The arterial anatomy of the eyelid: importance for reconstructive and aesthetic surgery

Eyelid and periorbital necrotizing fasciitis, a severe preseptal infection, a systemic review of the literature and anatomical illustrations

In necrotizing fasciitis, aggressive surgical debridement and broad-spectrum antibiotics are the cornerstone of treatment but cannot be proposed for the eyelid and periorbital area because of the risk of blindness, eyeball exposure and disfiguration. The aim of this review was to determine the most effective management of this severe infection while preserving eye function. A literature search of the PubMed, Cochrane Library, ScienceDirect and Embase databases was conducted for all articles published up to March 2022; 53 patients were included. Management was probabilistic, combining antibiotic therapy with skin (+/- orbicularis oculi muscle) debridement in 67.9% of cases, and probabilistic antibiotic therapy alone in 16.9% of cases. Radical surgery with exenteration was performed in 11.1% of patients; 20.9% of patients had complete loss of vision, and 9.4% died of the disease. Aggressive debridement was rarely necessary possibly because of the anatomical particularities of this region.

Less Is Better: Full-Incision Double-Eyelid Blepharoplasty with Rapid Recovery

SUMMARY

Full-incision double-eyelid blepharoplasty is effective, but postoperative complications, such as local trauma and persistent tissue swelling, are major concerns. Because tissue swelling is caused by the obstruction of blood and lymphatic flow, the authors modified the conventional full-incision method to minimize the trauma as much as possible. Twenty-five patients underwent the modified procedure. There was minor swelling immediately after the surgery, which subsided 1 to 5 days after the surgery. No patient reported loss of the double eyelid crease. Only 2 patients underwent a second operation because of a low crease. Satisfactory results were obtained in 92% of patients (23 of 25). According to our understanding of this technique, less trauma is the key to obtaining better results under certain conditions.

Hemorrhage Following Muller's Muscle Conjunctival Resection: Description and Case-Control Study

PURPOSE

The purpose of this study was to report a series of patients with postoperative hemorrhage after Muller's muscle conjunctival resection surgery and compare risk factors and outcomes with a control population.

METHODS

In this case-control study, records of patients who underwent Muller's muscle conjunctival resection over 5 years were reviewed for a history of postoperative hemorrhage occurring >24 hours after surgery. A 4:1 control population was matched for age and sex. Clinical data collected included demographics, medical history, medications, and subsequent surgery. Preoperative and 3-month postoperative marginal reflex distance 1 were measured digitally using ImageJ. The hemorrhage and control groups were compared using Fisher's exact tests for categorical variables and independent samples t tests for continuous variables.

RESULTS

The hemorrhage group contained 10 patients (mean age 66.4 ± 18.5 years). The control group consisted of 40 age and sex-matched controls. Of 350 charts reviewed, there were 10 cases of postoperative hemorrhage (incidence 2.9%). Hemorrhage occurred a mean of 4.2 ± 1.3 (range 2-7) days after surgery and lasted for a mean of 29.3 ± 19.1 (range 12-72) hours. In all 10 cases, the bleeding resolved with conservative measures. There was no difference between the hemorrhage and control groups in terms of medical conditions, blood thinners, and surgical revision. Preoperative, postoperative, and change in marginal reflex distance 1 did not differ between the hemorrhage and control groups.

CONCLUSIONS

Hemorrhage occurs approximately 4-5 days postoperatively in a small percentage of patients undergoing Muller's muscle conjunctival resection surgery. This investigation did not identify any consistent risk factors, and outcomes in this patient population appear no different than controls.

Comparison of Intense Pulsed Light Treatments including Upper Lid or Lateral Canthus in Patients of Meibomian Gland Dysfunction

Background: To determine the differences in the effects of intense pulsed light (IPL) treatment when including the upper and lower lid or lateral canthus area in patients with meibomian gland dysfunction (MGD). Methods: Patients who underwent three IPL treatment sessions at 3-week intervals were divided into three groups according to the treatment sites: group A, lower lid; group B, upper and lower lids; and group C, lower lid and lateral canthal area. Before and after the IPL treatment sessions, we obtained the lid abnormality score (LAS), meibum expressibility (ME), meibum quality (MQ), lipid layer thickness (LLT), type I Schirmer test (ST), tear break-up time (TBUT) test, corneal fluorescein staining scores (CFSs), and Ocular Surface Disease Index (OSDI). Results: IPL treatment significantly improved LASs, ME, MQ, TBUT, CFS, and OSDI values in all groups. Differences in LAS values before and after IPL treatment were significantly greater in groups B and C than those in group A. Conclusions: IPL treatment encompassing the upper lid and lateral canthus together with the lower lid elicited additional improvement in patients with MGD. The additional effect on treating the lateral canthus was similar to the effect observed on the additional treatment of the upper lid.

