Download Minimally Invasive Transpalpebral ``Eyelid`` Approach to the Anterior

CEREBROVASCULAR
Operative Technique
Minimally Invasive Transpalpebral ‘‘Eyelid’’
Approach to the Anterior Cranial Base
Khaled M. Abdel Aziz, MD,
PhD*
Sanjay Bhatia, MD*
Mohammed
Hammad Tantawy, MD*
Raymond Sekula, MD*
Jeffrey T. Keller, MD‡
Sebastien Froelich, MD§
Erik Happ, MDk
Departments of *Neurosurgery and
kOphthalmology, Allegheny General
Hospital, Drexel College of Medicine,
Pittsburgh, Pennsylvania; ‡Departments
of Neurosurgery, University of Cincinnati
College of Medicine and the Mayfield
Clinic, Cincinnati, Ohio; §Department of
Neurosurgery, University of Strasbourg,
Strasbourg, France
Correspondence:
Khaled M. Abdel Aziz, MD, PhD,
Department of Neurosurgery,
Allegheny General Hospital,
Drexel College of Medicine,
420 East North Avenue, Suite 302,
Pittsburgh, PA 15212.
E-mail: [email protected]
Received, August 27, 2010.
Accepted, February 22, 2011.
Published Online, April 14, 2011.
Copyright ª 2011 by the
Congress of Neurological Surgeons
NEUROSURGERY
BACKGROUND: Supra orbital frontal minicraniotomy is one of the most commonly used
minimally invasive approaches for anterior cranial fossa lesions.
OBJECTIVE: To describe our experience with the transpalpebral ‘‘eyelid’’ incision to
obtain access to the anterior cranial fossa.
METHODS: We describe the approach and technique of the transpalpebral eyelid incision in a step-by-step fashion and discuss the results of 40 cases for which the eyelid
incision was used. We retrospectively reviewed the charts of these patients to analyze
outcomes with regard to opening and closing time, length of hospital stay, residual
aneurysm or Simpson grade for resection, complications, and cosmetic result.
RESULTS: We treated 31 anterior circulation aneurysms (28 unruptured and 3 ruptured),
7 anterior skull base meningiomas, 1 frontal low-grade glioma, and 1 frontal cavernoma
using the transpalpebral incision. Opening time was about 45 to 60 minutes, and closure
time from dura to skin was about 45 to 60 minutes. The hospital length of stay was
similar to that in our open craniotomy cases. No residual aneurysm was demonstrated in
the follow-up studies of all 31 aneurysms. Simpson grade I resection was achieved
in 6 meningiomas. Complications included 1 postoperative eyelid hematoma, 2 postoperative infections, and a subclinical stroke discovered on postoperative imaging.
Excellent cosmetic outcome was accomplished in 39 of 40 patients.
CONCLUSION: The transpalpebral approach provides dissection in natural anatomical
planes, affords preservation of the frontalis muscle, avoids injury to nerve VII branches,
and results in an excellent cosmetic outcome.
KEY WORDS: Eyebrow, Eyelid, Fronto-orbital craniotomy, Spheno-orbital keyhole, Transpalpebral
Neurosurgery 69[ONS Suppl 2]:ons195–ons207, 2011
T
DOI: 10.1227/NEU.0b013e31821c3ea3
he concept of minimally invasive approaches in skull base surgery has evolved
during the past 2 decades. Supraorbital
frontal minicraniotomy with or without involving
the orbital rim is one of the most commonly used
minimally invasive approaches for anterior cranial fossa lesions.1-11 Minifrontal or fronto-orbital
craniotomy can achieve the same microsurgical
exposure as the standard frontotemporal approaches.13,15 This minicraniotomy is performed
through a ciliary or supraciliary eyebrow incision.1,5,6,13,15 Both incisions can achieve an
acceptable cosmetic outcome.3,4,13,15,16 However,
the transciliary incision can damage the hair follicles and result in local alopecia, and the
supraciliary incision is located at the upper edge of
the eyebrow. Both the ciliary and supraciliary
incisions involve a cut across the frontalis muscle,
which can result in eyebrow asymmetry.6,11
Therefore, both incisions can result in visible
skin scars.
With the transpalpebral approach, incising at
the natural skin crease of the upper eyelid allows
the surgeon to perform a minicraniotomy and
exposure similar to the eyebrow incision.17 We
have adopted and modified the transpalpebral
approach with a combined team effort of an
oculoplastic neuro-ophthalmologist and a skull
base surgeon since July 2007. We have successfully treated 31 anterior circulation aneurysms (28 unruptured and 3 ruptured), 7
anterior skull base meningiomas, 1 frontal low
glioma, and 1 frontal cavernoma. Here, we
describe the approach and technique in a stepby-step fashion and discuss the results of our
40 cases (the largest series published in the
literature) and the advantages of the transpalpebral approach.
