Infratemporal fossa approach: the modified zygomatico-transmandibular approach

Abstract

Background: The infratemporal fossa (ITF) is an anatomical lateral skull base space composed by the zygoma, temporal, and the greater wing of the sphenoid bone. Due to its difficult approach, surgical intervention at the ITF has remained a heavy burden to surgeons. The aim of this article is to review basic skull base approaches and ITF structures and to avoid severe complications based on the accurate surgical knowledge.

Methods: A search of the recent literature using MEDLINE (PubMed), Embase, Cochrane Library, and other online tools was executed using the following keyword combinations: infratemporal fossa, subtemporal fossa, transzygomatic approach, orbitozygomatic approach, transmaxillary approach, facial translocation approach, midface degloving, zygomatico-transmandibular approach, and lateral skull base. Aside from our Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) trial, there have been very few randomized controlled trials. The search data for this review are summarized based on the authors' diverse clinical experiences.

Results: We divided our results based on representative skull base approaches and the anatomy of the ITF. Basic approaches to the ITF include endoscopic endonasal, transzygomatic, orbitozygomatic, zygomatico-transmandibular, transmaxillary, facial translocation, and the midfacial degloving approach. The borders and inner structures of the ITF (with basic lateral skull base dissection schemes) are summarized, and the modified zygomatico-transmandibular approach (ZTMA) is described in detail.

Conclusions: An anatomical basic knowledge would be required for the appropriate management of the ITF pathology for diverse specialized doctors, including maxillofacial, plastic, and vascular surgeons. The ITF approach, in conjunction with the application of microsurgical techniques and improved perioperative care, has permitted significant advances and successful curative outcomes for patients having malignancy in ITF.

Keywords: Infratemporal fossa; Infratemporal fossa approach; Lateral skull base dissection; Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA); Zygomatico-transmandibular approach.

Fig. 1

Schematic drawings of representative skull base approaches showing the endoscopic endonasal approach (a), the transzygomatic approach (b), the orbitozygomatic approach (c), the zygomatico-transmandibular approach (d), the transmaxillary approach (e), the facial translocation approach (f), and the midfacial degloving approach (g)

Fig. 2

Lateral skull base showing the boundary (left) and contents of the infratemporal fossa (right)

Fig. 3

Surgical procedures of the modified zygomatico-transmandibular approach to the infratemporal fossa, showing the incision with facial flap elevation (a), exposure and isolation of the facial nerve with mandibulotomy (b), direct exposure of the infratemporal fossa (c), mass dissection by orbito-zygomectomy with temporal muscle dissection (d), identification of the internal jugular vein, internal maxillary artery, ligation (e), and mass resection with temporal craniotomy (f)

Fig. 4

The modified zygomatico-transmandibular approach to the infratemporal fossa with latissimus dorsi muscular free flap reconstruction, showing the incision line (a), mobilization of the parotid gland (b), pathologic mass exposure by orbito-zygomectomy (c) and coronoidectomy (d), whole mass removal (e), the temporal or skull base craniotomy state (f), and dura mater repair with latissimus dorsi free flap reconstruction (g to i)

Fig. 5

Surgical images showing the zygomatico-transmandibular approach to the lateral skull base (a) and its repositioned state, with reconstruction plate and sural nerve graft to the facial nerve trunk (b)