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Original Article |

Atypical Facial Access An Unusually High Prevalence of Use Among Patients With Skull Base Tumors Treated at 2 Centers FREE

Claudio Roberto Cernea, MD; Fernando L. Dias, MD, PhD; Roberto Araujo Lima, MD; Terence Farias, MD; Ullyanov B. T. Mendonça, MD; Eduardo Vellutini, MD; Marcos Q. T. Gomes, MD; Janio Nogueira, MD; Renata R. G. Lorencetti, MD; Lenine Garcia Brandão, MD; Luiz R. M. Dos Santos, MD; Julio Morais-Besteiro, MD; Luiz Carlos Ishida, MD; Mario S. L. Galvão, MD
[+] Author Affiliations

Author Affiliations: Departments of Head and Neck Surgery (Drs Cernea, Lorencetti, Brandão, and Dos Santos), Neurosurgery (Drs Vellutini and Gomes), and Plastic Surgery (Drs Morais-Besteiro and Ishida), University of São Paulo Medical School, São Paulo, Brazil; and Departments of Head and Neck Surgery (Drs Dias, Lima, Farias, and Mendonça), Neurosurgery (Dr Nogueira), and Plastic Surgery (Dr Galvão), National Cancer Institute, Rio de Janeiro, Brazil.


Arch Otolaryngol Head Neck Surg. 2007;133(8):816-819. doi:10.1001/archotol.133.8.816.
Text Size: A A A
Published online

Objective  To analyze the influence of the unique percentage of skin carcinomas with skull base invasion on the choice of the facial surgical approach.

Design  Multi-institutional retrospective analysis of the medical charts of all patients who had undergone oncological craniofacial operations from 1981 to 2005. Data were collected on demographic distribution, location of the primary tumor, histologic type, type of operation, reconstruction, complications, and outcome. Special attention was directed toward the choice of facial approach.

Setting  Two major tertiary care centers.

Patients  A total of 484 patients who had undergone major skull base operations.

Intervention  Frequency of atypical facial approaches.

Main Outcome Measures  Impact on the need for more sophisticated reconstructions and on surgical morbidity.

Results  During this 25-year period, 484 patients underwent major skull base operations in the 2 centers; data concerning 467 cases were available for analysis. The median age of the patients was 52.8 years (range, 4-88 years), and the male-female ratio was 1.9:1.0. The initial location of the tumor was the craniofacial skin in 63.5% of cases, ethmoid in 10.8%, maxilla in 2.3%, orbit in 1.9%, and other origins, including endocranial, in 19.4%. The histologic type of the lesions was basal cell carcinoma in 42.0% of cases, squamous cell carcinoma in 29.5%, esthesioneuroblastoma in 5.3%, adenocarcinoma in 3.9%, adenoid cystic carcinoma in 2.8%, and other types in 16.5%. Owing to this high prevalence of advanced skin carcinomas, the most commonly employed facial approach was atypical, tailored to encompass all compromised skin and underlying tissues, in 55.5% of cases, followed by the Weber-Ferguson approach, with all its variations (eg, nasal swing) in 17.8%, lateral rhinotomy in 12.2%, facial translocation in 3.8%, and other facial techniques in 7.7%. No facial approach was required in 1.5% of cases.

Conclusion  In most situations, head and neck surgeons chose an atypical surgical approach to properly resect all facial structures invaded by very advanced skin cancers.

Figures in this Article

The basic technical principles of craniofacial oncological operations were established by Ketcham et al1 and Ketcham and Van Buren2 in their landmark articles. Since the 1980s, some authors38 have presented their experience with combined craniofacial procedures for the treatment of skull base tumors. One of the most important advantages of these skull base surgical procedures is the possibility of performing an en bloc resection of the cancer because it results in free margins and better local control. To obtain an adequate visualization, the choices in the facial approach usually include lateral rhinotomy, medial maxillectomy, and/or degloving.9 Some variations of lateral rhinotomy, like the nasal swing and the maxillary swing,10 have been described. More recently, some authors have proposed surgical excision of lesions involving the anterior skull base through a subfrontal approach1113 or using only endoscopic techniques.14,15

In many series of patients, the most prevalent skull base tumors are sinonasal cancers.1619 However, in Brazilian series, for several reasons, most craniofacial oncological resections are indicated for very advanced skin carcinomas.2023 This finding may be related to Brazil's tropical climate, combined with other factors associated with the aggressive behavior and increased recurrence rates of these tumors, such as location in areas of embryological fusion or in the naso-orbital region, or may be related to previous therapeutic attempts.23 These extremely advanced skin lesions often involve the skull base as well as portions of the bone and soft tissue of the face and thus require more extensive operations. The resulting complex defects usually represent formidable reconstructive challenges, suitable only for microsurgical free-flap reconstruction. These resections have been called extended cranial base resections by some authors,16,23,24 creating a subgroup within skull base surgery. In these instances, planning of the facial incisions is often dictated by the invasion of skin, soft tissues, and facial skeleton, precluding any standard, less invasive approach.

