2024 Volume 52 Issue 6 Pages 440-447
Direct surgery is safe and reliable for various types of cerebral aneurysms. However, frontotemporal craniotomy, frequently used in the treatment of cerebral aneurysms, sometimes causes aesthetic problems, such as temporal muscle atrophy, skin depressions causing bone atrophy, hair loss along the scalp incision, protrusion of artificial materials, and facial nerve palsy. Various techniques have been reported over the years; however, they have not been widely accepted because they require sufficient experience and skill to perform safely. At our institution, we maintain aesthetic results without sacrificing the conventional craniotomy size by modifying the conventional open and closed procedures. Our main surgical modifications were as follows: 1) Use of a local anesthetic with epinephrine in the skin incision area reduces bleeding during skin incision. 2) The incisions for the periosteum and temporalis muscle were designed to obtain a sufficient craniotomy area while avoiding manipulation of the temples, where temporal muscle atrophy is often prominent. After using a monopolar electrocautery device for temporal muscle incisions, the periosteum and temporalis muscles were peeled off gently using a periosteal elevator. 3) A craniotomy was performed without wasting the bone by creating a fracture line on the sphenoid ridge before fracturing the bone. For craniotomy margins, the use of foreign materials, such as bone wax, which prevents bone fusion, is avoided as much as possible. 4) In the closing phase, the bone defect was filled with bone powder obtained during craniotomy and was closed tightly with the periosteum and temporalis muscles, without exposing the craniotomy edge.
This study included 66 patients (44 with unruptured cerebral aneurysms and 22 with ruptured cerebral aneurysms) who underwent clipping between July 2017 and November 2023. We categorized the degree of temple depression, seen on CT images, into three classes: excellent in 58 cases, good in six cases, and poor in two cases. The thickness of the temporalis muscle and subcutaneous tissue, and that of the subcutaneous tissue considering the titanium plate, compared to the preoperative conditions, suggested that, the greater the thickness of the titanium plate, the better aesthetics were maintained. These attempts resulted in satisfactory aesthetic effects, both subjectively and statistically (p = 0.0008, p = 0.0046, and p = 0.0057, respectively). Our technique requires no special skills and can be performed by residents. In addition, this technique has been widely adapted for various cerebral aneurysms, because the conventional craniotomy area is obtained. Given that our technique maintains surgical opportunities, it is also effective in surgical education.