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ABDEL AZIZ ET AL
RELEVANT MICROSURGICAL ANATOMY
Frontal (Temporal) Branch of the Facial Nerve Relative
to the Periorbital Region
Many studies have evaluated the anatomic pattern of the facial
nerve. Because the frontal branch travels forward to enter the
frontalis muscle and orbicularis oculi, it is vulnerable to injury
during surgery in the periorbital or eyebrow region. The orientation of the frontal branch fibers becomes horizontal as it
approaches the lateral canthus and eyebrow. Incisions in this
region should therefore be as horizontal as possible. In a study by
Schmidt et al,18 a relative ‘‘safety zone’’ free of nerve branches was
identified that exists up to 2.5 cm lateral to the lateral canthus
(Figure 1A).
Upper Eyelid Anatomy
The upper eyelid is typically divided into 2 lamellae: anterior and posterior. The anterior lamella contains the skin and
orbicularis oculi muscle. The posterior lamella consists of the
levator aponeurosis, the Müller muscle, and the palpebral conjunctiva. The orbital septum divides the 1 lamellae. The septum
originates at the superior orbital rim, arising from the arcus
marginalis, a thickened band of periosteum that is continuous
with the frontal periosteum superiorly and the periorbita. Posterior to the orbital septum is the preaponeurotic fat pad. This fat
pad is an important landmark during upper eyelid surgery because the levator aponeurosis lies immediately posterior to it.
Staying anterior to this landmark will avoid damage to the
levator/Müller complex (Figure 1B and 1C).
The upper eyelid crease is located 8 to 11 mm superior to the
eyelid margin. It is formed by the attachment of the levator
aponeurosis in the subcutaneous tissue inferior to its union with
the orbital septum. There is potential space superior to the
upper eyelid crease between the septum and the skin/orbicularis
oculi complex. This space creates a natural, avascular plane that
can be used to dissect up to the orbital rim without damage to
the posterior lamella19-21 (Figure 1B and 1C). Therefore, the
upper eyelid crease creates an excellent incision point for all
eyelid surgery and is used extensively by oculoplastic and orbital
surgeons.15,16,19,20,22-26
STEPS OF THE OPERATIVE PROCEDURE
Brain Relaxation
First, a lumbar drain is placed before the patient is positioned,
about 20 to 40 cc is drained during the surgery, according to the
need, after the dura is opened. Intravenous mannitol (0.5 g/kg of
20%) is given at the beginning of the craniotomy. The lumbar
drain is usually removed 3 to 4 days postoperative as long as there
is no CSF leak.
FIGURE 1. A, patient photo showing the ‘‘safety zone’’ marked on patient’s face.
The safety zone is an area 2.5 cm lateral to the lateral canthus, which is free of facial
nerve branches. The solid line marks the path of the temporal branch of the facial
nerve. The dotted line marks the extent of the eyelid incision. B, sagittal cross section
of the eyelid demonstrating the layers encountered after an upper eyelid incision
Printed with permission from Mayfield Clinic. C, sagittal cross section demonstrating separation of the layers of the eyelid. The periosteum is divided sharply along
the midpoint of the orbital rim, just above the orbital septum. Dissection of the
periorbita from the roof of the orbit may be extended as far posteriorly as the orbital
apex. m, muscle. Printed with permission from Mayfield Clinic.
ons196 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
Positioning and Prepping
While the patient is still awake, the upper eyelid crease is
marked across its entire length (Figure 1A). A crow’s foot is
looked for in the most lateral aspect and, if present, is also
marked. The incision may be extended approximately 1 to 1.5 cm
beyond the lateral canthal angle along the crow’s foot if needed in
a particular case. If no crow’s foot is present, then the incision line
is extended laterally from the lateral canthus along the eyelid
crease line (with a slight upward bend).
The head is secured in a head clamp. The head is angled
according to the lesion approached. The head is also slightly
extended, making the malar eminence the highest point on the face.
We inject local anesthetic before prepping to allow adequate
time for hemostatic effect to take place. We use approximately
3 to 5 cm3 of a 1:1 combination of 2% lidocaine with 1:100 000
epinephrine and 0.75% bupivacaine.
