The Le Fort I-palatal split approach for skull base tumors: efficacy, complications, and outcome

The Le Fort I, split-palate approach provides intraoral surgical access to a region of the midline skull base ranging from the upper clivus to the second cervical vertebra. Although this approach provides perhaps the largest exposure of all the intraoral techniques, there is little concerning it in the literature. Furthermore, there are no detailed descriptions of case histories, complications, and outcome. The purpose of this study was to evaluate this procedure's effectiveness and identify associated complications as well as outcome. Seven cases of patients who underwent eight skull base surgeries using the Le Fort I, split-palate approach were evaluated retrospectively. Particular attention was paid to postoperative occlusion, speech, mouth opening, infection, tumor recurrence, postoperative recovery period, and viability of maxillary bone and teeth. Follow-up ranged from 4 months to 7 years with a mean of 3.9 years. Pathologic diagnoses included three chordomas (two recurrent), one recurrent meningioma, one liposarcoma, one chondrosarcoma, and one inflammatory mass. One patient with chordoma underwent a second operation using the same approach. No deaths or major neurologic problems related to the procedure occurred. One patient who had known local metastases at the time of operation died several months after surgery. All other patients are still living. Duration of hospital stay ranged from 5 to 53 days with a mean of 25.4 days. Postoperative complications included one case of meningitis with an associated cerebrospinal fluid leak, three cases of malocclusion, one case of velopharyngeal insufficiency, and one extracranial soft-tissue infection. The case of meningitis was successfully treated by antibiotics. The malocclusions were corrected by conservative treatment. No problems with mouth opening or bone or tooth viability occurred. Tumor recurred in both cases in which malignancy was involved, whereas only one recurrence was noted among the benign cases. It is concluded that the Le Fort I-palatal split technique is a relatively safe and effective means for approaching midline skull base tumors. Several modifications to the surgical protocol and surgical technique are detailed herein.