The objective of this study was to quantify the percentage of these atypical “customized” facial approaches in 2 Brazilian skull base referral centers.

In this retrospective study, the medical charts of 484 patients who underwent craniofacial operations in 2 tertiary care institutions were reviewed. Of these patients, sufficient information regarding the craniofacial surgical approach employed was obtained in 467 cases. The following data were also collected: initial location of the tumor, histologic type, type of facial and cranial approach, reconstruction, and complications. Special attention was directed toward the percentage of atypical facial approaches, which were directly related to the incidence of advanced skin neoplasms, as well as the impact of these approaches on surgical morbidity. Atypical facial access was defined as a nonstandard extended surgical approach, designed to encompass all invaded skin and/or soft tissues. Eyelid resection, in continuity with a maxillectomy, was not considered an atypical facial access.

The male to female ratio of the patients was 1.9:1.0, and the median age was 52.8 years (range, 4-88 years). The initial location of the tumor was the craniofacial skin in 63.5% of cases, ethmoid in 10.8%, maxilla in 2.3%, orbit in 1.9%, and other origins, including endocranial, in 19.4%. The histologic type of the lesion was basal cell carcinoma in 42.0% of cases, squamous cell carcinoma in 29.5%, esthesioneuroblastoma in 5.3%, adenocarcinoma in 3.9%, adenoid cystic carcinoma in 2.8%, and other types in 16.5%. Most of the patients (58.2%) had been previously treated with surgery and/or radiotherapy. Because of this high prevalence of advanced skin carcinoma, the most commonly employed facial approach was atypical, tailored to encompass all compromised skin and underlying tissues, in 55.5% of cases, followed by the Weber-Ferguson approach, with all its variations (eg, nasal swing) in 17.8%, lateral rhinotomy in 12.2%, facial translocation in 3.8%, and other techniques in 7.7%. No facial approach was required in 1.5% of cases. An example of the atypical approach is demonstrated in Figure 1.

Place holder to copy figure label and caption
Figure 1.

Multicentric basal cell carcinoma, with invasion of the frontal bone and frontal lobe.

Graphic Jump Location

Primary reconstruction (including prosthesis) was possible in 33.2% of cases. Most of the surgical defects (37.2%) required microvascular flaps (1.1% required more than 1 free flap), whereas conventional flaps (local or distant) and skin grafts were employed in 21.5% and 2.8% of the situations, respectively. A combination of different reconstructive techniques was used in 18.9% of the patients (Figure 2).

Place holder to copy figure label and caption
Figure 2.

Three-year postoperative view of a patient with recurrent basal cell carcinoma who underwent extended craniofacial resection and was rehabilitated with an association of 3 reconstructive techniques: split-thickness skin graft, forearm free flap, and facial prosthesis. A, Aspect of the surgical defect; B, the patient's appearance with prosthesis in place.

Graphic Jump Location

Major complications included bony necrosis (in 10.1% of cases), cerebrospinal (CSF) fistula (in 8.2%), meningitis (in 7.3%), prolonged coma (in 6.4%), microvascular flap necrosis (in 6.4%), local or distant conventional flap necrosis (in 6.4%), brain abscess (in 2.7%), pneumocephalus (in 2.7%), and subdural hematoma (in 2.7%). More than 1 complication occurred in 24.6% of patients. Treatment of bony necrosis, flap necrosis, abscess, and hematoma was always surgical. Prolonged coma was associated with frontal lobe manipulation and was managed conservatively in most cases. Minor CSF fistulas responded to prolonged lumbar drainage, but larger fistulas required a reoperation. The mortality rate was 5.9%, generally related to CSF fistula and meningitis. During a median follow-up period of 39.2 months, the disease-free survival rate for patients with malignant tumors was 48.2%. This survival rate was reduced to 38.2% among those patients who underwent atypical facial access, especially when microvascular reconstruction was required.

