[Cranio-facial resections]

Four basic steps should be considered in craniofacial tumor surgery: dismantling and re-assembling of preservable bone structures to reach the tumor; en bloc resection of the "box" in malignancies (i.e., the unaffected boundaries surrounding and including the tumor), internal rigid fixation and, reconstruction by using whenever possible regional structures. In benign tumors and so-called pseudotumors, the treatment is total removal and immediate reconstruction of all structures, including the bone. The primary goal of craniofacial surgery for malignancies is to create an entrance to the box that is to be resected. This necessitates the dismantling and reassembly of some uninvolved skeletal structures. Among these are the nose, the maxilla, the nose and maxilla en bloc, the nose and the maxilla bilaterally to the mandible. The introduction of internal rigid fixation by using plates and screws has facilitated the realignment of the pedicled bone fragments in a correct position. After cranial base resection, the communication between neuro- and splanchno-cranium must be closed with viable flaps. Many techniques have been described. The horizontal forehead flap is certainly effective but results in a significant secondary defect. Where there is an orbital resection en bloc with the cranial base, the temporalis muscle flap is effective in providing vascularized coverage and simultaneously obliterating the orbital cavity. The galeal frontal flap is versatile and easy to use. It has been used to cover anterior and lateral defects with good results. The orbit is another area that requires immediate reconstruction so that there is no resulting external defect. The temporalis muscle flap, with or without a skin island, can be used to repair it. Distant flaps can likewise be used. If the resection includes the maxilla, reconstruction of the defect can be performed immediately, or it can be delayed. The authors prefer to use the temporalis muscle flap if it has not already been used. On the basis of 10 years of experience in craniofacial surgery the following conclusions can be drawn: 1. Craniofacial surgery is not a single concept. Therefore, the surgeon who deals with facial tumors involving the cranial base must have expertise in the entire field. Oncology must be part of his basic biological education. 2. Complications functional and aesthetic consequences are minimal if some basic principles are applied, both in the resection and the primary reconstructive phase. 3. In the past few years, surgical techniques have been modified and improved considerably, resulting in an operation that combines an excellent approach, oncological resection, low postoperative morbidity, good aesthetic results and improved prognosis.