Surgery around the Orbit: How to Select an Approach

Orbital region pathologies may be safely and effectively treated through a various number of approaches. As the concept of "outcome" and minimally invasive surgery keeps gaining popularity in neurosurgery, these approaches-each with specific indications and limitations-together provide the best surgical options.

[Transpalpebral craniotomy in skull base surgery]

The concept of minimally invasive neurosurgery has significantly evolved in recent years, which is associated with improvements in diagnostics, microneurosurgical techniques, anesthesiology, and intraoperative imaging.

MATERIAL AND METHODS

We present the preliminary results of using transpalpebral craniotomy in surgery of supratentorial aneurysms and anterior cranial fossa tumors. In the period between 2015 and 2107, we used this approach in surgical treatment of 30 aneurysms (10 aneurysms in the 'cold' period of hemorrhage and 20 unruptured aneurysms) and 10 anterior cranial fossa base tumors. The approach included a superior eyelid incision and a fronto-orbital craniotomy. We retrospectively evaluated outcomes, postoperative complications, and cosmetic results after these operations. The mean follow-up period was 6 months.

RESULTS

There were no deaths, disabilities, or serious permanent approach-associated complications. All patients had expected periorbital edema that was not considered as a complication.

CONCLUSION

Transpalpebral craniotomy is a safe and effective approach to anterior cranial fossa neoplasms and anterior circle of Willis aneurysms. This approach avoids injury to the frontal and temporal muscles as well as to the facial and trigeminal nerve branches. Patients assessed the postoperative cosmetic result as excellent.

"Push-Pull Technique" for the Management of a Selected Superomedial Intraorbital Lesion

Orbital lesions are traditionally managed through external approaches when laterally located, and through a transnasal approach or other external approaches when medially located. However, when the lesion is superomedially located, it may determine a technical challenge.

In this study, we present the case of a patient with a superomedial intraconal venous malformation of the left eye. We addressed the mass through a combined approach, using the transnasal route as the main approach, and the superior eyelid approach to push down the lesion to facilitate the excision. We have called this approach “push–pull technique.”

We achieved a complete resection of the lesion and did not observe any intraoperative or postoperative complications. The last follow-up at 6 months postoperatively showed no recurrence, and the patient was satisfied and completely recovered.

According to our experience, the “push–pull” technique seems to be a safe procedure and might be considered a valid alternative to address selected superomedial intraconal lesions.