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Craniofacial Resection

A craniofacial resection is a major resection for tumors involving the anterior skull base, including those of the ethmoid sinus, frontal sinus, nasal cavity, skull, scalp and the region around the eyes.

A craniofacial resection involves removing the tumor via incisions on the face as well through the skull (cranium) to gain access to a tumor that has grown inside, or approaches, the skull. By coming at the tumor from above and below, your surgeons have a better chance to confidently remove all of the tumor while decreasing possible damage to the brain, nerves and other major structures.

This procedure is usually performed in conjunction with a neurosurgeon.

If an MRI shows that a tumor has grown into the brain, this type of surgery might not be an option for you.

Preparing for surgery

Your doctor and care team will let you know what you need to do to prepare for surgery. In general, you should not eat or drink anything (except essential medications) anytime after midnight prior to surgery. You should inform your doctor if you have a fever, productive cough or any other signs of infection. Your doctor will give you a medical clearance evaluation and give recommendations to optimize all the other organs in your body prior to undergoing general anesthesia and surgery.

On the day of surgery, you will need to arrive at the hospital a few hours before the scheduled operation. This allows the nurses and anesthesiologist to ensure everything is in order for you to have as safe a surgery as possible. You will see your surgeon one last time before receiving the anesthesia and falling asleep, and you can ask any last-minute questions at that time.

What to expect

This procedure is done with general anesthesia, so you will be completely sedated.

A tracheotomy is performed for a craniofacial resection.

The eyes are either protected with corneal shields or are sutured closed. Your scalp will be shaved. A neurosurgeon or anesthesiologist might place a lumbar drain (also called a spinal drain). The purpose of a spinal drain is to decrease the fluid around the brain, which can make it easier to remove the bone of the skull without damaging the underlying brain covering. Alternatively, medications can be given to decrease the fluid around the brain.

A combination of incisions will be made, including one that is well hidden next to your nose and another just behind the hairline all across the scalp. The incision next to your nose might need to be extended in some areas, such as down to the lip, under an eye or across the bridge of the nose to the other side. This extension will depend on exactly where the tumor is located. This is a standard approach to a craniofacial resection, but it can certainly be modified, depending on your specific situation.

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After the incisions are made, the bones of the skull and the face are exposed by raising coronal flaps. In a way, this is like flipping down all of the soft tissue of the upper face down to the bone.

Then a neurosurgeon will drill a few burr holes in the skull, and these will be connected with a saw. The challenge for the neurosurgeon is to keep the lining covering the brain (the dura) down while removing a piece of the bone. This is so your surgeon can gain adequate exposure from above the tumor. By removing a large piece of the skull, your surgeon will have better access to the entire tumor at the skull base to remove it completely in one piece. Avoiding entering the dura (or stitching it up securely if it is entered) is important to prevent bacteria from the sinuses from entering the area around the brain.

At the end of the procedure, the piece of bone removed from this area will be secured back in place with metallic plates and screws.

Once the exposure from above is adequate, your head and neck surgeon will make the required incisions to get exposure from below the tumor. This is where the facial incisions may be necessary. Some of the bones of the orbit, or the mid-face, might need to be removed for exposure. In some cases, these can be secured back into place using plates and screws at the end of the procedure.

After everything is well exposed and the tumor is apparent, the required bone cuts can be made to remove the cancer in one piece. This might require performing a maxillectomy or an orbital exenteration. Whatever needs to be done to completely remove the tumor in one piece should be done.

Once the tumor is out and your surgeon is confident with the margins, he or she will start the reconstruction and the closure. A variety of reconstructive approaches are possible, depending on the extent of the resection. A pericranial flap is a regional flap, preserved when the upper facial soft tissue is peeled from the frontal bone. This can be used to cover the dura and separate the intracranial contents from the nasal contents. Again, this is important to prevent bacteria from the nose and sinuses from entering the brain and surrounding area inside the skull. A free flap is sometimes used in cases of major resections in which the nasal contents must be kept separate from the contents inside the skull.

Associated procedures might include orbital exenteration, dacryocystorhinostomy and tracheostomy.

Recovery and aftercare

The recovery course will depend on the extent of the surgery and reconstruction. Following a craniofacial resection, you will go to an intensive care unit for very close monitoring. You will be monitored for your neurological function, blood sodium levels, urine output and other factors. If a free flap was done, that will also be monitored very closely.

