NEUROSURGICAL ATLAS SERIES

The Orbitozygomatic Craniotomy and Its Judicious

Use
Aaron Cohen-Gadol, MD, MSc,
The concept of maximizing bone removal along the skull base has been advocated
∗‡
to expand the operative space for large, firm, and encasing ventral and ventrolateral
MBA
skull base tumors. However, indications for the use of such osteotomies have not
∗
Goodman Campbell Brain and Spine, been well defined. The improved maneuverability and enhanced extent of expansion
Department of Neurosurgery, Indiana of the operative corridor via the skull base approaches compared to those of standard

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University, Indianapolis, Indiana; ‡ The craniotomies have been based on cadaveric studies that might not simulate the operative
Neurosurgical Atlas, Indianapolis, Indiana
environment realistically. Bony removal alone is not adequate to protect neurovascular
Correspondence: structures, and strategic use of dynamic retraction and innovative operative routes are
Aaron Cohen-Gadol, MD, MSc, MBA, some of the other factors that contribute to successful microsurgery. In this analysis, the
Goodman Campbell Brain and Spine,
Department of Neurosurgery,
more discriminate indications and modified techniques for orbitozygomatic osteotomy
Indiana University, are discussed.
355 W. 16th Street, Suite 5100,
Indianapolis, IN 46202.
KEY WORDS: Craniotomy, Operative anatomy, Orbitozygomatic, OZ, Virtual reality
Email: acohenmd@gmail.com
Operative Neurosurgery 18:559–570, 2020 DOI: 10.1093/ons/opz246

Received, January 30, 2019.

T
Accepted, May 31, 2019.
Published Online, August 29, 2019. he orbitozygomatic craniotomy (OZ)
(Video) involves an expansion of the
Copyright "
C 2019 by the
pterional approach through osteotomy of
Congress of Neurological Surgeons
various sections of the superior/lateral orbital
rim/roof and zygoma. This additional bone
removal broadens the subfrontal trajectory and
can minimize the need for brain retraction to
access the floor of the anterior and middle
skull base and the parasellar and interpeduncular
spaces.1-6 It also allows for an enhanced inferior-
to-superior operative trajectory and working
angles with flexible maneuverability and multi-
directional degrees of operative freedom. Its
judicious and selective or discriminate use is
important for justifying the potential risk of
cosmetic deformity and additional operative time
associated with this skull base osteotomy.
Multiple variations of the OZ involving
different amounts of bone work have been
described7-42 and the discussion below is an
efficient technique. The most widely used and
practical modifications are the “1-piece” and
“2-piece” supraorbital osteotomies, which
include limited resection of the zygoma. These
modified variations involve mobilization of the
ABBREVIATIONS: CT, Computed tomography; 3D,
3-dimensional; OZ, orbitozygomatic craniotomy
orbital roof and rim as well as the frontal process
of the zygoma.
In the 1-piece osteotomy (Figure 1), the
frontotemporal craniotomy and supraorbital
osteotomy are completed in 1 bone flap. In
the 2-piece osteotomy, a traditional pterional
craniotomy is first elevated, and then the
supraorbital osteotomy is performed. The
1-piece frontotemporal craniotomy and supraor-
bital osteotomy (referred to as modified OZ) is
the least disruptive and most efficient alternative
and provides most of the advantages of all the
other OZ variations; this approach, referred to
simply as OZ, is the topic of discussion here
(Model).
The patient provided written informed
consent for the surgery shown in Video and
Figures 6 and 9. Institutional review board/ethics
committee approval was neither sought nor
required for the data presented here.
Indications for the Modified OZ
Modifications of the OZ have been widely
used for both vascular and neoplastic lesions
within the orbital apex, paraclinoid and
parasellar regions, cavernous sinus, and the
interpeduncular and upper paraclival terri-
tories.1-6 Paramedian cranial base masses with
tremendous superior extension can benefit from

