Planning and positioning
Bifrontal Craniotomy 16-1: Positioning for bilateral subfrontal approach. The positioning for either approach is supine.
Bifrontal Craniotomy 16-2: Skin incision. The skin incision for either side of this approach begins at the posterior aspect slightly anterior to the tragus and reaches the zygomatic root at its inferiormost extent. Care should be taken to preserve the superficial temporal artery if possible. The i1ncision extends superior and anterior in a curvilinear fashion to reach the hairline in the sagittal midline. If a bifrontal approach is planned, these incisions should meet in a gradual anteriorly directed peak.
Bifrontal Craniotomy 16-3: Soft tissue elevation. Forehead pericranium should be harvested with any subfrontal or bifrontal approach for repair of anterior fossa floor bony defects and for exclusion of the frontal sinus from the intracranial space. After the scalp has been reflected forward over the superior orbital rim, a large rectangular piece of pericranium is cut with a monopolar cautery and reflected anteriorly over the forehead with its blood supply. The frontalis nerve is contained in a fat pad that lies superficial to the temporalis fascia. This fat pad should be reflected over the frontozygomatic process using either a suprafascial or a subfascial technique.