2025 Poster Presentations
P061: THE MINI-PEELING OF MIDDLE FOSSA TECHNIQUE: INDICATIONS AND DESCRIPTION OF THE PROCEDURE
Fabian Castro Barros, MD; Sergio Pallini, MD; Daniel Desole, MD; Gonzalo Bonilla, MD; Federico Gresta, MD; Army Central Hospital
Introduction: The mini-peeling of the middle cranial fossa is an emerging surgical technique in the treatment of complex pathologies of the skull base, such as meningiomas, neurinomas, and vascular lesions that affect the temporal region and adjacent structures. This approach aims to minimize invasiveness and postoperative complications associated with traditional procedures, which involve wide craniotomies and greater manipulation of surrounding tissues. The technique aims to provide safe and effective access to the middle fossa, respecting critical structures such as cranial nerves and blood vessels. Its growing popularity is due to promising results in terms of faster recovery, lower morbidity, and better aesthetic satisfaction for patients.
Methods: The excision of a tumor (meningioma) located in the wing of the sphenoid bone was performed through a pterional transzygomatic approach using the mini-peeling technique. The main blood supply to these tumors comes from branches of the middle and accessory meningeal arteries. Surgical removal of meningiomas requires early devascularization of the tumor.
Results: The patient is positioned with a cephalic rotation of 10-30 degrees. After making an arched skin incision, the interfascial/subfascial dissection is performed, allowing for retraction of the temporal muscle caudally. This allows for optimal exposure of the zygomatic arch. Once this is removed, a craniotomy is performed, with the opening as close as possible to the floor of the middle cranial fossa. The dura mater is then dissected from the sphenoid wing towards the frontal and temporal regions, with the dissection being more extensive in the temporal region. The sphenoid wing is drilled to open the roof of the orbit in its posterior third. The approach continues until reaching the beginning of the anterior clinoid process, where the orbitomeningeal band is found laterally, a key point in the approach. This is is coagulated with a bipolar forceps, followed by incision. A sharp dissector is used to section the first layer of the dura mater from medial to lateral, continuing to separate both layers downwards. the middle meningeal artery enters through the spinous foramen laterally. This artery must be dissected, coagulated, cut, and then the dissection continues downwards and laterally.
Conclusions: The mini-peeling technique of the middle skull base represents a significant advancement in the surgical treatment of skull base pathologies by providing safer and less invasive access to complex lesions. Clinical results have shown that this technique can reduce neurological and aesthetic complications, offering patients a quicker recovery and better long-term outcomes. However, the success of this approach largely depends on rigorous preoperative planning and the expertise of the surgical team. As more specialized centers adopt this technique, it is likely that its application will expand and the criteria for its use will be further refined.