Ten-year Experience with the Supraorbital Subfrontal Approach through an Eyebrow Skin Incision

Department of Neurosurgery, Johannes-Gutenberg University, Mainz, Germany.
Neurosurgery (Impact Factor: 3.62). 11/2005; 57(4 Suppl):242-55; discussion 242-55. DOI: 10.1227/01.NEU.0000178353.42777.2C
Source: PubMed


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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    • "gland and infundibulum is common [6]. The supraorbital " eyebrow " craniotomy is also performed with minimal brain retraction and allows excellent access to the frontal base, the medial part of the middle fossa and under endoscopic visualization a panoramic view over the whole supra-and parasellar area [3] [16] [17]. "
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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.
    Full-text · Article · Dec 2014 · Clinical Neurology and Neurosurgery
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    • "Furthermore, controversy exists not only about the value of adding an orbitotomy but also the criteria used for its selection.3 18 19 20 21 22 23 24 25 To date, no morphometric criteria exist to aid the surgeon during the preoperative planning phase in the selection of additional orbitotomy. "
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    ABSTRACT: Objectives In anatomic and radiologic morphometric studies, we examine a predictive method, based on preoperative imaging of the anterior cranial base, to define when addition of orbital osteotomy is warranted. Design Anatomic and radiographic study. Setting In 100 dry skulls, measurements in the anterior cranial fossa included three lines and two angles based on computerized tomography (CT) scans taken in situ and validated using frameless stereotactic navigation. The medial angle (coronal plane) was the intersection between the highest point of both orbits and the midpoint between the two frontoethmoidal sutures to each orbital roof high point. The oblique angle (sagittal plane) was the intersection at the midpoint of the limbus sphenoidale. Results No identifiable morphometric patterns were found for our classification of anterior fossae; the two-tailed distribution pattern was similar for all skulls, disproving the hypothetical correlation between visual appearance and morphometry. Orbital heights (range: 6.6–18.7 mm) showed a linear relationship with medial and oblique angles, and they had a linear distribution relative to angular increments. Orbital heights > 11 mm were associated with angles ≥ 20 degrees and more likely to benefit from orbitotomy. Conclusion Preoperative CT measurement of orbital height appears feasible for predicting when orbitotomy is needed, and it warrants further testing.
    Full-text · Article · Aug 2014 · Skull Base Surgery
    • "The Perneczky method consists of an eyebrow (“supraciliary”) skin incision and supraorbital keyhole mini-craniotomy [Figure 2a].[145] Although the supraorbital keyhole approach is the representative keyhole approach to treat various intracranial pathologies in the supra- and parasellar regions, other types of keyhole approaches can be used, such as the subtemporal, interhemispheric, and retromastoid keyhole approaches, to treat cerebral aneurysms according to location.[6] "
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    ABSTRACT: The keyhole concept in neurosurgery is designed to minimize the craniotomy needed for the access route to deep intracranial pathologies. Such keyhole surgeries cause less trauma and can be less invasive than conventional surgical techniques. Among the various types of keyhole mini-craniotomy, supraorbital or lateral supraorbital mini-craniotomy is the standard and basic keyhole approaches. The lateral supraorbital keyhole provides adequate working space in the suprasellar to parasellar areas and planum sphenoidale area including the anterior communicating artery complex. Despite the development of neuro-endoscopic techniques and intra-operative assistant methods, the limited working angle to manipulate and observe deeply situated pathologies is a major disadvantage of the keyhole approaches. Neurosurgeons should understand that keyhole mini-craniotomy surgeries aim at "minimally invasive neurosurgery" but still carry the risks of malpractice unless we understand the advantages and disadvantages of these keyhole concepts and strategies.
    No preview · Article · Mar 2014
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