OPERATIVE NEUROSURGERY VOLUME 18 | NUMBER 5 | MAY 2020 | 559

COHEN-GADOL
VIDEO. Technical nuances for modified orbitozygomatic craniotomy/osteotomy.
With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
the expanded inferior-to-superior operative trajectory and from
the medial-to-lateral operative working angles afforded by using
the OZ pathway; OZ can mitigate the vector of retraction on the
frontal lobes.
The judicious use of the 1-piece modified OZ for select
lesions within the above-mentioned regions is recommended.
A complete zygomatic osteotomy of the temporal portion of
the zygomatic arch does not add to the exposure signifi-
cantly.1,6 Compared to the standard frontotemporal transsylvian
approach, previous studies have demonstrated, on average, an
FIGURE 1. Shown are fundamental osteotomy locations for the 1-piece modified OZ. The first osteotomy A cuts across the orbital rim. The second osteotomy B
disconnects the frontal process of the zygoma, and the last cut C is made across the roof of the orbit through an expanded keyhole. The “key” location of the keyhole for
exposing the orbit and frontal dura is important for planning subsequent osteotomies. These bony cuts lead to disarticulation of the orbital rim, zygoma, and orbital
roof. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.
560 | VOLUME 18 | NUMBER 5 | MAY 2020
increased exposure of 26% to 39% (significant) via the addition
of orbital rim osteotomy and an additional 13% to 22% (not
statistically significant) via removal of the zygomatic arch.34
In fact, temporal zygomatic osteotomy can be redundant for
exposure of most lesions and increases the risk of cosmetic
deformity.
I do not routinely use the OZ for lesions that can be
exposed through “extended pterional” craniotomy, which requires
aggressive drilling of the roof of the orbit and lateral sphenoid
wing; these 2 maneuvers expand the reach of the standard
subfrontal pterional corridor43 ; this was just accepted for publi-
cation in Operative Neurosurgery).
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More judicious and selective use of OZ is indicated for large
lesions within the following:
1) the paramedian and midline parasellar regions extending
superiorly into the third ventricular space (Figure 2) and
2) orbital lesions within the posterior one-third of the orbit.
These lesions are directly in line with the expanded operative
corridor achieved by supraorbital osteotomy of the OZ. Figure 3
shows the structures in line with the osteotomy through the
modified OZ.
The softer indications involve giant anterior skull base menin-
giomas or anterior communicating aneurysms. As there is
typically residual bone along the paramedian anterior skull base
after completion of the OZ, the effectiveness of OZ for these
lesions is diminished. The lesions within the cavernous sinus can
potentially benefit from the modified OZ. The list of discriminate
uses of OZ is relatively short and selective.
www.operativeneurosurgery-online.com