Craniofacial oncological operations have been the gold standard for the treatment of skull base tumors since the last decades of the 20th century.38 Usually, excision of these lesions is accomplished by an association of a neurosurgical access to the skull base, combined with a transfacial approach. Several options for this approach have been described in the literature, ranging from variations of paralateronasal incision9,10 to complex facial disassembling techniques.25 Recently, some authors1115 presented successful resections of skull base lesions without any kind of facial incision. However, when an extensive skin cancer located in the craniofacial area invades the skull base, surgical incisions have to be tailored to include all its boundaries. In this instance, it is virtually impossible to perform a radical operation with no facial incision or even through a conventional facial approach. In contrast with most published series of skull base tumors,1619 skin carcinomas are the most frequent histologic type among Brazilian published series.2023 The reasons for this high prevalence are unclear. Some possible epidemiological and clinical explanations have been considered. Brazil is both a tropical and subtropical country, with most of its territory situated within low-latitude limits wherein the pathological effects of UV-B exposure are more pronounced. Interestingly, findings from a series of skull base tumors that originated from Australia, which is situated in a similar latitude, did not show this increased prevalence of skin carcinomas.26 Another reason could be the delay in seeking medical treatment by patients of a low economic class living in rural areas, leading to neglected, extensive skin cancers with deep invasion. Some recent articles2729 have suggested the role of molecular factors in these extremely aggressive tumors.

In articles22,23 reporting a previous series, extended procedures, particularly those creating a wide communication between the extracranial and intracranial cavities that required free-tissue transfer for 3-dimensional reconstruction, and dural invasion and resection were the most significant risk factors associated with major postoperative complications. Other authors30,31 also have considered the presence of large combined defects, involving both frontal and temporal areas, as the single most important risk factor for the development of postoperative complications. In the present study, the complication rate was comparable with those of other available series in the literature.16,22,24,32

The main objective of this study was to evaluate the prevalence of atypical facial access among patients who underwent major craniofacial oncological operations in 2 tertiary centers in Brazil. Most of these operations were indicated for very advanced skin cancers (63.5%); hence, the most frequent transfacial approaches were atypical (55.5%) to properly encompass all macroscopical tumor boundaries. Two immediate consequences were a high incidence of surgical complications and the need for elaborate reconstructive techniques, such as microvascular flaps, which were employed in more than one-third of the cases in this series. In fact, in a previous publication,20 indication of a free flap was a statistically significant prognostic factor. Evidently, an extensive facial defect increases the potential morbidity in skull base operations, especially in the event of a free-flap failure, leading to life-threatening situations. Similarly, a trend toward reduced survival was noted among patients who underwent atypical facial approaches.

In conclusion, in this retrospective study, which encompasses a 25-year experience with skull base operations in 2 major Brazilian centers, in most situations, head and neck surgeons chose an atypical surgical approach to properly resect all facial structures invaded by very advanced skin cancers.

Correspondence: Claudio Roberto Cernea, MD, Alameda Franca, 267, Room 21, CEP 01422-000, São Paulo, Brazil (cerneamd@uol.com.br).

Submitted for Publication: January 22, 2007; final revision received March 15, 2007; accepted March 25, 2007.

Author Contributions: Drs Cernea, Dias, Lima, Farias, Mendonça, Vellutini, Gomes, Nogueira, Lorencetti, Brandão, Dos Santos, Morais-Besteiro, Ishida, and Galvão had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Cernea, Morais-Besteiro, and Ishida. Acquisition of data: Cernea, Dias, Lima, Farias, Mendonça, Vellutini, Gomes, Nogueira, Lorencetti, Brandão, Dos Santos, Morais-Besteiro, Ishida, and Galvão. Analysis and interpretation of data: Cernea, Vellutini, and Gomes. Drafting of the manuscript: Cernea, Dias, Farias, Mendonça, Nogueira, Lorencetti, Brandão, Dos Santos, and Galvão. Critical revision of the manuscript for important intellectual content: Cernea, Lima, Vellutini, Gomes, Morais-Besteiro, and Ishida. Administrative, technical, and material support: Vellutini and Gomes. Study supervision: Cernea and Morais-Besteiro.

Financial Disclosure: None reported.

Previous Presentation: This study was presented at the American Head and Neck Society 2006 Annual Meeting and Research Workshop on the Biology, Prevention, and Treatment of Head and Neck Cancer; August 17-20, 2006; Chicago, Illinois.

