Facial Translocation

This surgical approach begins with a hemi-coronal incision posterior to the hairline and is carried inferi-orly into the preauricular region around the lobule of the ear, and then extended to the upper neck if exposure of the carotid sheath structures is planned (Figure 12-9). A horizontal incision is then carried from the pre-auricular incision medially. This incision passes over the superior edge of the zygomatic arch to the level of the lateral canthus and sometimes severs the upper branches of the facial nerve. If they are to be divided, these branches should be identified, isolated, and labeled prior to their division in order to facilitate nerve re-anastomosis at the end of the operative procedure. An ipsilateral Weber-Ferguson approach is then completed with a trans-conjunctival incision in the inferior fornix of the conjunctiva joining the horizontal incision previously made over the zygomatic arch. Soft tissue overlying the anterior maxillary face is then elevated, and both the lacrimal duct and infraorbital nerves are divided. The facial skin flap is inferiorly reflected while the frontotem-poral scalp flap is medially reflected, providing access to the zygomatic arch, lateral orbit and maxilla. Fron-tozygomatic, zygomaticomaxillary, and orbitomaxil-lary osteotomies permit translocation of segments of the facial skeleton. Finally, the temporalis muscle can be released from its insertion into the temporal line of the scalp and, if its blood supply from the internal maxillary artery is preserved, it can be transposed and used for reconstruction of the post-resection defect if necessary. In addition to the aforementioned osteotomies, the coronoid process of the mandible can be either retracted or osteotomized to facilitate greater exposure. Modifications and extensions of the

Figure 12-9. Incision for facial translocation approach to the middle cranial fossa.

facial translocation approach can additionally permit bilateral surgical exposure when necessary.45

At the conclusion of the tumor resection, the mobilized temporalis muscle may be used to partially reconstruct or seal off the surgical defect. The segments of the facial skeleton are then repositioned and rigidly fixated to the cranium utilizing reconstruction plates. Large soft-tissue defects are reconstructed using free tissue transfer (rectus abdominis or radial forearm) in an attempt to prevent a CSF leak, with reestablishment of orbital support as described previously.

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