Ten-year experience with the supraorbital subfrontal approach through an eyebrow skin incision.

Department of Neurosurgery, Johannes-Gutenberg University, Mainz, Germany.
Neurosurgery (Impact Factor: 3.03). 11/2005; 57(4 Suppl):242-55; discussion 242-55. DOI: 10.1227/01.NEU.0000178353.42777.2C
Source: PubMed

ABSTRACT More than ever before, the priority in contemporary neurosurgery is to achieve the greatest therapeutic effect while causing the least iatrogenic injury. The evolution of microsurgical techniques with refined instrumentation and illumination and the enormous development of preoperative and intraoperative diagnostic tools enable neurosurgeons to treat different lesions through limited and specific keyhole approaches.
Based on our surgical experience, the technique of supraorbital subfrontal craniotomy is described in detail in this article. After an eyebrow skin incision is made, a limited supraorbital craniotomy is performed with a width of 15 to 25 mm and a height of 10 to 15 mm.
We have been using the supraorbital keyhole craniotomy since 1985 and have approached a variety of lesions within the anterior, middle, and posterior cranial fossae. During a 10-year period between July 1994 and June 2004, the lesions treated via the supraorbital approach in our department comprised 1125 intracranial tumors or cystic lesions, cerebral aneurysms, and other miscellaneous diseases, performed by 23 different surgeons and residents. Of these 1125 patients, we operated on 471 of them, and information obtained from 450 contributed to the follow-up data. Three months after surgery, the Glasgow Outcome Scale scores for this very heterogeneous group of patients were as follows: 5 in 387 patients (86.0%), 4 in 29 patients (6.4%), 3 in 16 patients (3.5%), 2 in 10 patients (2.2%), and 1 in 8 patients (1.8%). Of the 450 patients, 229 were treated for intracranial aneurysms, 93 for cranial base meningiomas, 39 for craniopharyngiomas, 23 for pituitary adenomas, 18 for deep-seated brainstem tumors, and 48 for other miscellaneous frontotemporal or suprasellar lesions.
In our experience, the supraorbital craniotomy allows a wide, intracranial exposure for extended, bilaterally situated, or even deep-seated intracranial areas, according to the strategy of keyhole craniotomies. The supraorbital craniotomy offers equal surgical possibilities with less approach-related morbidity owing to limited exposure of the cerebral surface and minimal brain retraction. In addition, the short skin incision within the eyebrow and careful soft tissue dissection result in a pleasing cosmetic outcome.

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    ABSTRACT: Conventional open surgery of large meningiomas has proven to be challenging even in experienced hands. Intense retraction and dissection around neurovascular structures increase morbidity and mortality. In the present study, we retrospectively analyzed the surgical technique, and outcome in 40 patients with large anterior cranial fossa meningiomas extending to the middle fossa. All patients were approached via a supraorbital mini craniotomy. It is a retrospective study of 40 patients (12 males, 28 females) who underwent surgery for large anterior cranial fossa meningiomas (diameter >5cm) extending to the middle fossa in four different neurosurgical centers within 6 years. Depending on the localization of the tumor, the skin incision was between 2.5 and 3cm long and was made without shaving the patient's eyebrow hair. Subsequently, a keyhole craniotomy was performed of approximately 0.8×1.2-1.4cm in diameter. Preoperative and postoperative clinical and radiological data were analyzed and discussed. Headache and psycho-organic syndrome were the most common presenting symptom in all patients. Presenting symptoms were associated with psychological changes in 23 cases, visual impairment in 19 patients, and anosmia in 17 patients. In overall, 36 of 40 patients (90%) showed a good outcome and returned at long-term follow-up to their previous occupations. The elderly patients returned to their daily routine. With the appropriate keyhole approach as a refinement of the classic keyhole craniotomy to a smaller key"burr"hole, and with use of modern and new designed equipment, it is possible to perform complete resection of large anterior and middle fossa meningiomas with the same safety, efficiency and with less complication rates as described in the literature for large meningiomas even performed with classic keyhole craniotomies. Copyright © 2014 Elsevier B.V. All rights reserved.
    Clinical Neurology and Neurosurgery 12/2014; 129C:27-33. DOI:10.1016/j.clineuro.2014.11.024 · 1.25 Impact Factor
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    ABSTRACT: In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital "keyhole" approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration.
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    ABSTRACT: Objective: The cranio-orbital minicraniotomy is a modification of the subfrontal approach with orbital osteotomy. The purpose of this study is to describe the technique of this approach and evaluate the outcome in 28 consecutive patients suffering from various orbital lesions. Methods: This is a retrospective study carried out on 28 patients having different orbital lesions. All the patients were operated upon by cranio-orbital minicraniotomy through eyebrow skin incision and a small craniotomy measured 2.5cm height and 3.5cm width with added orbital osteotomy. All the patients were evaluated for the degree of surgical excision and outcome. Results: A cranio-orbital minicraniotomy was used to treat 28 orbital lesions over a period of 8.5 years. The mean age of the patients was 29.5 years (range 2-66 years). They were 16 women and 12 men. This series includes periorbital meningioma in seven patients (25%), cavernous hemangioma in six patients (21.4%), orbital abscesses in four patients (14.3 %), neurofibroma in three patients (10.7%), depressed fracture of the orbital roof in three patients (10.7 %), depressed fracture of the lateral orbital wall in two patients (7.1%), dermoid cyst, epidermoid cyst and optic nerve glioma in one patient for each diagnosis (3.6%). Total removal was achieved in 12 patients: six patients with cavernous hemangiomas, three patients with periorbital meningiomas, and one patient with dermoid, epidermoid and neurofibroma respectively. Partial excision of the lesions was obtained in six patients: four patients with periorbital meningiomas and two patients with neurofibromas. Biopsy was taken in one patient of optic nerve glioma. Evacuation of an orbital abscess was achieved in four patients. Correction of depressed bone with correction of bone defect was done effectively in five patients. Conclusion: Despite the small size of craniotomy and skin incision, the cranio-orbital minicraniotomy allowed enough room for intra-orbital manipulation and excision of different orbital lesions. Microsurgery with cranio-orbital minicraniotomy is a safe and effective method for treatment of patients having orbital lesions.