MODEL. A, (https://sketchfab.com/3d-models/orbitozygomatic-7c9363672e604
c1a9c51bc84c2b1f244): The outline of osteotomies for the OZ are shown. B,
(https://sketchfab.com/3d-models/orbitozygomatic-craniotomy-03c574c2f33a4
efd864423e6df2cab3c?cursor=cD0yMDE4LTEwLTE2KzIwJTNBMTglM0Ew
NS4xMDExMTU%3D) The completed osteotomy lines are shown. C, (https://
sketchfab.com/3d-models/orbitozygomatic-craniotomy-extent-of-exposure-eecf227
153354b979dfd70a4e20e1bcc) The osteotomies and extent of exposure for the
OZ are shown in 3-dimensional (3D) space. The neural structures within the
operative corridor are highlighted. The instructions for use of this model are as
follows: please use the full-screen function for optimal visualization [by clicking
on the arrows on the right lower corner of the model]. To move the model in
3D space, use your mouse’s left-click and drag; to enlarge or decrease the size
of the object, use the mouse’s wheel. The right-click and drag function moves
the model across the plane. With permission from The Neurosurgical Atlas by
Aaron Cohen-Gadol.
OPERATIVE NEUROSURGERY
ORBITOZYGOMATIC CRANIOTOMY
Preoperative Considerations and Pitfalls
Anterior skull base meningiomas can lead to hyperostosis of the
roof of the orbit and lateral sphenoid wing; this finding should
be evaluated with preoperative imaging. If the modified OZ is
performed for the resection of a sphenoid wing and/or orbital
meningioma, the osteotomy along the orbital roof should be
conducted under direct vision and not blindly. Because of the
increased thickness of the orbital roof, uncontrolled fracture of
the roof and rim could extend as far as the optic canal and lead
to optic nerve injury. Such a fracture can also involve the walls
of the sphenoid and ethmoid sinuses and generate postoperative
cerebrospinal fluid leakage (Figure 4).
Using a lumbar drain before performing an OZ should be
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considered, because dural decompression can protect the dura and
the brain during OZ osteotomies. In addition, the lateral extent of
the frontal sinuses should be studied with preoperative imaging.
The risk of entry into the frontal sinus should not compromise
adequate exposure. A computed tomography scan is not routinely
obtained in expectation of an OZ craniotomy.
MODIFIED ORBITOZYGOMATIC
CRANIOTOMY/OSTEOTOMY
The steps for completing an OZ osteotomy are summarized
in Figures 5-15. The subfacial technique is applied for protection
of the facial nerve branches. The superficial temporalis fascia is
incised and reflected along with the fat pad.
Usually, 2 to 3 cm of dissection over the periorbita is suffi-
cient in expectation of the osteotomy along the orbital roof. If the
periorbita is disrupted, intraorbital fat that herniates through the
defect can be shrunken using bipolar electrocautery. Disruption
of the periorbita leads to more pronounced postoperative perior-
bital edema and bruising.
Once the supraorbital nerve is released, it can be easily reflected
inferiorly along with the pericranial flap and periorbita. The
small osteotomy around the nerve can also be used as the exit
point for the footplate of the craniotome at the time of the
craniotomy.
This retrograde muscle dissection may permit better preser-
vation of the subperiosteal layer containing the deep temporal
arteries and nerves that nourish the muscle, which could minimize
postoperative atrophy. The muscle is then retracted inferiorly, not
anteriorly, to maximize its mobilization away from the subfrontal
working zone.
The closure is conducted using standard cranial plates; the
zygomatic arch is plated, and major defects in the bone in the
areas anterior to the hairline are filled with cranioplasty material.
In cases of intraosseous pathology and significant bone resection,
titanium mesh can be used for minimizing the risk of cosmetic
deformity. The roof of the orbit is not routinely constructed; we
have not observed any incidence of enophthalmos with such a
strategy.
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FIGURE 2. A and B, This large medial sphenoid wing meningioma was resected via the modified OZ. The significant superior extension of
the tumor required a steep inferior-to-superior intradural operative trajectory afforded through the orbital trim osteotomy. C and D, Similarly,
this third ventricular craniopharyngioma was removed via the same approach through the lamina terminalis. With permission from The
Neurosurgical Atlas by Aaron Cohen-Gadol.

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FIGURE 3. A, The OZ provides an expanded trajectory toward the anterior sylvian fissure and the M1. B, This corridor remains expanded for the region
of the carotid bifurcation and proximal A1. C, However, expansion of the operative trajectory is significantly less effective for lesions anterior to the chiasm
because of the bulk of the orbital contents and medial orbital roof. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol, MD.

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FIGURE 4. Aggressive elevation of the orbitozygomatic or pterional bone flap without completely disconnecting it along
the orbital roof or lateral sphenoid wing under direct vision should be avoided. Attempts to blindly fracture the bone flap
at its margin at the hyperostotic lateral sphenoid wing in case of sphenoid wing meningioma can lead to an inadvertent
extension of the fracture into the optic canal A or ethmoid sinus B and result in an optic nerve injury or unrecognized
postoperative cerebrospinal fluid leak, respectively. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

FIGURE 5. The plane between the galea and the pericranium is developed in case a vascularized pericranial flap is needed
at the time of closure. The scalp flap is reflected anteriorly and separated from the temporalis fascia. The belly of the no.
10 scalpel blade can be used to separate the pericranium from the galea. A, The fat pad is exposed. B, The plane between
the galea and the pericranium is developed anteriorly until the subgaleal fat pad containing the frontotemporal (frontalis)
branches of the facial nerve becomes visible. These branches are located in the superficial fascia of the fat pad, not within
the fat pad itself. Therefore, one of two techniques for reflecting the fat pad without injuring these branches can be used:
(1) the interfascial technique, in which the superficial temporal fascia is reflected anteriorly along with the fat pad via
dissection underneath the fat pad but superficial to the deep temporal fascia; or (2) the subfascial technique, in which the
superficial temporal fascia is reflected anteriorly along with the fat pad and the deep temporal fascia, all as one layer (this
is my preferred method because it offers maximal protection for the facial nerve branches). This fat pad is usually located
2.5 to 3 cm posterior to the frontal process of the zygoma and the orbital rim. Bovie electrocautery is used to cut the deep
temporal fascia and reflect the fat pad in the subfascial manner (see Video). With permission from The Neurosurgical Atlas
by Aaron Cohen-Gadol.

