The supraorbital keyhole approach: how I do it

Treatment of Ethmoidal Dural Arteriovenous Fistulae Using Supraorbital Keyhole Subfrontal Approach

Due to a unique cortical venous drainage pattern without sinus drainage, ethmoidal dural arteriovenous fistula (DAVF) are uncommon cerebral vascular lesions that carry a high risk of brain bleeding and neurologic deficit. Surgical intervention has been found to have a lower complication rate and a more satisfactory obliteration rate than endovascular treatment among the various DAVF treatment options. The supraorbital keyhole subfrontal approach is one of the least invasive and appropriate surgical techniques for addressing the anterior fossa vascular lesion in eDAVFs. We describe two men, ages 60 and 71, who underwent this surgical intervention to treat asymptomatic Cognard type IV eDAVFs. Complete obliteration with a detached fistulous point and skeletonization was accomplished with the aid of intraoperative neuronavigation. Thus, we suggest that a suitable surgical method for the treatment of eDAVFs would be to use a supraorbital keyhole subfrontal approach.

The Pterional Keyhole Craniotomy Approach: A Historical Perspective

The pterional craniotomy is a workhorse of cranial surgery that provides access to the anterior and middle fossae. However, newer "keyhole" approaches, such as the micropterional or pterional keyhole craniotomy (PKC) can offer similar exposure for many pathologies while reducing surgical morbidity. The PKC is associated with shorter hospitalizations, reduced operative time, and superior cosmetic outcomes. Furthermore, it represents an ongoing trend toward smaller craniotomy size for elective cranial procedures. In this historical vignette, we trace the history of the PKC from its origins to its current role in the neurosurgeon's armamentarium.

Eyebrow incision with a crescent-shaped orbital rim craniotomy for microscopic and endoscopic transorbital approach to the anterior and middle cranial fossa: A cadaveric study and case presentation

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The transorbital approach combining eyebrow incision and crescent-shaped craniotomy increases the surgical freedom to access the anterior and middle skull-base.

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The technic allows the use of both endoscope and microscope.

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The concept is at the crossroad between the supraorbital keyhole and endoscopic trans-orbital approach.

Mini Fronto-Orbital Approach: "Window Opening" Towards the Superomedial Orbit - A Virtual Reality-Planned Anatomic Study

BACKGROUND

Surgical approaches to the orbit are challenging and require combined multispecialist skills. Considering its increasing relevance in neurosurgical practice, keyhole surgery could be also applied to this field. However, mastering a minimally invasive approach necessitates an extended learning curve. For this reason, virtual reality (VR) can be effectively used for planning and training in this demanding surgical technique.

OBJECTIVE

To validate the mini fronto-orbital (mFO) approach to the superomedial orbit, using VR planning and specimen dissections, conjugating the principles of skull base and keyhole neurosurgery.

METHODS

Three-dimensional measurements were performed thanks to Surgical Theater (Surgical Theater© LLC), and then, simulated craniotomies were implemented on cadaver specimens.

RESULTS

The mFO approach affords optimal exposure and operability in the target area and reduced risks of surrounding normal tissue injuries. The eyebrow skin incision, the minimal soft-tissue retraction, the limited temporalis muscle dissection and the single-piece craniotomy, as planned with VR, are the key elements of this minimally invasive approach. Furthermore, the "window-opening" cotton-tip intraorbital dissection technique, based on widening surgical corridors between neuromuscular bundles, provides a safe orientation and a deep access inside the orbit, thereby significantly limiting the risk of jeopardizing neurovascular structures.

CONCLUSION

The mFO approach associated to the window-opening dissection technique can be considered safe, effective, suitable, and convenient for treating lesions located in the superomedial orbital aspect, up to the orbital apex.

The Transpalpebral Versus the Transciliary Variant of the Supraorbital Keyhole Approach: Anatomic Concepts for Aneurysm Surgery

BACKGROUND

The supraorbital craniotomy (SOC) is classically performed through a skin incision in the patient's eyebrow. A variant with a skin incision in the patient's eyelid has become increasingly popular in recent years.

OBJECTIVE

To compare the transpalpebral and the transciliary variants of the SOC with regard to their potential role in aneurysm surgery.

