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Transmaxillary Exposure of the Cranial Base

Surgical Correlation

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A, In this dissection, a midfacial soft tissue flap has been reflected laterally to expose the anterior surface of the right maxilla. The operative approach to the maxillary sinus is more commonly performed using a sublabial incision in the gingivobuccal margin rather than through an incision on the face. The approach can be completed without dividing the infraorbital nerve, but in this dissection, it was divided below the infraorbital foramen. The nerve, if divided, can be resutured at the time of closing. The infra-temporal fossa, which is situated below the greater sphenoid wing, has been exposed by removing the coronoid process of the mandible and a narrow wedge of zygoma. B, The anterior wall of the maxillary sinus has been removed. The roof of the maxillary sinus forms the majority of the floor of the orbit. The infratemporal fossa contains the pterygoid muscles, mandibular nerve, maxillary artery, and the pterygoid venous plexus. C, The medial and lateral walls of the maxillary sinus have been opened, but the posterior part of the sinus wall, which forms the anterior wall of the pterygopalatine fossa, has been preserved. Removing the medial wall of the sinus exposes the nasal cavity, turbinates, and nasal septum. The maxillary artery crosses the lateral pterygoid muscle to reach the pterygopalatine fossa, which is located behind the upper part of the posterior wall of the maxillary sinus and below the orbital apex. D, The posterior wall of the maxillary sinus has been removed to expose the pterygopalatine fossa and orbital floor. The pterygopalatine fossa is located below the orbital apex and the posteromedial part of the inferior orbital fissure. The maxillary nerve enters the pterygopalatine fossa by passing through the foramen rotundum. The maxillary nerve gives rise to the infraorbital nerve, which passes forward in the infraorbital canal in the sinus roof and orbital floor. E, Enlarged view of infratemporal and pterygopalatine fossae. Distally, the maxillary artery enters the pterygopalatine fossa, which is located in the lateral wall of the nasal cavity below the orbital apex. F, The exposure has been directed medially through the nasal cavity to the clivus, which has been opened to expose the vertebral and basilar arteries and the front of the brainstem. The exposure has been extended upward by opening the sphenoid sinus and exposing the left intracavernous carotid. The margin of the foramen magnum has been preserved. (Images courtesy of AL Rhoton, Jr.)

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