The transmaxillary approach (Level V)

The transmaxillary approach (Level V), also known as the Le Fort I osteotomy approach, is indicated for midline extradural lesions of the upper two-thirds of the clivus. Extensive lateral and intradural access is limited with this approach. The most common pathology treated by using the Le Fort I osteotomy is clival chordoma, followed by chondrosarcoma. The use of the approach for clipping midbasilar and vertebrobasilar junction aneurysms has been reported. The transmaxillary approach can be divided into the following steps: incision, osteotomy, mobilization of the maxilla, pharyngotomy, clivectomy, dural opening, tumor removal, and closure. This article describes the surgical anatomy and techniques related to the transmaxillary approach and discusses the indications, the variants, and the possible complications of the procedure. Several case presentations are illustrated.