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Reconstruction After Resection of Sphenoid Wing Meningiomas

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Reconstruction After Resection of Sphenoid Wing Meningiomas ORIGINAL ARTICLE Reconstruction After Resection of Sphenoid Wing Meningiomas Deirdre Leake, MD; Chad Gunnlaugsson, MD; Janet Urban, MD; Lawrence Marentette, MD Objective: To review our experience of reconstructing Results: A total of 24 resections were performed on 22 the lateral and superior orbital walls after resection of sphe- patients. The average follow-up was 14.6 months. All pa- noid wing meningiomas. We will review the presenta- tients had meningiomas with similar preoperative pre- tion and complications, examine the aesthetic results post- sentations, and for 21 of the 22 patients aesthetic recon- operatively, and compare preoperative and postoperative struction resulted in the near symmetry of the 2 sides. computed tomographic scans. To our knowledge, a com- All patients are currently alive, those who underwent com- parative analysis of preoperative defect and postopera- plete resection are without recurrence, and 15 (68.2%) tive reconstruction has not been performed. did not incur complications. One patient experienced a worsening of temporal wasting following radiation Methods: We conducted a retrospective analysis, with therapy. a minimum of 5 months and a maximum of 9 years of follow-up in an academic multidisciplinary skull base cen- Conclusion: Reconstruction of the defect with split cal- ter. Twenty-two patients were treated for sphenoid wing varial bone and free abdominal fat grafts affords the pa- meningiomas by resection and reconstruction with split calvarial bone graft and, for more than half of the pa- tient excellent aesthetic results as well as good symme- tients, also with free abdominal fat graft. The main out- try, as demonstrated by a postoperative computed come measures were aesthetic evaluation of patients and tomographic scan. analysis of tumor control using computed tomographic scans, survival, and complications. Arch Facial Plast Surg. 2005;7:99-103 ENINGIOMAS ARE SLOW- gan. Our main outcome measures were growing, expansile be- aesthetic evaluation by physicians as well nign tumors that can as analysis of tumor control using com- involve the bone and puted tomographic (CT) scans, survival dura.1 These tumors time, and complications. Marise from arachnoid cells of the perineu- ral sheaths or the arachnoid layer of the METHODS meninges.1,2 The incidence of hyperosto- sis in sphenoid wing meningiomas ap- proaches 90%,3,4 and histopathologic stud- OPERATIVE TECHNIQUE ies have revealed that the hyperostosis is due to meningiomatous infiltration of the A bicoronal or hemicoronal flap and orbital/ 3,4 5 pterional craniotomy were performed by the bone. Terstegge et al also showed by neurosurgical team in the usual fashion. A means of magnetic resonance imaging with fronto-orbital, zygomatic temporal crani- gadolinium enhancement in the area of the otomy was then performed, followed by the re- hyperostosis that this condition may be re- moval of the posterolateral wall of the orbital lated to meningiomatous bone infiltra- bone and the major sphenoid wing lateral to tion. Predisposing factors to the develop- the foramen spinosum (the frontotemporal and ment of sphenoid wing meningiomas orbitozygomatic approach).7 Two osseous flaps Author Affiliations: Private include female sex, previous ionizing ra- were obtained from the frontotemporal and su- practice in St Augustine diation, and type 2 neurofibromatosis.6 To perolateral orbital bones. The frontotemporal (Dr Leake) and Tallahasse our knowledge, a comparative analysis of portion was completely separated and set aside (Dr Gunnlaugsson), Fla, and while the superior and lateral orbital walls could Department of preoperative defect with postoperative re- be left attached to the zygomatic arch. The cra- Otolaryngology–Head and Neck construction has not been performed. We niotomy could be extended to include the su- Surgery, University of Michigan, will review our experience with resec- perior orbital rim to resect the tumor in its en- Ann Arbor (Drs Urban and tion of sphenoid wing meningiomas and tirety. Careful attention was paid to avoid Marentette). reconstruction at the University of Michi- disrupting the deep portion of the levator (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 7, MAR/APR 2005 WWW.ARCHFACIAL.COM 99 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Diamond burrs could be needed when drilling around the or- A bital apex to gain control of the meningioma, as they provide access to the orbital contents and apex and to the pterygopala- tine and infratemporal fossae. The lateral orbital rim was then taken away to be drilled down to remove all aspect of the tumor. Templates were drawn on the parietal scalp. Two split calvarial bone grafts were taken from these templates and were rigidly fixed with X plates and 1.2-mm screws to recreate the superior and lateral orbital walls (Figure 1A). This complex was then plated to the