Principles of anterior skull base resection: Open and endoscopic techniques

Resection of a neoplasm is the most common indication for an anterior skull base approach. This surgery aims to obtain a complete extirpation (with negative histologic margins) yielding the best oncologic outcome, while producing the least degree of functional and cosmetic morbidity. Open or endoscopic endonasal routes, or both, may be used for the resection based on the tumor stage, histology, and patient's specific needs and characteristics, as well as the surgeon's training and preference. Traditional open craniofacial approaches require a craniotomy and maxillofacial osteotomies that include those necessary for a subfrontal approach. This technique remains one of the primary strategies to manage anterior cranial base lesions, especially those with significant extension or involving critical neurovascular structures. A significant recent development in cranial base surgery is the adoption of endonasal endoscopic approaches, which have been applied to resect the anterior cranial base. Its benefits include the minimal manipulation of the brain (no retraction), avoidance of maxillofacial osteotomies, and lack of cosmetic deficits. Endoscopic, endoscopic-assisted, and open approaches afford advantages and disadvantages and have different indications and limitations; therefore, the skull base surgeon (or the skull base surgery team) must be versed in all techniques.