Ketcham  ASWilkins  RHVan Buren  JM  et al.  A combined intracranial facial approach to the paranasal sinuses. Am J Surg 1963;106698- 703
PubMed Link to Article
Ketcham  ASVan Buren  JM Tumors of the paranasal sinuses: a therapeutic challenge. Am J Surg 1985;150 (4) 406- 413
PubMed Link to Article
Terz  JJYoung  HFLawrence  W  Jr Combined craniofacial resection for locally advanced carcinoma of the head and neck, I: tumors of the skin and soft tissues. Am J Surg 1980;140 (5) 613- 617
PubMed Link to Article
Terz  JJYoung  HFLawrence  W  Jr Combined craniofacial resection for locally advanced carcinoma of the head and neck, II: carcinoma of the paranasal sinuses. Am J Surg 1980;140 (5) 618- 624
PubMed Link to Article
Jackson  ITMarsh  WRHide  TA Treatment of tumors involving the anterior cranial fossa. Head Neck Surg 1984;6 (5) 901- 913
PubMed Link to Article
Janecka  IPSen  CSekhar  LN  et al.  Cranial base surgery: results in 183 patients. Otolaryngol Head Neck Surg 1994;110 (6) 539- 546
PubMed
Andersen  PEKraus  DHArbit  E  et al.  Management of the orbit during anterior fossa craniofacial resection. Arch Otolaryngol Head Neck Surg 1996;122 (12) 1305- 1307
PubMed Link to Article
Patel  SGSingh  BPolluri  A  et al.  Craniofacial surgery for malignant skull base tumors: report of an international collaborative study. Cancer 2003;98 (6) 1179- 1187
PubMed Link to Article
Osguthorpe  JDPatel  S Craniofacial approaches to tumors of the anterior skull base. Otolaryngol Clin North Am 2001;34 (6) 1123- 1142
PubMed Link to Article
Wei  WILam  KHSham  JS New approach to the nasopharynx: the maxillary swing approach. Head Neck 1991;13 (3) 200- 207
PubMed Link to Article
Panje  WRDohrmann  GJ  IIIPitcock  JK  et al.  The transfacial approach for combined anterior craniofacial tumor ablation. Arch Otolaryngol Head Neck Surg 1989;115 (3) 301- 307
PubMed Link to Article
Raveh  JLaedrach  KSpeiser  M  et al.  The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 1993;119 (4) 385- 393
PubMed Link to Article
Gatot  AFliss  DMZucker  G  et al.  The subcranial approach to the anterior skull base: retrospective study of 75 cases. Ann Otolaryngol Chir Cervicofac 2000;117 (6) 367- 373
PubMed
Leong  JLCitardi  MJBatra  PS Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms. Am J Rhinol 2006;20 (5) 476- 482
PubMed Link to Article
Buchmann  LLarsen  CPollack  ATawfik  OSykes  KHoover  LA Endoscopic techniques in resection of anterior skull base/paranasal sinus malignancies. Laryngoscope 2006;116 (10) 1749- 1754
PubMed Link to Article
Clayman  GLDeMonte  FJaffe  DM  et al.  Outcome and complications of extended cranial-base resection requiring microvascular free tissue transfer. Arch Otolaryngol Head Neck Surg 1995;121 (11) 1253- 1257
PubMed Link to Article
Kelly  MBWaterhouse  NSlade  DE  et al.  A 5-year review of 71 consecutive anterior skull base tumours. Br J Plast Surg 2000;53 (3) 184- 190
PubMed Link to Article
Ganly  IPatel  SGSingh  B  et al.  Craniofacial resection for malignant paranasal sinus tumors: report of an International Collaborative Study. Head Neck 2005;27 (7) 575- 584