A Novel Approach to Reduce Lid Weight in the Upper Eyelid Blepharoplasty: Split-Thickness Excision of the Palpebral Part of Orbicularis Oculi Muscle

OBJECTIVES

With the effect of advancing age and environmental factors, excess skin and muscle start to weigh on the eyelids and cause a tired facial expression. The prevailing opinion is that by partially excising muscle in surgical treatment, this load on the eyelid will be reduced, and more successful results will be obtained. Using a classic strip orbicularis oculi excision, the integrity of the muscle is disrupted, and morbidities such as lagophthalmos and edema increase. In this paper, we share our clinical experiences regarding the split excision of the palpebral part of the orbicularis oculi muscle and the subsequent process.

METHODS

Twenty-seven patients who applied to our clinic to undergo blepharoplasty were operated on under local anesthesia. The orbicularis oculi muscle was split-excised together with the skin from the marked areas.

RESULTS

The split excision of the orbicularis oculi muscle did not cause prolonged edema. The general appearance of the eyelid and face of the patients was observed to have significantly improved in the third month after surgery compared with the preoperative period. No complications such as wound healing, hypertrophic scar, asymmetry, or infection were observed during the follow-up period.

CONCLUSIONS

The split excision of the orbicularis oculi muscle can be considered a new and effective method in cases in which a muscle excision is planned as part of blepharoplasty. Prolonged edema due to the strip muscle excision is not observed clinically. This technique can eliminate the negative effects of excess muscle tissue on the eyelid without disrupting the integrity of the muscle.

LEVEL OF EVIDENCE

Evidence Based Medicine Level V.

A new skin flap from the zygomaticotemporal region: Anatomical study and clinical application to eyelid reconstruction

BACKGROUND

Eyelid reconstruction is a demanding task faced by plastic surgeons. Island flaps from the zygomaticotemporal region, where the zygomatico-orbital artery predominates in vascularization, represent the recent local approaches to this problem. Questions exist as to where and on what element the flap should be based, and whether or not they should be adapted in relation to the behavior of the zygomatico-orbital artery.

METHODS AND MATERIALS

A total of 22 fresh-frozen adult cadaver heads were employed. The fasciocutaneous perforators of the zygomatico-orbital artery and their anastomoses with the surrounding arteries, especially those in the upper palpebra, were investigated. On this basis, a distally based perforator flap was created and executed for eyelid reconstruction in 7 patients.

RESULT

The zygomatico-orbital artery was interconnected through its perforators with the subdermal plexus over the zygomaticotemporal region and with the arteries in the surroundings. The transverse facial artery took the place of zygomatico-orbital artery where it was absent. Both the arteries anastomosed consistently with the superficial orbital arcade at a predictable site. All 7 flaps survived completely.

CONCLUSION

A new distally based perforator flap from the zygomaticotemporal region is described regarding its anatomical basis and clinical applications to eyelid reconstruction. With a vascular axis consistently present and a pivot adjacent to the defects, the flap is more reliable in vascularization, and less harm to its donor site than orbicularis oculi myocutaneous flaps, and poses no concern about whether the zygomatico-orbital artery is present or not.

Perfusion Monitoring During Oculoplastic Reconstructive Surgery: A Comprehensive Review

PURPOSE

Knowledge of how blood perfusion is affected during and after reconstructive surgery is of great importance to predict the survival of grafts and flaps. When commonly used reconstructive procedures were developed a century ago, they were based on empirical observations of clinical outcome.

METHODS

This is a comprehensive literature review that summarizes the current state of knowledge regarding microvascular perfusion monitoring during oculoplastic procedures.

RESULTS

Over the years, a number of techniques for perfusion monitoring have been developed as an attempt to be more objective than clinical examination using traditional methods such as observations of skin temperature, turgor, color, smell, and capillary refill time. There are limited publications regarding microvascular perfusion monitoring during reconstructive procedures in the periocular area. Modern laser-based techniques have been attractive due to their noninvasive nature.