Full-strength Betadine solution is toxic to the ocular surface;
therefore, we use a half-strength Betadine solution diluted with
normal saline. The upper and lower eyelids and the eyebrow are
prepared with this solution. The cornea and surrounding sclera
are protected with an antibiotic-lubricated plastic eye shield.
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
Surrounding areas, including the nose, maxillary eminence, and
ipsilateral forehead, are prepared with chlorhexidine paint.
Eyelid Incision and Dissection
Just before incision, a traction stitch is placed through the
upper lid margin and secured to the inferior portion of the head
drape with a hemostat. This allows gentle traction and stretch to
be applied to the upper eyelid skin to facilitate incision. The
incision is made sharply with a No. 15 Bard-Parker blade through
skin only in the upper lid crease. It can be extended laterally along
the aforementioned premarked line (Figure 2A). Care is taken not
to incise deep through the orbicularis oculi muscle. Hemostasis is
achieved with low-voltage bipolar cautery. The orbicularis oculi
muscle is then lifted with fine forceps on either side of the
incision. This elevates it from the underlying orbital septum. A
small horizontal cut is made through the orbicularis oculi with
Westcott scissors. The incision is then extended medially and
laterally in the same plane. The orbital septum is identified
immediately (Figure 2B). Hemostasis is again achieved as
required to allow continuous recognition of the proper surgical
plane. A plane between the orbicularis oculi and the orbital
septum is developed superiorly and laterally until the orbital rim is
identified (Figures 1C and 2C). The landmarks for an orbital rim
periosteal incision are the supraorbital notch medially (Figure 2D)
and the lateral orbital tubercle laterally. The periosteum is divided
sharply along the midpoint of the orbital rim with the No. 15
blade (Figure 2C and 2D). Periosteal elevation is begun on the
orbital side, with care taken not to buttonhole the periorbita,
resulting in unwanted fat prolapse. Dissection of the periorbita
from the roof of the orbit may be extended as far posteriorly as the
orbital apex (Figures 2D and 3A).
The frontal periosteum is then elevated superiorly, laterally,
and medially. Typically, the supraorbital neurovascular bundle is
indentified medially, and care is taken not to injure it. A relaxing
incision is made just lateral to the supraorbital neurovascular
bundle in the periosteum. Elevation of the periosteum across the
frontal bone is continued laterally beyond the frontozygomatic
suture or junction.
FIGURE 2. Operative still images. A, eyelid skin incision. B, the orbital septum
is identified after a horizontal incision through the orbicularis oculi. C, the
orbital rim is identified after expansion of the plane between the orbicularis oculi
and the orbital septum superiorly and laterally. D, the periosteum is divided
sharply along the midpoint of the orbital rim. Dissecting forceps is pointing at the
supratrochlear nerve. Printed with permission from Allegheny General Hospital.
FIGURE 3. Operative still images. A, dissection of the periorbita from the roof of
the orbit. B, exposure of the anterior and superior portions of the temporalis
muscle and fascia attached to the superior temporal line. C and D, dissection of
the temporalis fascia and muscle from the superior temporal line is continued
until the extracranial surface of the greater wing of the sphenoid bone and the
pterion are exposed. Printed with permission from Allegheny General Hospital.
Draping
After drape towels are placed, an Ioband sheet is placed with
a hole to keep the eye uncovered. Craniotomy drapes are then
placed also with a hole to keep the eye uncovered.
NEUROSURGERY
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ABDEL AZIZ ET AL
Another relaxing incision is made in the periosteum immediately above the superior temporal line. This allows posterior
subperiosteal dissection of the flap up to 3 cm superior to the
supraorbital ridge. Before proceeding, four 2-0 absorbable sutures
are placed at the edges of the periosteum straddling the relaxing
incisions. We have determined this to be the most beneficial and
optimum closure of this layer.
Temporalis Muscle
The lateral extension of the eyelid incision allows exposure of
the anterior and superior portions of the temporalis muscle and
fascia attached to the superior temporal line (Figure 3B). Dissection of the temporalis fascia and muscle from the superior
temporal line is continued until the extracranial surface of the
greater wing of the sphenoid bone and the pterion are exposed
(Figure 3C and 3D).
Bone Exposure
We are able to expose an inch of the frontal bone above
the superior orbital ridge. The bony exposure starts lateral to
the supraorbital notch and extends lateral to the frontozygomatic
suture, including the extracranial surface of the greater wing of
the sphenoid bone.