PubMed Link to Article
Howard  DJLund  VJWei  WI Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience. Head Neck 2006;28 (10) 867- 873
PubMed Link to Article
Dos Santos  LRCernea  CRBrandão  LG  et al.  Results and prognostic factors in skull base surgery. Am J Surg 1994;168 (5) 481- 484
PubMed Link to Article
Cernea  CRTeixeira  GVMedina dos Santos  LR  et al.  Indications for, contraindications to, and interruption of craniofacial procedures. Ann Otol Rhinol Laryngol 1997;106 (11) 927- 933
PubMed
Dias  FLSa  GMKligerman  J  et al.  Complications of anterior craniofacial resection. Head Neck 1999;21 (1) 12- 20
PubMed Link to Article
Dias  FLSa  GMKligerman  J  et al.  Prognostic factors and outcome in craniofacial surgery for malignant cutaneous tumors involving the anterior skull base. Arch Otolaryngol Head Neck Surg 1997;123 (7) 738- 742
PubMed Link to Article
Urken  MLCatalano  PJSem  C  et al.  Free tissue transfer for skull base reconstruction: analysis of complications and a classification scheme for defining skull base defects. Arch Otolaryngol Head Neck Surg 1993;119(12)1318- 1325
PubMed Link to Article
Janecka  IP Classification of facial translocation approach to the skull base. Otolaryngol Head Neck Surg 1995;112 (4) 579- 585
PubMed
Bridger  GPKwok  BBaldwin  M  et al.  Craniofacial resection for paranasal sinus cancer. Head Neck 2000;22 (8) 772- 780
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  Angiogenesis and skin carcinomas with skull base invasion: a case-control study. Head Neck 2004;26 (5) 396- 400
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  Evaluation of basement membrane status in aggressive skin carcinomas with skull base invasion: a case-control study. Ann Diagn Pathol 2005;9 (3) 130- 133
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  p53 and skin carcinomas with skull base invasion: a case-control study. Otolaryngol Head Neck Surg 2006;134 (3) 471- 475
PubMed Link to Article
Wornom  ILNeifeld  JPMenrhof  AJ  et al.  Closure of craniofacial defects after cancer resection. Am J Surg 1991;162 (4) 408- 441
PubMed Link to Article
Irish  JCGulane  PJGentili  F  et al.  Tumors of the skull base: outcome and survival analysis of 77 cases. Head Neck 1994;16 (1) 3- 10
PubMed Link to Article
Backous  DDDeMonte  FEl-Naggar  A  et al.  Craniofacial resection for nonmelanoma skin cancer of the head and neck. Laryngoscope 2005;115 (6) 931- 937
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Multicentric basal cell carcinoma, with invasion of the frontal bone and frontal lobe.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Three-year postoperative view of a patient with recurrent basal cell carcinoma who underwent extended craniofacial resection and was rehabilitated with an association of 3 reconstructive techniques: split-thickness skin graft, forearm free flap, and facial prosthesis. A, Aspect of the surgical defect; B, the patient's appearance with prosthesis in place.