CONCLUSIONS

Today, modern, noninvasive techniques are available to monitor perfusion during and after surgery. This has increased our knowledge on the perfusion in common oculoplastic surgery procedures. A detailed understanding of how blood perfusion is affected will hopefully allow the improvement of surgical techniques for better clinical outcome.

Transconjunctival versus transcutaneous local anaesthetic administration for lower eyelid surgery: a randomised controlled trial

AIM

To compare the associated discomfort and safety between transcutaneous (Tskin) and transconjunctival (Tconj) approaches of local anaesthetic (LA) administration in lower eyelid surgery.

METHODS

A prospective randomised controlled trial comparing Tskin and Tconj LA in patients undergoing bilateral lower eyelid surgeries for horizontal laxity. Patients were randomised to receive LA via Tskin to one side and Tconj to the fellow side. LA injection was administered in a slow fashion accompanied by distraction (tapping of patient's forehead). Self-reported discomfort from the injections was rated using a 0-10 numerical rating scale. A single blinded assessor graded photographs for eyelid bruising (0 = absent, 1 = mild, 2 = moderate, 3 = severe).

RESULTS

A total of 30 patients (mean age ± SD, 75.9 ± 6.7 years) were enrolled. The overall pain score (mean ± SD) was statistically lower for the Tconj than the Tskin group (3.90 ± 2.28 versus 5.33 ± 2.23, p = 0.017). More patients in the Tconj group reported substantially less pain (score of ≤3) in comparison to the Tskin group (56.7% versus 23.3%, p = 0.017). In individual patients, the Tconj pain score was found to be significantly lower than the Tskin side (p = 0.008). Bruising scores were higher in the Tskin group, but this was not statistically significant (p = 0.13). No other adverse effects were found.

CONCLUSION

Tconj delivery of LA in lower eyelids with horizontal laxity is safe and associated with less discomfort and bruising than the conventional Tskin route.

TRIAL REGISTRATION NUMBER

NCT04102878.

Ocular redness - I: Etiology, pathogenesis, and assessment of conjunctival hyperemia

The translucent appearance of the conjunctiva allows for immediate visualization of changes in the circulation of the conjunctival microvasculature consisting of extensive branching of superficial and deep arterial systems and corresponding drainage pathways, and the translucent appearance of the conjunctiva allows for immediate visualization of changes in the circulation. Conjunctival hyperemia is caused by a pathological vasodilatory response of the microvasculature in response to inflammation due to a myriad of infectious and non-infectious etiologies. It is one of the most common contributors of ocular complaints that prompts visits to medical centers. Our understanding of these neurogenic and immune-mediated pathways has progressed over time and has played a critical role in developing targeted novel therapies. Due to a multitude of underlying etiologies, patients must be accurately diagnosed for efficacious management of conjunctival hyperemia. The diagnostic techniques used for the grading of conjunctival hyperemia have also evolved from descriptive and subjective grading scales to more reliable computer-based objective grading scales.

CLEAR - Anatomy and physiology of the anterior eye

A key element of contact lens practice involves clinical evaluation of anterior eye health, including the cornea and limbus, conjunctiva and sclera, eyelids and eyelashes, lacrimal system and tear film. This report reviews the fundamental anatomy and physiology of these structures, including the vascular supply, venous drainage, lymphatic drainage, sensory innervation, physiology and function. This is the foundation for considering the potential interactions with, and effects of, contact lens wear on the anterior eye. This information is not consistently published as academic research and this report provides a synthesis from all available sources. With respect to terminology, the report aims to promote the consistent use of nomenclature in the field, and generally adopts anatomical terms recommended by the Federative Committee for Anatomical Terminology. Techniques for the examination of the ocular surface are also discussed.

The Effect of Canthotomy on Blood Perfusion During the Repair of Lower Eyelid Defects

PURPOSE

Canthotomy is frequently used to mobilize extra tissue when repairing larger lower eyelid defects. The aim of this study was to explore the effect of canthotomy on blood perfusion and oxygen tension.

METHODS

Eight pigs underwent a wedge resection of the lower eyelid and canthotomy (with cantholysis involving the lateral palpebral artery). The wedge resection was performed 8, 6, and 4 mm from the canthotomy. Perfusion and oxygen tension were monitored in the eyelid between the wedge resection and canthotomy using laser Doppler velocimetry and a Clark electrode. Verapamil was administered, and measurements were also performed 12 hours after surgery, to investigate the possible effects of vasospasm RESULTS:: The wedge resection alone did not affect perfusion. Canthotomy led to a reduction in perfusion; being 60% when the length of remaining eyelid was 8 mm, 32% when it was 6 mm, and 24% when it was 4 mm. Similar results were observed for oxygen tension. Vasospasm did not affect the results.