METHODS

We carried out cadaveric dissections and virtual craniotomies on computerized tomography datasets. The skin incision, the craniotomy location and size, the working angles, and the achievable exposure of neurovascular structures were assessed and compared for both variants of the SOC.

RESULTS

The skin incision measured 4 cm for the transpalpebral and 3 cm for the transciliary variant. The skin could be retracted 1.5 cm upward from the lower edge of the orbital rim with the transpalpebral and 2.5 cm upward with the transciliary variant. The craniotomy size was 2.5 × 1.5 cm for both variants, given that the transpalpebral variant included an orbital osteotomy. The bony opening in the transpalpebral variant was 1 cm more caudal; this restricted the craniocaudal working angles and, thereby, limited the achievable exposure of neurovascular structures in the paraclinoid area and along the sphenoid ridge.

CONCLUSION

If the orbital rim and the anterior aspect of the orbital roof are removed, then the transpalpebral variant of the SOC enables a bony opening that is just as large as that of the transciliary variant. Nonetheless, the more caudal location of the bony opening alters the available working angles and may impede exposure of key structures during aneurysm surgery.

Supraorbital keyhole approach for suprasellar arachnoid cyst: how I do it

BACKGROUND

Keyhole approaches have lately sparked strong interest because these approaches address skull base pathologies as reported by Eroglu et al. (World Neurosurg, 2019); Hickmann, Gaida, and Reisch (Acta Neurochir (Wien) 159:881-887, 2017); Jallo and Bognar (Neurosurgery, 2006); and Poblete et al. (J Neurosurg 122:1274-1282, 2015), minimizing brain retraction and improving cosmetic results. We describe the step-by-step surgical technique to drain a suprasellar arachnoid cyst by a supraorbital approach.

METHOD

The eyebrow incision is a direct route to expose the supraorbital corridor and even if it is smaller than a pterional approach, it permits to open the cisterns and to visualize neurovascular structures. The arachnoid cyst could be safely drained and a T-tube is placed.

CONCLUSION

This technique represents a suitable option for suprasellar arachnoid cyst, avoiding more extended and invasive approaches.

Supraorbital Keyhole Approach for Intracranial Aneurysms : Transitioning from Concerns to Confidence

For surgical minimalism to reduce iatrogenic traumatization, a supraorbital keyhole approach has already been successfully applied to treat many unruptured anterior circulation aneurysms. However, using this minimal approach also raises several technical concerns due to the small cranial opening and cosmetic impact of a facial incision. Yet, such technical limitations can be overcome by using favorable surgical indications, slender surgical instruments, and optimized surgical techniques, while excellent cosmetic outcomes can be achieved using a short skin incision located <1 cm from the supraorbital margin, reconstruction of any bone defects around the bone flap, and meticulous wound closure. Thus, given such reassuring surgical results, in terms of the clipping status, neurological effects, and cosmetic outcomes, any concerns can be transitioned into confidence.

How I do it-the eyebrow approach for anterior circle of Willis aneurysms

BACKGROUND

The eyebrow approach is a keyhole technique that gives a wide access to the anterior circle of Willis.

METHODS

A 4-cm linear incision is placed in the upper limit of the eyebrow and a small supraorbital bone flap is raised. A wide arachnoid dissection is essential to maximize the working space. One or multiple aneurysms may be treated by the same approach.

CONCLUSIONS

The eyebrow approach is a safe technique for selected aneurysms of the anterior circle of Willis.

Supraorbital approach through eyebrow skin incision for aneurysm clipping: how I do it

BACKGROUND

Surgery has been in a huge development where the aim is to achieve same or better results with less complication in a less invasive way; these minimal approaches can be applied in a very safe way to aneurysmal neurosurgery.

METHOD

Images are studied to optimize the patient positioning and the surgical roadmap. After the positioning, the skin incision, craniotomy, and dura incision are performed and intradural lesion is reached. A watertight closure is performed under the microscope.

CONCLUSION

The keyhole approach requires some adaption from the side of the surgeon and can be performed only in cases envisioned to have no increased risk for the patient.

