L-Shaped Zygotomy: A Safe and Versatile Modification of the Zygomatic Approach with Quantitative and Cosmetic Advantages in Skull Base Surgery.

Abstract

The zygomatic approach provides extensive exposure of the anterior and middle skull base but carries risks of facial nerve injury, cosmetic deformity, and unstable arch reconstruction. We developed a modified L-shaped zygotomy designed to improve safety, reduce flap retraction, and ensure stable cosmetic and reconstructive outcomes, while allowing seamless transition to an orbitozygomatic craniotomy when required. Thirty-five patients who underwent L-shaped zygotomy between August 2017 and February 2025 were retrospectively reviewed. The extent of resection, perioperative complications, and cosmetic outcomes were evaluated. Cosmetic assessment included objective ratings by 2 independent neurosurgeons and patient self-assessments using a 5-point Likert scale. Quantitative validation was also performed in one cadaveric head preserved with the saturated salt solution method and 4 3D-printed skull models to compare the L-shaped and conventional zygotomy techniques. Gross total resection was achieved in 25 patients (71%). No new permanent facial palsy, mastication disturbances, or wound complications occurred. At a mean follow-up of 46±14 months, cosmetic outcomes were excellent (Likert scores: surgeons 4.4±0.5, patients 4.7±0.5). In cadaveric analysis, the L-shaped technique required 11 mm less skin flap retraction and, in 3D models, expanded the anterior surgical corridor by 3.9-4.2 mm compared with conventional zygotomy. The L-shaped zygotomy is a safe and versatile modification of the zygomatic approach. It provides reproducible quantitative advantages in exposure, minimizes flap retraction, ensures stable cosmetic outcomes validated by long-term follow-up, and allows seamless transition to orbitozygomatic when broader exposure is necessary.