CONCLUSIONS

Canthotomy in combination with a wedge resection of the lower eyelid affects blood perfusion. A smaller length of remaining eyelid tissue will have less perfusion. This may not have any implications in cases of direct closure, but may play a role when the eyelid is to provide oxygen and nutrients to avascular grafts.

A New Anatomy Finding of Levator Aponeurosis and Müller Muscle at Pretarsal Plate in Asian Males

PURPOSE

To examine the fine anatomic structures between levator aponeurosis and Müller muscle in front of the tarsus.

MATERIALS AND METHODS

Postmortem specimens of 6 Chinese males (5 elderly men, aging from 68 to 86 years; 1 child, 10 years old) were used. A 3-μm thickness sagittal section of the central part of the upper eyelid was prepared, and the samples were examined microscopically by using hematoxylin-eosin, Masson trichrome, and anti-smooth muscle actin antibodies staining.

RESULTS

There are 2 new findings in this study, one is the posterior layer of the levator aponeurosis and the other is the extensions of Müller muscle. The posterior levator aponeurosis had different insertion patterns that approximately paralleled the extension line of the levator aponeurosis at the confluence of attachment site of the orbital septum on the levator superioris. Below the confluence, it took the form of a layered insertion, and then extended to the orbicularis oculi muscle and subcutaneous tissue rather than inserting directly into tarsus. The Müller muscle was a multilayered structure at the upper border of tarsus. The superior Müller muscle extended above the peripheral arcade, and the inferior Müller muscle tendon was attached to the surface of tarsus with an Umbrella-shaped fiber.

CONCLUSIONS

The authors discovered that the levator aponeurosis had different insertion patterns of the posterior layers. The Müller muscle gave branches at the peripheral arcade: the anterior one crossed the peripheral arcade and extended to the tarsus, and the posterior one attached and extended to the tarsus.

Posterior lamellar reconstruction: a comprehensive review of the literature

The aim of the review is to describe the different techniques and materials available to reconstruct the tarsoconjunctival layer of the eyelid; to analyze their indications, advantages, and disadvantages. We searched the Cochrane, PubMed, and Ovid MEDLINE databases for English articles published between January 1990 and January 2017 using variations of the following key words: "posterior lamella," "eyelid reconstruction," "tarsoconjunctival," "flap," and "graft." Two reviewers checked the abstracts of the articles found to eliminate redundant or not relevant articles. The references of the identified articles were screened manually to include relevant works not found through the initial search. The search identified 174 articles. Only a few articles with a therapeutic level of evidence were found. Techniques for the posterior lamellar reconstruction can be categorized as local, regional, and distant flaps; tarsoconjunctival, heterotopic, homologous, and heterologous grafts. Several techniques and variations on the techniques exist to reconstruct the posterior lamella, and, for similar indications, there's no evidence of the primacy of one over the other. Defect size and location as well as patient features must guide the oculoplastic surgeon's choice. The use of biomaterials can avoid possible complications of the donor site.

Three-Dimensional Topography of the Emerging Point of the Ophthalmic Artery

BACKGROUND

During periorbital noninvasive and surgical procedures, there is the risk of iatrogenic injury to the emerging point of the ophthalmic artery. This study aimed to determine the three-dimensional location of the emerging point of the ophthalmic artery and to provide clinicians with anatomical information that would help them to avoid associated complications.

METHODS

Seventeen hemifaces of the emerging point of the ophthalmic artery from 10 Korean and seven Thai cadavers were dissected and scanned by a three-dimensional scanner. The emerging points of the ophthalmic artery of 30 healthy Korean volunteers were also detected using an ultrasound imaging system.

RESULTS

The transverse distance from the medial canthus to the emerging of the ophthalmic artery was 3.8 ± 1.0 mm medially, and the vertical distance was 14.0 ± 2.9 mm superiorly. The transverse distance from the midline was 16.5 ± 1.7 mm to the emerging point of the ophthalmic artery and 20.0 ± 2.0 mm to the medial canthus. The measured depth from the skin surface to the emerging point of the ophthalmic artery was 4.8 ± 1.7 mm by means of three-dimensional scanning and 4.5 ± 1.1 mm using ultrasound detection. The vertical distance from the inferior margin of the superior orbital rim to the emerging point of the ophthalmic artery was 5.3 ± 1.4 mm.