Supraorbital Keyhole Approach to the Sella and Anterior Skull Base via a Forehead Wrinkle Incision

OBJECTIVE

To evaluate safety and effectiveness of supraorbital keyhole approach to the sella and anterior skull base via a forehead wrinkle incision.

METHODS

We analyzed and reclassified forehead wrinkle types in 100 recruited healthy individuals. Twenty patients with different intracranial lesions in the sella and anterior skull base areas were selected for surgery using the supraorbital keyhole approach via a forehead wrinkle incision by forehead wrinkle type. All clinical patient records were retrospectively reviewed.

RESULTS

Based on the feasibility of the surgical approach, the forehead wrinkles in Chinese individuals were categorized into 2 types: horizontal linear and nonlinear. Gross total removal of the lesions was achieved in 90% of the cases using this approach. All patients had excellent cosmetic results. Except for 2 patients with poor prognoses, a high level of comfort and satisfaction with the forehead wrinkle incisions was obtained based on the scale scores of pain from scars and headaches and satisfaction with the cosmetic results. No permanent approach-related complications occurred.

CONCLUSIONS

The supraorbital keyhole approach via a forehead wrinkle incision was safe and effective. This approach provided a sufficient visual field for lesion resection and satisfactory cosmetic results for patients.

Fully endoscopic combined transsphenoidal and supraorbital keyhole approach for parasellar lesions

OBJECTIVE Parasellar tumors that extend far laterally beyond the internal carotid artery or that are fibrous and adhere firmly to critical structures are difficult to remove totally via the endoscopic transsphenoidal approach alone. In such cases, a combined transsphenoidal-transcranial approach is effective to achieve maximal resection in a single stage. In this paper, a new minimally invasive surgical technique for complicated parasellar lesions, a fully endoscopic combined transsphenoidal-supraorbital keyhole approach, is presented. METHODS A retrospective review of patients who had been treated via a fully endoscopic combined transsphenoidal-supraorbital keyhole approach for complicated parasellar lesions was performed. The data for resection rate, perioperative mortality and morbidity, and postoperative outcomes were analyzed. RESULTS A total of 12 fully endoscopic combined transsphenoidal-supraorbital keyhole approaches were performed from March 2013 to February 2016; 10 were for pituitary adenomas and 2 were for craniopharyngiomas. Gross-total resection or near-total resection was achieved in 7 of 12 cases. Among the 11 patients who had presented with preoperative visual disturbances, 7 had visual improvement. However, 1 patient showed deterioration in visual function. No patient experienced postoperative hemorrhage, needed additional surgical treatment, or had postoperative CSF leakage. CONCLUSIONS In the combined transsphenoidal and transcranial approach, safe and effective cooperative manipulation with 2 surgical corridors can be performed for complicated parasellar lesions. The goal of this procedure is not to achieve gross-total resection, but to achieve safe resection. Moreover, this new surgical approach offers neurosurgeons a simpler operative field with less invasiveness than the conventional microscopic combined approach. The fully endoscopic combined endonasal-supraorbital keyhole approach is an efficacious procedure for complicated parasellar lesions with acceptable results.

Interfascial Dissection for Protection of the Nerve Branches to the Frontalis Muscles during Supraorbital Trans-Eyebrow Approach: An Anatomical Study and Technical Note

Introduction Preservation of the temporal branches of the facial nerve during anterolateral craniotomies is important. Damaging it can inflict undesirable cosmetic defects to the patient. The supraorbital trans-eyebrow approach (SOTE) is a versatile keyhole craniotomy but still has a high rate of frontalis muscle (FM) palsy. Objective Anatomical study to implement the interfascial dissection during the SOTE to preserve the nerves to the FM. Methods Slight modification of the standard technique of the SOTE was performed in 6 cadaveric specimens (12 sides). Results Distal rami to the FM were exposed. The standard "u-shape" incision of the FM can cross over the nerves. Alternatively, an "l-shape" incision was performed until the superior temporal line (STL). An interfascial dissection was performed near to the STL and the interfascial fat pad was used as a protective layer for the nerves. Conclusion Various pathologies can be addressed with the SOTE. In the majority of the cases the cosmetic results are good, but FM palsy remains a drawback of this approach. The interfascial dissection may be used in an attempt to prevent frontalis rami palsy.