Localization of Maxillary artery for cerebral revascularization: L-shaped perpendicular two-step drilling technique stretching from the foramen ovale to rotundum

Background and Objectives The use of maxillary artery (MA) as a donor has increasingly been utilized as an alternative method for cerebral revascularization. Localization difficulties emerge due to rich infratemporal anatomical variations and MA’s complicated relationships with neuromuscular structures. Our aim is to propose an alternative localization method via the interforaminal route along the middle fossa floor. Methods Five silicone injected adult cadaver heads (10 sides) were dissected. Safe and effective localization of the MA was also evaluated. Results MA displayed anatomical variations in relation to the lateral pterygoid muscle (LPM) and the mandibular nerve (V3) branches. The proposed L-shaped perpendicular two-step drilling technique revealed a long MA segment that allowed generous rotation to the intracranial area for an end-to-end anastomosis. The first step of drilling involved medial to lateral expansion of foramen ovale up to the lateral border of the superior head of the LPM. The second step of drilling extended at an angle approximately 90 degrees to the initial path and reached anteriorly to the foramen rotundum. The MA was localized by gently retracting the upper head of the LPM medially in a posterior to anterior direction. Conclusion Considering all anatomical variations, the L-shaped perpendicular two-step drilling technique through the interforaminal space is an attainable method to release an adequate length of MA. The advantages of this technique include the early identification of precise landmarks for the areas to be drilled, preserving all V3 branches, the deep temporal arteries and maintaining the continuity of the LPM.