Your recovery can take place in a few different parts of the hospital. Your pathway might include trips to the recovery room, intensive care unit, step-down unit and a shared or private “floor” bed. You might be required to sit still in bed for a few days post-operatively and not be too active. The tracheotomy tube may stay in to help limit increased pressure in your skull area—for example, if you cough or sneeze. The lumbar drain, if placed during the procedure, will be removed when the time is right. In the post-operative period, the lumbar drain can help keep the cerebrospinal fluid pressure low and therefore decrease the chance of fluid leaking through the area of closure at the skull base.

As soon as possible and when the time is right for each step, you will progress from having your tubes and drains removed to being disconnected from the lines, and eventually getting up and out of bed. If placed, the tracheotomy tube should be ready to come out after a few days.

Once your doctors determine that you no longer need in-patient level care, you will be ready for discharge. The discharge planning process begins well before you are ready to leave the hospital. While some patients can go home from the hospital with or without visiting nurses or receiving home care, others might go to a rehabilitation or skilled nursing facility for a short while before going home. Your discharge planning team, which includes your doctors, social workers, nurses and physical therapists, along with you and your family, will determine the best place for you to go once you’re ready to leave the hospital.

Any additional reconstruction, cosmetic procedures or treatments are planned after discharge. This gives you time to recover from the initial surgery, get the pathology results of the surgery and make appropriate arrangements for your next steps.

Risks

Risks of this procedure are those related to the neurosurgical component as well as those related to the head and neck component.

  • Infection: Because the nose is not a sterile part of the body, while the area inside the skull around the brain is sterile, the risk of infection is serious. Antibiotics are administered prior to performing the surgery and at regular intervals during and after the surgery. Infection in this area can lead to major problems, including meningitis, epidural abscess and brain abscess. These must be treated quickly and efficiently and may require surgical drainage. The key is to prevent them.
  • Bleeding: As with any surgery, there is always a chance of bleeding post-operatively. This would likely require a return to the operating room.
  • Pneumocephalus: This is air in the area around the brain. If this keeps getting bigger, it could compress parts of your brain and cause major problems. If you notice a sudden change in your mental status, your doctors might take you down for an urgent CT scan to see what’s going on inside your head.
  • CSF leak: This is a leak of cerebrospinal fluid down into the nose, and means that the closure was not watertight. If fluid is getting out into the nose, the bacteria from the nose could migrate toward the brain. This must be taken seriously until it closes up. Antibiotics are typically required. Sometimes the closure can happen on its own, perhaps by keeping you in bed and placing a spinal drain in your back. In some cases, additional surgery might be required.
  • Diabetes insipidus: This is the result of a water and sodium imbalance in your body that may be related to neurosurgical procedures. Your blood sodium levels, urine output and urine electrolytes will be measured to monitor this.
  • Loss of smell: The nerves for smell are located in the middle part of the anterior skull base, just above your nose. If these area needs to be resected, you could lose your sense of smell.
  • Facial nerve injury: As part of the bicoronal flap that is raised to get exposure, the frontal branch of the facial nerve can be injured. This would make it difficult for you to raise your forehead. This could be temporary if the nerve is stretched or permanent if the nerve is cut.
  • Tearing (also called epiphora): Normally, tears empty into your nose through a little tube (nasolacrimal duct) from the corner of your eye next to your nose. If damage to the nasolacrimal duct occurs, you might have chronic tearing problems. This can be prevented by either placing tubes into the nasolacrimal duct that empties into your nose or by performing a dacryocystorhinostomy (DCR), which is the creation of a new opening in the nose to empty the duct. One of these associated procedures will be done if this is seen as a potential problem during surgery.
  • Blindness: Even in cases where the eye does not need to be removed, surgery close to the eye can lead to complications. For example, bleeding into the eye socket, if not recognized quickly, can lead to permanent blindness. Even if blindness does not occur, double vision (diplopia) can be a complication of this surgery as well.
  • Facial numbness: Numbness of the upper part of the face can be caused by damage to a nerve that runs just above the eye. The mid-face can be affected if the nerve under the eye is injured.
  • Mucocele: If part of the frontal sinus is removed and there is scarring of the duct that empties this sinus, the frontal sinus can fill with mucous and cause major problems. Getting a CT scan or MRI at regular intervals as well as checking for symptoms of severe pain might help in the prevention of these challenges.