO), and fronto-orbitozygomatic (FOZ) approaches.

Methods: Our protocol encompasses each step of the craniotomy, from placement of the incision, skin flap, and muscle elevation, burr hole placement and elevation of the bone flap, through fixation and closure of the craniotomy, and muscle reattachment. The protocol preserves soft tissue trophism and minimizes bone loss. The cranial flap is rigidly fixed with low-profile hardware.

Results: From 2004 to 2007, the protocol was applied in 137 anterolateral craniotomies, all primary surgeries, including 103 pterional, 30 FO, and 4 FOZ procedures for removal of neoplasms and vascular lesions involving the cavernous sinus, sphenoid ridge, tuberculum sella, olfactory groove, and other structures. Complications have been minimal. One case of wound infection required bone flap removal and cranioplasty; three cases of persistent pseudomeningocele following FO craniotomies were successfully managed with continuous lumbar spinal drain and pressure dressings. Postoperative cranial imaging shows preserved temporal soft tissue volume and maintenance of temporal bone symmetry in patients operated with this protocol.

Conclusions: Careful preservation of soft tissues, bone-sparing work, and special techniques for bone and soft tissue fixation, together with the availability of modern drilling hardware, enable perfect aesthetic long-term outcomes after anterolateral skull base procedures.