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 ORBITOZYGOMATIC CRANIOTOMY

FIGURE 6. Subfascial technique. A, The 2 layers of the temporal fascia encasing the fat pad are incised to the level of the muscle fibers and parallel

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to the frontal zygomatic arch. This flap containing the fat pad and the nerve branches (inset) is elevated and reflected anteriorly along with the
scalp flap. The pericranium medial to the superior temporal line is cut perpendicular to the superior temporal line. In other words, the cut along the
superior temporal line should be made parallel to and in continuity with the cut used to elevate the fat pad, not perpendicular to it, in order to avoid
any injury to the branches of the facial nerve. This maneuver reflects the subfascial flap and the pericranial flap medial to the superficial temporal
line in 1 layer. B, Subperiosteal exposure of the zygoma is shown C. The deep temporalis fascia is fused along its anterior edge with the periosteum
of the frontal zygomatic process. The subfascial dissection is continued anteriorly with subperiosteal dissection over the frontal zygomatic bone to
achieve full exposure of the superior orbital rim and frontal zygomatic process. The pericranium over the frontal bone is also reflected anteriorly
toward the orbital rim, and subperiosteal dissection is continued until the supraorbital nerve and notch are identified. With permission from The
Neurosurgical Atlas by Aaron Cohen-Gadol, MD.

FIGURE 7. A, The superiosteal or subpericranial dissection is carried around the orbital rim and underneath the anterior
roof of the orbit. Beyond the rim, the periosteum of the zygomatic and frontal bones blends into the periorbita. Blunt
dissection is used to free the periorbita from the orbital rim lateral to the supraorbital notch. The periorbita is often
adherent at the frontozygomatic suture. This attachment is dissected first, and then a blunt dissector is used to sweep over
the periorbita from the inferior orbital fissure toward the supraorbital notch until the subperiosteal plane is well defined.
B, The supraorbital nerve is often embedded within its notch but can be mobilized out of its groove with gentle blunt
dissection. However, the nerve rarely owns its own foramen. If such a foramen is present, a straight small-caliber side-
cutting drill bit is used to cut a halo of the orbital rim around the supraorbital nerve to allow for anterior mobilization of
the nerve with its foramen without injury to the nerve (inset). With permission from The Neurosurgical Atlas by Aaron
Cohen-Gadol.

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FIGURE 8. Next, the temporalis muscle is incised along its insertion at the superior temporal line and posteriorly parallel
to the scalp-incision line. A, A myofascial cuff is left in place at the superior temporal line to allow for repair of the muscle
at the time of closure. The muscle is then elevated in a subperiosteal manner using a periosteal elevator, starting at the
zygomatic arch and working toward the superior temporal line. B, Two burr holes are needed to create an orbitozygomatic
bone flap. Additional burr holes can be added, if necessary, to preserve the integrity of the dura. The first burr hole is
placed immediately caudal to the superior temporal line, close to the posterior margin of the bony exposure. Note the use of
fishhooks to maximally mobilize the soft tissues; the temporalis muscle is mobilized inferiorly rather than anteriorly. With
permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

FIGURE 9. A, It is imperative to place the keyhole at the appropriate location and drill at the correct angle to expose both the periorbital and
frontal dura through the expanded burr hole. Accurate creation of the keyhole facilitates execution of the 1-piece orbitozygomatic craniotomy and
prevents excessive bone loss in the keyhole region and resultant cosmetic deformity. The keyhole is made approximately 7 mm superior and 5 mm
posterior to the frontozygomatic suture (yellow arrow).6 The shaft of the drill is held at a 45-degree angle measured from the plane of the temporal
bone. B, The supraposterior half of this burr hole exposes the dura of the anterior fossa, and the anteroinferior part exposes the periorbita (inset).
C, The roof of the orbit divides these 2 compartments within the keyhole. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

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 ORBITOZYGOMATIC CRANIOTOMY

! Selective use of OZ is highly recommended. The modified OZ

Pearls and Pitfalls

could be a good fit for high-riding lesions that extend superiorly

within the parasellar/third ventricular/interpeduncular spaces
! Accurate placement of the keyhole is important for successfully
and the posterior one-third of the orbit.

