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翼点或额颞入路向来在幕上入路中扮演“主力军”角色，得益于其简易性、灵活性、高效性和普及性，该入路是处理前、中颅窝病变最常用的手术入路。本文主要描述一种新的颅骨处理方式。
翼点开颅的步骤及手术解剖。切口（A）。帽状腱膜下分离，分别形成独立的皮瓣和肌辦（B）。筋膜下分离以保护面神经额支（C）。向下牵开颞肌显露颅骨（D-F）。
Figure1: Bone exposure below muscle outlining two part craniotomy outlining position of burr holes and cut lines in bone. 图1 暴露颅骨后，初步勾勒出两部分颅骨切开的手术轮廓，勾勒出钻孔位置和切割线的位置。
Figure2: Surgical simulation photographs illustrating the position of the two-part pterional craniotomy. 图2：显示翼点开颅术位置的手术模拟照片。 A Right pterional approach. After a wide skin flap, the temporal fascia was carefully dissected to preserve both facial and supraorbital nerves. The temporal muscle was incised 1 cm from its attachment along the superior temporal line to leave a muscle cuff in order to ease closure and optimize postoperative muscle function. The first part pterional craniotomy (Green) was performed first. Then, the complimentary second part sphenoidal craniotomy (Orange) is removed using foot plate under direct view. A 右翼点入路 在广泛的皮瓣后，仔细解剖颞筋膜，以保留面部和眶上神经。沿颞上线从颞肌附着处切开1 cm，留下一个肌肉袖，以减轻肌肉萎缩和优化术后肌肉功能。首先行部分翼点开颅术(绿色)。然后，第二部分蝶骨开颅术(橙色)在直视下用铣刀摘除。 B Detail of the right classic McCarty Keyhole and relative position of the frontal burr hole for the two-part pterional craniotomy. The McCarty Keyhole has been performed to show the limit between the orbital and intracranial compartments. The exocranial facet of the sphenoid bone has been identified (Dotted line) and the frontal (White circle number one) and temporal (White circle number two) burr holes have been identified. B 右侧经典McCarty关键孔的细节和翼点开颅术的额部钻孔的相应位置。McCarty关键孔被用来显示眼眶和颅内间隔之间的界限。蝶骨的外颅面已被识别（虚线），额叶（白色圆圈1号）和颞部（白色圆圈2号）的钻孔部位已被识别。
Figure3: Frontal burr hole and second burr hole positions.Frontal burr hole for anterior fossa is behind standard standard key-hole. Second burr hole posteriorly in squamous temporal bone. 图3: 前钻孔和后钻孔的位置。 前颅窝钻孔位置（前钻孔）位于在标准关键孔的后面。 颞骨鳞部后方为第二钻孔（后钻孔）位置。
Figure4: Skull photographs illustrating the two-piece pterional craniotomy.A: Left exocranial view of the skull showing the modified bone flaps in the two part pterional craniotomy. First part (green) and the second part craniotomy (Orange). B: Right endocranial view of the skull showing the relation of the craniotomy sub-parts to the petrous temporal bone, lesser sphenoid wing and orbit. The modified Keyhole (Green circle) is placed posterior and superior to the classic pterional keyhole. 图4：双骨瓣翼点开颅的颅骨照片 A：左侧颅外观，显示两部分翼点开颅时改良骨瓣。第一部分(绿色)和第二部分开颅(橙色)。 B：右侧颅内观，显示与开颅部位相关的颞骨、蝶骨小翼和眼眶的关系。改良的关键孔(绿色的圆圈)放置在后面和上的经典翼点关键孔。
Figure5: Recommended sequence of cuts with footplate.(1) begin in temporal burr hole and cut in curvilinear fashion to supra-orbital margin, then back out. (2) From frontal burr hole cut forward towards keyhole and then turn up towards supra-orbital margin, pivoting drill so footplate does not hang up on inner table of frontal bone above roof of orbit. (3) From frontal burr hole cut posteriorly around back edge of sphenoid wing, then forward below wing into middle fossa turning back at end into temporal burr hole. 图5：铣刀切割的推荐顺序。 (1)先在颞部打孔，曲线切至眶上边缘，再收回。 (2)由前部钻孔处向前切向关键孔，然后向上翻向眶上边缘，旋转铣刀使铣刀头不挂在眶顶以上的额骨内骨嵴上。 (3)由额部钻孔沿蝶骨嵴后缘向后切开，再由蝶骨嵴下方向前至中窝，末端再折回颞部关键孔。
Figure6: First part pterional bone piece removed showing V-shaped cut around lateral sphenoid wing. 图6：除去第一部分翼点骨片，显示在蝶骨侧翼周围有“V形”骨质。
Figure7: Extradural dissection begins over roof of orbit working backwards to sphenoid wing.Once wing identified dura dissected off to dural fold over lateral aspect of superior orbital fissure. Then dura below wing to anterior limits of middle fossa dissected. 图7：从眶顶开始的硬膜外剥离向后延伸至蝶翼 蝶骨翼硬脑膜剥离至眶上裂外侧的硬脑膜折返处。 将蝶骨翼下硬脑膜剥离至中颅窝前缘。
Figure8: Final bone cut begins on temporal side cutting to anterior limits of middle fossa (4). Then drill is rotated (5) towards the sphenoid wing. 图8：切割始于颞侧至颅中窝前缘(4)。然后将铣刀旋转(5)至蝶骨翼。
Figure9: Under direct vision from above footplate is advanced passing under sphenoid wing just lateral to the dural reflection (6). 图9：铣刀在视下，向前通过蝶骨翼下方，正好位于硬膜返折的侧面(6)。
Figure10: Once footplate passes the sphenoid ridge drill is turned anteriorly and cut is directed parallel to roof of orbit directly towards keypoint (7). 图10：一旦铣刀通过蝶骨嵴，向前转，切割方向与眶顶部平行，直接朝向关键孔(7)。
Figure11: Final exposure after second part pterional craniotomy that has not required any drilling of lateral sphenoid wing. 图11：除去第二部分翼点骨片的暴露情况，不需要在蝶骨翼外侧钻孔。 参考文献
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