Anchoring the Temporalis Muscle with an Intact Fascial Layer Along the Superior Temporal Line in Pterional Craniotomy: A Technical Note.

BACKGROUND: Manipulation of the temporalis muscle during pterional and frontotemporal approaches poses major cosmetic and functional issues postoperatively. The temporalis muscle has usually been secured in its normal position using implants or by leaving a thin rim of muscle and fascia attached along the superior temporal line. In the present report, we have described a pure tissue-based method of anchoring the intact temporalis muscle precisely along the superior temporal line. METHODS: A total of 30 consecutive cases of pterional or frontotemporal craniotomy were performed by single surgeon (SKR). A subfascial dissection technique was used to expose the transition zone of the frontal pericranium with the temporalis fascia. These were then separated by sharp dissection along the superior temporal line at which the muscle is attached. The temporalis muscle and fascia were repositioned during closure, precisely at their original anatomical location by passing multiple anchoring sutures along the free edge of the muscle and fascia lying along the superior temporal line. RESULTS: Temporalis muscle reattachment was achieved in all 30 cases with good cosmesis and functional outcome without temporalis muscle-related complications at 6 months of follow-up. CONCLUSIONS: The approximation of sutures running through the free edge of the temporalis muscle with intact fascia along the superior temporal line from anteriorly to posteriorly restored the muscle and fascial layer to its original position. Avoidance of the formation of any potential dead space during surgical exposure will prevent periorbital edema and/or subgaleal collection postoperatively. The described inexpensive technique avoids implant-related complications, with good functional and aesthetic outcomes. A comparative study is needed to establish the superiority of this procedure over other techniques.

Modified Ipsilateral Endonasal Endoscopic Trans-Sphenoidal Approach to Sphenoid Sinus Lateral Recess Cerebrospinal Fluid Leak Management in Two Cases: A Technical Note.

Background Cerebrospinal fluid (CSF) leak from the sphenoid sinus lateral recess (SSLR) is very rare. Majority prefer transpterygoid approach which is extensive and time consuming. Two such cases were managed with least possible dissection/destruction of paranasal sinus. Methods Two cases of SSLR were accessed through the ipsilateral nostril from the side of CSF leak. Wide ipsilateral anterior sphenoidotomy was done preserving intersinus septum of sphenoid sinus. Middle turbinate was lateralized and remaining paranasal structures were preserved. Two handed single nostril approach was done in both the cases by 45- and 70-degree endoscope along with angled instruments. SSLR defects were visualized and packed with autologous fat graft and glue. Results SSLR defects could be visualized and packed with fat graft in both the cases from ipsilateral side. Both cases had uneventful outcome with no leak with mean -follow-up of 11.5 months. Conclusion Modified ipsilateral endonasal endoscopy trans-sphenoidal approach is least invasive technique for SSLR leak. Use of angled scope and instruments help in defect visualization, avoiding extensive paranasal sinus dissection and bony removal. Tedious time-consuming reconstructive procedures can be avoided with simple fat graft with good outcome.

Brain Tumor Interface Dissection Technique with Surgical Blade from Laboratory to Neurosurgical Operating Room.

BACKGROUND: Ideal tumor resection requires brain/spinal cord tumor interface separation in perfect and precise surgical planes within a few micrometers for radical tumor resection and maximum normal tissue preservation. Despite the availability of several dissection techniques, the search for additional alternatives and an ideal technique continues. We evaluated the feasibility and advantages of dissection using a No. 15-blade scalpel in special brain tumor surgery situations. We developed a leaf model wherein its outer layer is progressively dissected from its inner skeleton using a scalpel. An additional model used was a tomato wherein its skin was peeled off its pulp using the same technique. OBJECTIVE: We developed an inexpensive leaf model. A scalpel knife was used in a microneurosurgical setting, and the leaf's outer layer is peeled off. The technique is then used in an operating room setup where surgery on extra-axial tumors like meningiomas and intra-axial brain and spinal cord tumors is done. METHODS: A No. 15 scalpel was used for dissection between the layers of the Peltophorum pterocarpum leaf model. This dissection method was compared with other neurosurgical dissecting tools. RESULTS: We dissected 120-µm thick leaves into 2 layers with removal of an 18- to 55-µm thick layer. Leaving behind a transparent layer was possible using a No. 15 blade scalpel. Similarly, it was possible to preserve a 35- to 40-µm thick arachnoid layer that separated a meningioma from the underlying brain parenchyma. CONCLUSION: A scalpel with a sharp edge could be used to perform precise and fine dissection. The scalpel deserves to occupy a place of pride as a dissecting tool in neurosurgery.