! Indiscriminate and blind fracture of the orbital roof should be

completing a 1-piece OZ.

avoided during exposure of an anterior skull base meningioma.

Because of the resultant hyperostosis of the orbital roof, such a
fracture could extend to the level of the optic canal and result
in optic nerve injury.

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FIGURE 10. The craniotome with a footplate attachment is now
used for the craniotomy. The first bony cut starts within the supraor-
bital notch, where the small osteotomy was previously performed to
release the nerve. Alternatively, and more commonly, the temporal
burr hole can be used as the starting point. This cut stays superior to
and follows the contour of the superior temporal line. If the supraor-
bital notch does not require drilling to release the nerve, the orbital
rim osteotomy is conducted lateral to the notch by using a side-cutting
drill bit. With permission from The Neurosurgical Atlas by Aaron
Cohen-Gadol.

FIGURE 11. The footplate attachment is also used to create the inferior portion of the craniotomy. A, Starting at the
temporal burr hole, the craniotome is directed inferiorly and then anteriorly until the progress of the footplate is stopped by
the sphenoid wing. At this point, the drill is “turned around on itself ” (steps 1 and 2) to expand the last few millimeters
of the bony cut, creating enough space so that the footplate can be removed from the epidural space (step 3). B, Next, the
footplate is replaced with a straight side-cutting B1 drill bit and the first orbital osteotomy is performed. This cut involves
connecting the orbital portion of the keyhole to the previous exit point of the craniotome via an osteotomy along the lateral
wall of the orbit and sphenoid wing. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

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FIGURE 12. A, Next, the same straight side-cutting drill bit is used to cut the zygomatic process approximately 2 cm
inferior to the frontozygomatic suture. A spatula protects the intraorbital contents. The last 2 osteotomies disconnect the
frontal zygomatic process. B, The periorbita is further dissected away from the lateral orbital wall and the roof in preparation
for the next osteotomy. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

FIGURE 13. A, A thin small osteotome is used to perform the final osteotomy along the orbital roof from the medial-to-
lateral direction, starting at the osteotomy that was used to release the supraorbital nerve. The bone of the orbital roof can
be very thin, and excessive force while using the mallet should be avoided. B, An alternative and preferred method for
completing the orbital roof osteotomy involves the use of a small thin osteotome to cut across the roof of the orbit through
the keyhole. Two cotton patties can be used to protect the frontal dura posteriorly and the periorbita inferiorly from the
osteotome. It is important that the osteotome is angled toward the exit point of the supraorbital nerve. With permission
from The Neurosurgical Atlas by Aaron Cohen-Gadol.

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FIGURE 14. Once the craniotomy and the zygomatic and orbital osteotomies are complete, the 1-piece modified OZ bone flap is free and can
be elevated carefully. If the frontal sinus is entered, its mucosa should be thoroughly curetted away/removed and the sinus packed with muscle
and bone wax. The vascularized pericranial flap can be used for its coverage during the closure stage. With permission from The Neurosurgical
Atlas by Aaron Cohen-Gadol.

FIGURE 15. Once the cranio-orbital bone flap is elevated, additional bone from the anterolateral aspect of the orbital
roof is removed, and the lesser sphenoid wing is reduced further; a straight side-cutting B1 drill bit is used for this purpose.
The orbital contents are protected. This small piece of orbital roof might not need to be replaced during closure A and B.
Additional bony removal along the subfrontal corridor can be tailored on the basis of the location of the target lesion. An
extradural clinoidectomy might be necessary for lesions around the proximal internal carotid artery along the skull base.
The clinoidectomy provides an early decompression of the optic nerve at its foramen before the adjacent compressive tumor
is manipulated. With permission from The Neurosurgical Atlas by Aaron Cohen-Gadol.

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Disclosures
The author has no personal, financial, or institutional interest in any of the
drugs, materials, or devices described in this article.
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Acknowledgments
I appreciate the generous support of the Samerian Foundation for the
completion of this work.
www.operativeneurosurgery-online.com