CONCLUSION

These data inform clinicians about the anatomical three-dimensional location of the emerging point of the ophthalmic artery, which will help them to avoid iatrogenic injury when they are performing periorbital clinical procedures.

Review of Eyelid Reconstruction Techniques after Mohs Surgery

Mohs micrographic surgery achieves high cure rates while preserving healthy tissue making it the optimal treatment for skin cancer. The goals of eyelid reconstruction after Mohs surgery include restoring eyelid structure and function while attaining acceptable aesthetic results. Given the variety of eyelid defects encountered after Mohs surgery, a thorough understanding of the complex eyelid anatomy as well as an in-depth knowledge of the numerous reconstructive techniques available are required to accomplish these reconstructive goals. In this article, the authors review eyelid anatomy and discuss a variety of techniques used for the reconstruction of defects involving the periocular region.

Sentinel Artery in Double Eyelid Blepharoplasty: Identification, Prevention, Management

In double eyelid blepharoplasty, unexpected bleeding may cause intraoperative hematoma, swelling, and temporary ptosis, which could cause asymmetry and prolong recovery time. In 1725 patients (3450 eyes), double eyelid blepharoplasties were performed on Chinese patients from January 2014 to July 2016 by our senior author. In 36 eyes, the authors identified a variant artery, which the authors named the "sentinel artery," located in the inferolateral superficial orbital septum. The sentinel artery courses between the orbital septum and the levator palpebrae finally drain into the peripheral arcade. This artery is uncommon since only 1.04% of eyes have it. If the artery is severed accidentally, the cleaved arterial end will retract into the levator palpebrae and bleed causing a large hematoma to rapidly form posterior to the levator palpebrae. The authors actively avoided unexpected bleeding caused by tearing up this artery while opening the orbital septum during double eyelid blepharoplasty procedure.

Topographic Anatomy of the Inferior Medial Palpebral Artery and Its Relevance to the Pretarsal Roll Augmentation

BACKGROUND

A detailed analysis of the topography of the inferior medial palpebral artery is needed to optimize the safety and efficacy of pretarsal roll augmentation.

METHODS

Thirty-one hemifaces from 13 Korean and 8 Thai cadavers (15 male and six female cadavers) were dissected. The distributions of the inferior medial palpebral artery were determined with respect to the superior medial palpebral artery and the supratrochlear artery.

RESULTS

Four distribution patterns were observed. The inferior and superior medial palpebral arteries branched individually from the ophthalmic artery, with the ophthalmic artery terminating as the supratrochlear artery on the forehead (type I); a short trunk branched from the ophthalmic artery and divided into the inferior medial palpebral artery and superior medial palpebral artery, and the ophthalmic artery terminated as the supratrochlear artery (type II); the inferior and superior medial palpebral arteries arose together from the ophthalmic artery, and the ophthalmic artery terminated as the supratrochlear artery (type III); or the inferior and superior medial palpebral arteries were the terminal branches of the ophthalmic artery, with the supratrochlear artery arising from the angular artery (type IV). The diameter of the artery was 0.94 ± 0.22 mm at the entry point and 0.37 ± 0.11 mm at the lateral canthus.

CONCLUSIONS

The inferior medial palpebral artery was located along the tarsal plate deep to the pretarsal part of the orbicularis oculi in the lower eyelid. Injections to augment the pretarsal roll should be made between the subcutaneous tissue and this pretarsal part of the orbicularis oculi.

The Paramidline Forehead Flap: A Clinical and Microanatomic Study

BACKGROUND

The traditional paramedian forehead flap (FHF) is an axial flap based on the supratrochlear artery (STA). Doppler examination is often used to ensure inclusion of the STA within the flap. The authors hypothesized that a FHF pedicle design could be simplified to extend from the midline of the glabella to 1.2 cm lateral to the midline without compromising outcomes.

OBJECTIVE

To compare clinical outcomes and vessel densities of 2 FHF designs.

METHODS

Two FHF designs were used to repair fifty nasal defects. One was based on Doppler identification of the STA; the other on clinical measurements from the glabellar midline (with no effort to identify the STA). Clinical outcomes, complication rates, and pedicle vasculature of both groups were compared.

