title: Refined and simplified surgical landmarks for the MacCarty keyhole and orbitozygomatic craniotomy.
abstract: BACKGROUND
  Precise placement of the MacCarty keyhole, a burr hole simultaneously exposing the anterior cranial fossa floor and orbit, provides accurate, efficient entry for orbitozygomatic and supraorbital craniotomies. To locate the optimal keyhole site, previous studies have used superficial landmarks that, in our experience, are not always visible or consistent on older crania.
  
  
  OBJECTIVE
  Therefore, we present a technique for accurate keyhole placement using landmarks that are easily visible across age ranges.
  
  
  METHODS
  From inside the cranium, 1-mm burr holes were placed along the anterior junction of the floor and lateral wall of the anterior cranial fossa in 50 adult skulls (100 sides, with calvaria removed). Additionally, from inside the orbit, 1-mm burr holes were placed into the lateral orbital roof. Exit sites of intracranial and intraorbital burr holes were referenced to the frontozygomatic suture. The center of the site between the exiting intracranial and intraorbital holes was deemed the best location for the keyhole.
  
  
  RESULTS
  The keyhole center was 6.8 mm (mean) superior and 4.5 mm (mean) posterior to the frontozygomatic suture, which was easily identified on all specimens. Although this keyhole center was slightly more superior on right sides than left, this was not statistically significant. In a minority of specimens, the keyhole was located near the meningo-orbital foramen (22%) and the lateral extent of the frontal sinus (2%).
  
  
  CONCLUSIONS
  We defined an alternative method for locating the MacCarty keyhole, based on a reliable external landmark, approximately 7 mm superior and 5 mm posterior to the frontozygomatic suture.
authors.affiliation: Section of Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama, USA.
authors.forename: R Shane
authors.initials: RS
authors.lastname: Tubbs
authors.forename: Marios
authors.initials: M
authors.lastname: Loukas
authors.forename: M M
authors.initials: MM
authors.lastname: Shoja
authors.forename: Aaron A
authors.initials: AA
authors.lastname: Cohen-Gadol
mesh_terms: D002102:Cadaver; D035262:Cranial Fossa, Anterior / Q000033:anatomy & histology / Q000601:surgery*; D035301:Cranial Fossa, Middle / Q000033:anatomy & histology / Q000601:surgery; D003393:Cranial Sutures / Q000033:anatomy & histology / Q000601:surgery; D003399:Craniotomy / Q000379:methods* / Q000592:standards; D004210:Dissection; D005624:Frontal Bone / Q000033:anatomy & histology / Q000601:surgery; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000379:methods* / Q000592:standards; D038361:Neuronavigation / Q000379:methods; D019635:Neurosurgical Procedures / Q000379:methods* / Q000592:standards; D009915:Orbit / Q000033:anatomy & histology / Q000601:surgery*; D015050:Zygoma / Q000033:anatomy & histology / Q000601:surgery*