Graphic Jump Location

Tables

References

Ketcham  ASWilkins  RHVan Buren  JM  et al.  A combined intracranial facial approach to the paranasal sinuses. Am J Surg 1963;106698- 703
PubMed Link to Article
Ketcham  ASVan Buren  JM Tumors of the paranasal sinuses: a therapeutic challenge. Am J Surg 1985;150 (4) 406- 413
PubMed Link to Article
Terz  JJYoung  HFLawrence  W  Jr Combined craniofacial resection for locally advanced carcinoma of the head and neck, I: tumors of the skin and soft tissues. Am J Surg 1980;140 (5) 613- 617
PubMed Link to Article
Terz  JJYoung  HFLawrence  W  Jr Combined craniofacial resection for locally advanced carcinoma of the head and neck, II: carcinoma of the paranasal sinuses. Am J Surg 1980;140 (5) 618- 624
PubMed Link to Article
Jackson  ITMarsh  WRHide  TA Treatment of tumors involving the anterior cranial fossa. Head Neck Surg 1984;6 (5) 901- 913
PubMed Link to Article
Janecka  IPSen  CSekhar  LN  et al.  Cranial base surgery: results in 183 patients. Otolaryngol Head Neck Surg 1994;110 (6) 539- 546
PubMed
Andersen  PEKraus  DHArbit  E  et al.  Management of the orbit during anterior fossa craniofacial resection. Arch Otolaryngol Head Neck Surg 1996;122 (12) 1305- 1307
PubMed Link to Article
Patel  SGSingh  BPolluri  A  et al.  Craniofacial surgery for malignant skull base tumors: report of an international collaborative study. Cancer 2003;98 (6) 1179- 1187
PubMed Link to Article
Osguthorpe  JDPatel  S Craniofacial approaches to tumors of the anterior skull base. Otolaryngol Clin North Am 2001;34 (6) 1123- 1142
PubMed Link to Article
Wei  WILam  KHSham  JS New approach to the nasopharynx: the maxillary swing approach. Head Neck 1991;13 (3) 200- 207
PubMed Link to Article
Panje  WRDohrmann  GJ  IIIPitcock  JK  et al.  The transfacial approach for combined anterior craniofacial tumor ablation. Arch Otolaryngol Head Neck Surg 1989;115 (3) 301- 307
PubMed Link to Article
Raveh  JLaedrach  KSpeiser  M  et al.  The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 1993;119 (4) 385- 393
PubMed Link to Article
Gatot  AFliss  DMZucker  G  et al.  The subcranial approach to the anterior skull base: retrospective study of 75 cases. Ann Otolaryngol Chir Cervicofac 2000;117 (6) 367- 373
PubMed
Leong  JLCitardi  MJBatra  PS Reconstruction of skull base defects after minimally invasive endoscopic resection of anterior skull base neoplasms. Am J Rhinol 2006;20 (5) 476- 482
PubMed Link to Article
Buchmann  LLarsen  CPollack  ATawfik  OSykes  KHoover  LA Endoscopic techniques in resection of anterior skull base/paranasal sinus malignancies. Laryngoscope 2006;116 (10) 1749- 1754
PubMed Link to Article
Clayman  GLDeMonte  FJaffe  DM  et al.  Outcome and complications of extended cranial-base resection requiring microvascular free tissue transfer. Arch Otolaryngol Head Neck Surg 1995;121 (11) 1253- 1257
PubMed Link to Article
Kelly  MBWaterhouse  NSlade  DE  et al.  A 5-year review of 71 consecutive anterior skull base tumours. Br J Plast Surg 2000;53 (3) 184- 190
PubMed Link to Article
Ganly  IPatel  SGSingh  B  et al.  Craniofacial resection for malignant paranasal sinus tumors: report of an International Collaborative Study. Head Neck 2005;27 (7) 575- 584
PubMed Link to Article
Howard  DJLund  VJWei  WI Craniofacial resection for tumors of the nasal cavity and paranasal sinuses: a 25-year experience. Head Neck 2006;28 (10) 867- 873
PubMed Link to Article
Dos Santos  LRCernea  CRBrandão  LG  et al.  Results and prognostic factors in skull base surgery. Am J Surg 1994;168 (5) 481- 484
PubMed Link to Article
Cernea  CRTeixeira  GVMedina dos Santos  LR  et al.  Indications for, contraindications to, and interruption of craniofacial procedures. Ann Otol Rhinol Laryngol 1997;106 (11) 927- 933
PubMed
Dias  FLSa  GMKligerman  J  et al.  Complications of anterior craniofacial resection. Head Neck 1999;21 (1) 12- 20
PubMed Link to Article
Dias  FLSa  GMKligerman  J  et al.  Prognostic factors and outcome in craniofacial surgery for malignant cutaneous tumors involving the anterior skull base. Arch Otolaryngol Head Neck Surg 1997;123 (7) 738- 742
PubMed Link to Article
Urken  MLCatalano  PJSem  C  et al.  Free tissue transfer for skull base reconstruction: analysis of complications and a classification scheme for defining skull base defects. Arch Otolaryngol Head Neck Surg 1993;119(12)1318- 1325
PubMed Link to Article
Janecka  IP Classification of facial translocation approach to the skull base. Otolaryngol Head Neck Surg 1995;112 (4) 579- 585
PubMed
Bridger  GPKwok  BBaldwin  M  et al.  Craniofacial resection for paranasal sinus cancer. Head Neck 2000;22 (8) 772- 780
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  Angiogenesis and skin carcinomas with skull base invasion: a case-control study. Head Neck 2004;26 (5) 396- 400
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  Evaluation of basement membrane status in aggressive skin carcinomas with skull base invasion: a case-control study. Ann Diagn Pathol 2005;9 (3) 130- 133
PubMed Link to Article
Cernea  CRFerraz  ARde Castro  IV  et al.  p53 and skin carcinomas with skull base invasion: a case-control study. Otolaryngol Head Neck Surg 2006;134 (3) 471- 475
PubMed Link to Article
Wornom  ILNeifeld  JPMenrhof  AJ  et al.  Closure of craniofacial defects after cancer resection. Am J Surg 1991;162 (4) 408- 441
PubMed Link to Article
Irish  JCGulane  PJGentili  F  et al.  Tumors of the skull base: outcome and survival analysis of 77 cases. Head Neck 1994;16 (1) 3- 10
PubMed Link to Article
Backous  DDDeMonte  FEl-Naggar  A  et al.  Craniofacial resection for nonmelanoma skin cancer of the head and neck. Laryngoscope 2005;115 (6) 931- 937
PubMed Link to Article

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