title: Quantification of the frontotemporal orbitozygomatic approach using a three-dimensional visualization and modeling application.
abstract: OBJECTIVE
  We sought to simulate the frontotemporal orbitozygomatic (FTOZ) craniotomy in a three-dimensional virtual environment on patient-specific data and to quantify the exposure afforded by the FTOZ while simulating controlled amounts of brain retraction.
  
  
  METHODS
  Four computed tomographic angiograms were reconstructed with commercially available software (Amira 4.1.1; Mercury Computer Systems, Inc., Chelmsford, MA), and virtual FTOZ craniotomies were performed bilaterally (n = 8). Brain retraction was simulated at 1 and 2 cm. Surgical freedom and projection angle were measured and compared at each stage of the FTOZ.
  
  
  RESULTS
  At 1 cm of retraction, surgical freedom increased by 27 +/- 14% for the removal of the orbital rim and by 31 +/- 18% for FTOZ (P < 0.01) when compared with frontotemporal (FT) craniotomy. At 2 cm of retraction, surgical freedom increased by 15 +/- 5% and 26 +/- 8% for the removal of the orbital rim and FTOZ, respectively (P < 0.01). With increased retraction, surgical freedom increased by 100 +/- 26%, 81 +/- 15%, and 82 +/- 27% for the FT, removal of the orbital rim, and FTOZ craniotomies, respectively (P < 0.001). Projection angle increased by 24.2% when orbital rim removal was added to the FT craniotomy (P < 0.01).
  
  
  CONCLUSIONS
  Surgical freedom increases significantly at every step of the FTOZ craniotomy. This effect is less robust when brain retraction is increased. Brain retraction alone has a greater impact on surgical freedom than bone removal alone. Projection angle is significantly increased when orbital rim removal is added to the FT craniotomy. This model overcomes two major limitations of cadaver-based models: quantification of brain retraction and incorporation of patient-specific anatomy.
authors.affiliation: Department of Neurological Surgery, Columbia University, New York, New York 10032, USA.
authors.forename: Anthony L
authors.initials: AL
authors.lastname: D'Ambrosio
authors.forename: J
authors.initials: J
authors.lastname: Mocco
authors.forename: Todd C
authors.initials: TC
authors.lastname: Hankinson
authors.forename: Jeffrey N
authors.initials: JN
authors.lastname: Bruce
authors.forename: Harry R
authors.initials: HR
authors.lastname: van Loveren
mesh_terms: D003198:Computer Simulation; D003399:Craniotomy / Q000379:methods*; D006801:Humans; D021621:Imaging, Three-Dimensional / Q000379:methods*; D008953:Models, Anatomic; D008954:Models, Biological; D014057:Tomography, X-Ray Computed / Q000379:methods; D015050:Zygoma / Q000000981:diagnostic imaging* / Q000601:surgery*