RESULTS

There was no significant difference in flap survival or complication rate. Forehead flaps designed on the paramidline glabella had more arteries within their pedicles than Doppler-based FHFs (p < .05). Small arteries predominated, whereas larger arteries were infrequent in both groups. Size and number of arteries were not related to flap survival.

CONCLUSION

A paramidline FHF has equivalent clinical outcomes as a flap based on the STA. A simple and reproducible design of the FHF using only surface landmarks is described.

Eyelid Reconstruction: Everything Is Not Lost When All Is Lost

Eyelid injuries are a common emergency room challenge in patients presenting with history of road traffic accidents. Overzealous debridement can result in tissue loss in which primary repair becomes impossible along with loss of critical landmarks especially in tissue as fragile as the eyelids. We present a 45-year-old male with avulsion injury of the right lower eyelid compounded by debridement at a primary health care facility. Nasolabial flap reconstruction was done with release of the bulbar conjunctiva to achieve aesthetic and functional endpoints. Adhering to the fundamental guidelines of repair of the eyelids as a primary and definitive surgery holds the crux to the best cosmetic and functional outcome.

Mohs micrographic surgery of the eyelid: an overview of anatomy, pathophysiology, and reconstruction options

BACKGROUND

Mohs micrographic surgery (MMS) is the ideal treatment for skin cancer removal. The advantages of MMS in the eyelid area include its high cure rate, tissue-sparing effects, and overall cost effectiveness.

OBJECTIVE

To review eyelid anatomy, detail ocular tumors that are amenable to MMS, and examine the surgical repair options commonly used in this area.

MATERIALS AND METHODS

A review of the literature on MMS of the eyelid was performed with specific reference to ocular anatomy, eyelid malignancy types, and surgical reconstruction.

CONCLUSION

Eyelid function is critical for the maintenance of ocular health and vision. MMS is an ideal skin cancer treatment for the delicate structure of the eyelid, where maximal tissue preservation is critical. There are a plethora of reconstruction options to consider after MMS has been performed in this area. The choice of repair and surgical outcome depend, in part, on the surgeon's knowledge of eyelid anatomy and his or her ability to assess the repair requirements of the post-MMS defect. Dermatologic surgeons can effectively work with other specialists to help ensure that their patients receive a cure with restored ocular function and optimal cosmesis.

Reconstructive options for the medial canthus and eyelids following tumor excision

General principles provide the framework for eyelid and periorbital reconstruction following tumor excision. Eyelid tumors involving the medial canthus region and/or lacrimal system add to the complexity of reconstructive planning. The nature of the tumor, patient and tissue factors, and surgeon preference guide repair design choices. Reconstructive considerations and options following medial canthal tumor resection are described.

Eyelid approach to the anterior cranial base

Skull base approaches play a fundamental role in modern neurosurgery by reducing surgical morbidity. Increasing experience has allowed surgeons to perform minimally invasive approaches without straying from the premises of skull base surgery. The eyelid approach has evolved from the orbitopterional osteotomy into a more effective and targeted approach to disease of the anterior cranial fossa. In this technique, after an incision is made on the supratarsal fold, the orbicularis oculi muscle is incised, and a myocutaneous flap composed of the elements of the anterior lamella is elevated. Subperiosteal dissection is used to expose the superior and lateral walls of the orbit, the superior and lateral orbital rim, and the frontosphenoidal suture. A MacCarty bur hole is drilled, and a frontal osteotomy is fashioned medial to the supraorbital notch and extending through the orbital roof back toward the orbital half of the MacCarty bur hole, exposing the frontobasal brain. A conventional microsurgical technique is used to treat tumors and aneurysms of the anterior cranial fossa under the operative microscope.

Five patients were treated for unruptured aneurysms of the anterior circulation (3 anterior communicating artery aneurysms, 1 ophthalmic artery aneurysm, and 1 posterior communicating artery aneurysm) using the eyelid approach. The mean aneurysm size was 5 mm, and all aneurysms were approached from the right side. Three tumors in the anterior fossa (2 suprasellar pituitary adenomas and 1 craniopharyngioma) were also excised using this approach. There was no surgical morbidity. Three months after surgery all patients presented excellent cosmetic results. The eyelid approach may be considered as an effective, cosmetically beneficial, and minimally invasive skull base approach to selected aneurysms and tumors of the anterior circulation.