A modified frontal–nasal–orbital approach to midline lesions of the anterior cranial fossa and skull base: technical note with case illustrations

The frontal–nasal–orbital craniotomy has been utilized for craniofacial abnormalities and resection of tumors involving the anterior skull base. We describe modifications of this technique to approach extra-axial and intradural midline lesions of the anterior fossa with or without involvement of the skull base. A craniotomy was planned with an endoscope and image guidance. A modified frontal–nasal–orbital craniotomy encompassing the entire frontal sinus complex was performed in conjunction with osteotomies incorporating the bilateral superior orbital ridges and nasal septum. Removal of the posterior wall of the frontal sinus was completed if necessary. Dural repair and final reconstruction are detailed. Our initial experience using this approach in five patients harboring lesions of the anterior skull base resulted in adequate exposure of the targeted pathology. There were no complications of the procedure. Cosmetic results were acceptable. We present a detailed account of this procedure via photographs and a video. The frontal–nasal–orbital craniotomy provides access to the floor of the anterior fossa while avoiding excessive brain retraction associated with facial incisions. In addition, this approach is associated with a lower incidence of complications, such as CSF leak, brain retraction edema, or infection. The frontal–nasal–orbital craniotomy is a useful technique for midline lesions of the anterior skull base, and it should be in the armamentarium of neurological surgeons.