remaining superior orbital rim and zygoma. Abdominal fat was har- vested and placed in the temporal space and around the supe- rior and lateral bony grafts when needed (Figure 1B). The peri- cranial flap was used as a watertight seal to protect the bony reconstruction.The cranial flap was then placed back in the nor- mal anatomic position (Figure 1C), the cranial bone defect was filled with hydroxyapatite cement to prevent topographic con- cavity, and the temporalis muscle was resuspended and the skin B closed in a 2-layer fashion. The maxillary sinus was not en- tered; dural grafts were sometimes necessary; and if the fron- tal sinus was entered, cranialization could be necessary. PATIENT EVALUATION From December 1995 to March 2004 we performed a retro- spective analysis of 22 patients who underwent resection of sphe- noid wing meningiomas with reconstruction at the University of Michigan Multidisciplinary Skull Base Center. A complete medical history was taken and a physical examination per- formed by our cranial skull base and neurosurgical team for all patients. Patient assessment included visual acuity, visual fields, subjective degree of proptosis, extraocular motion, lid position, status of optic nerve, and temporal fullness. All pa- C tients underwent CT scans and magnetic resonance imaging preoperatively and postoperatively. Radiation was used for se- lected patients who had subtotal excision. Total excision was confirmed by postoperative imaging. Follow-up ranged from 4 months to 9 years. RESULTS The patients, 5 men and 17 women, ranged in age from 31 to 73 years (mean age, 53 years). They were analyzed according to age, presenting symptoms, functional and aesthetic satisfaction, history of radiation, tumor vol- ume, tumor recurrence, and complications. Most pa- tients presented with incidental proptosis (n=8) or pro- ptosis associated with diplopia or visual loss (n=7). Other Figure 1. Description of the surgical technique used for resection of presenting signs and symptoms included visual field or sphenoid wing meningioma. A, Split calvarial bone grafts are plated to mimic acuity loss (n=5), swelling/dysthesias of cranial nerve V the superior and lateral orbital walls. B, The split-plated calvarial bone grafts (n=2), or seizure and dysphagia (n=1). Eighteen pa- are then plated to the lateral orbital rim and zygoma, with the abdominal fat graft placed into the temporal defect and hydroxyapatite placed into the tients had involvement of the sphenoid wing only. The parietal defect. C, A pterional craniotomy bone flap is plated back into normal tumor extended to the cavernous sinus, middle fossa, and anatomic position. infratemporal fossa in 2 patients and in another patient it had further extension, causing encasement of the tu- muscle. Once the craniotomy was carried out, zygoma oste- mor around the carotid artery. One patient had menin- otomy was performed to the malar eminence, the frontozygo- gioma involving the clinoid. One patient required fron- matic suture, and the zygomatic arch (away from the tempo- tal cranialization because of tumor extension. Two patients romandibular joint). The body of the zygoma was then cut required orbital decompression because of tumor in- through its midportion and directed toward the anterolateral end of the inferior orbital fissure, preventing entrance to the volvement of the apex. maxillary sinus. Infraorbital cuts were made along the sphe- Reconstruction consisted of calvarial bone and ab- nozygomatic suture. Attempts were then made to remove in dominal fat grafts in 11 patients. Ten patients under- its entirety a tumor that can extend laterally to the foramens went reconstruction with bone only and 1 patient with rotundum and ovale and inferiorly to the pterygomaxillary space. titanium mesh and abdominal fat. Blood loss ranged from (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 7, MAR/APR 2005 WWW.ARCHFACIAL.COM 100 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 minimal to 1200 mL. Most patients had a 3-day hospital A stay, of which 1 day was spent in the intensive care unit. The exception was 1 patient who had a 20-day hospital stay, with 12 of those days in the intensive care unit be- cause of pneumocephalus. Of the 22 patients, 3 had had prior resection of their meningiomas at another institution and complete resec- tion was achieved at our institution for 1 of these 3; in- cluding this patient, 11 had complete tumor resection but 1 of them was lost to follow-up. There was residual dis- ease in a total of 10 patients owing to tumor involve- ment of the carotid artery or cavernous sinus; among these 10 patients, 3 requested that complete resection not be attempted because they did not want to risk any loss of vision. Of the patients who had incomplete resections, 1 was lost to follow-up, 3 remained stable during a mini- mum follow-up of 6 years, 1 had marginal growth with- B out any further treatment per patient desire, 3 had post- operative radiation therapy, 1 had reresection, and 1 had reresection with postoperative radiation.
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