Midline mandibulotomy and interposition grafting for lesions involving the internal carotid artery below the skull base

A schematic drawing of the autologous interposition graft (blue) and its relation to the bony structures and the resected carotid bifurcation and internal carotid artery (ICA) (dotted red line). A, Intraosseal part of the internal carotid artery; B, distal anastomosis; C, resected carotid artery; D, autologous vein interposition; E, common carotid artery; I, intracranial ICA; S, styloid process; T, tympanic bone. Medial (and oral cavity) is the right side of the picture.

Skin incision for combined midline mandibulotomy and radical neck tumour surgery exposure.

Operative field after a radical neck dissection with the interposition in place. In this operation for an extensive lingual epidermoid carcinoma, the left hemimandible was resected (Patient 1). In the other cases, the hemimandible was lifted up as a hinge and did not restrict the exposition to the distal internal carotid artery (ICA). Note that the neck is hyperextended and thus the graft seems to be under tension, which will be relieved when the neck is neutralized. Arrows, proximal and distal anastomosis; A, anteriorly transsected mandible.

Computed tomography (CT) reconstruction of a bipartial benign noncapsular paraganglioma in a 21-year-old male (Patient 4). The white arrows mark the two parts of the tumor. The smaller, more cranial part is extending into the carotid canal. The upper internal carotid artery (ICA) interposition anastomosis was performed at the level marked with a small black arrow. This picture shows the limiting bony structure of the tympanic bone. ECA, External carotid artery; DEX, dexter.

A computed tomography (CT) reconstruction of a 60 mm internal carotid artery (ICA) aneurysm showing the distal proportions of skull base and the artery cranial to the aneurysm (white arrow). B marks the level of the carotid bifurcation (Patient 5).

A 54-year-old male internal carotid artery (ICA) aneurysm patient 2 years after the operation (Patient 5). He had no major surgery-related difficulties and stated that after 12 years of follow-up and uncertainty, he was very happy with the physical and psychological impact of the operation.