Vertical ramus osteotomy allows exposure of the distal internal carotid artery to the base of the skull

Exposure of the distal internal carotid artery (ICA) above the level of the second cervical vertebra can be difficult and often require maneuvers such as division of the digastric muscle or mandibular subluxation. These techn iques increase exposure but may not provide adequate access. We report a se ries of eight cases in which vertical division of the mandibular ramus prov ided access of the ICA up to the base of the skull. Over the last 10 years, eight patients underwent vertical ramus osteotomy (VRO) to aid in distal I CA exposure. Preoperative arteriography revealed ICA lesions within 1.5 cm of the skull base. Indications for surgery were compelling and included gun shot wounds to zone III of the neck (n = 2), transient ischemic attack (n = 2), and preocclusive stenosis (n = 4). VRO was performed through a standar d vertical neck incision and was created from the depth of the sigmoid notc h to the angle of the mandible after elevating the masseter muscle from the bone. Miniature titanium plates were used to reapproximate the mandible af ter endarterectomy (n = 5), bypass (n = 2), or arterial repair (n = 1). We found that VRO provides reliable exposure of the distal ICA up to the base of the skull. Unlike mandibular subluxation, it requires no pre-incision pr eparation, thus mandibulotomy can be performed after carotid artery dissect ion has begun, and may even be avoided. VRO is especially useful when carot id artery pathology unexpectedly extends beyond the usual field of exposure . Work on the carotid artery at the skull base is associated with significa nt complications and should be reserved for compelling indications.