Spheno-Orbital Keyhole Burr Hole
This burr-hole opening (Figure 4A and 4B) involves the greater
wing of the sphenoid and the junction between the lateral wall
and the roof of the orbit. We start drilling the extracranial surface
of the greater wing of the sphenoid bone at the frontosphenoidal
and the sphenosquamosal sutures, posterior to the zygomaticosphenoidal suture, and 1 cm behind the frontozygomatic
junction (Figure 4C). Drilling is continued, aiming for exposure
of the frontal lobe dura, temporal lobe dura, and periorbita
(Figure 4B and 4D). A soft malleable retractor blade protects the
periorbita during this step. After the spheno-orbital keyhole is
finished, the exposed lateral edge of the roof of the orbit is
thinned with a bone nibbler to prepare for the orbital cuts.
Bony Cuts for the 1-Piece Fronto-Orbital Approach
Five bony cuts are necessary to complete a 1-piece frontoorbital approach (Figure 5A through 5G).
1. In the first cut, a frontal craniotomy, frontal dura is dissected
from the overlying frontal bone with a dissector. A frontal
craniotomy is performed with the footplate and extends from
the frontal portion of the spheno-orbital burr hole, continues
2 cm behind the superior orbital ridge, and ends anteriorly at
the superior orbital ridge lateral to the supraorbital notch
(Figure 5B and 5C). Staying lateral to the supraorbital notch
decreases the risk of entering the frontal air sinus. This cut
should not continue across the frontal bone to keep the
fronto-orbital craniotomy in 1 piece.
2. The second cut is also made with the drill, guarding the
periorbita. This cut extends the first cut through the supraorbital ridge just lateral to the supraorbital notch (Figure 5D).
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FIGURE 4. A, cadaver photo illustrating the extracranial surface of the sphenoid
wing and the area of the spheno-orbital key-hole. C, coronal suture; S, squamosal
suture; SF, sphenofrontal suture; SP, sphenoparietal suture; SS, sphenosquamosal
suture; SZ, sphenozygomatic suture. B, cadaver photo showing exposure after
drilling the spheno-orbital keyhole exposing periorbita, frontal dura, and temporal dura. C and D, operative still images showing the spheno-orbital keyhole. A
soft malleable retractor blade protects the periorbita during this step. Printed with
permission from Allegheny General Hospital.
3. The third cut is performed with the footplate, extending from
the orbital portion of the spheno-orbital burr hole across the
frontal process of the zygomatic bone (Figure 5E).
4. The fourth cut is made along the roof of the orbit with
a specially designed and custom-made KA chisel (Axon
Medical Inc, Pittsburgh, Pennsylvania) with a sharp center to
cut bone and blunt edges to protect tissue (dura and periorbita). A soft malleable retractor blade protects the periorbita
during this step (Figure 5F).
5. The fifth cut is made across the roof of the orbit from the
orbital portion of the spheno-orbital burr hole laterally with
the KA chisel while the periorbita is visualized and protected
by that malleable retractor blade. The cut extends medially to
reach the posterior end of the fourth cut. The goal is to cut the
anterior two-thirds of the orbital roof to keep it attached to the
frontal bone in 1 piece.
After the 5 cuts are finished, the fronto-orbital bone flap is
elevated in 1 piece without difficulty (Figure 5G). Residual
sphenoid ridge is drilled with a 4-mm rough diamond burr to
allow exposure of frontal dura and temporal dura. Described
bony exposure, cuts, and craniotomy size were standard in
all cases. Bone flap extends from the sphenoid keyhole opening
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
FIGURE 5. B through G, operative still images. A, cartoon illustrations of skull with the fronto-orbital bony cuts outlined. Bony
exposure, cuts, and craniotomy size are standard in all cases. Bone flap extends from the sphenoid keyhole opening medially to the
lateral edge of the supratrochlear notch or foramen medially; anteroposterior extension is 2.5 cm from the supraorbital ridge. The
bone flap includes the anterior two-thirds of the roof of the orbit. Printed with permission from Mayfield Clinic. B and C, frontal
bone cut starts from the frontal portion of the sphenoid keyhole and ends at the supraorbital ridge lateral to the supratrochlear
notch. D, supraorbital ridge cut. E, zygomatic cut. F, orbital roof cut with the KA chisel. A soft malleable retractor blade protects
the periorbita during this step. G, 1-piece fronto-orbital bone flap. Printed with permission from Allegheny General Hospital.
medially to the lateral edge of the supratrochlear notch or foramen medially; anteroposterior extension is 2.5 cm from the
supraorbital ridge.
Frontal Air Sinus
Computed tomography scans and magnetic resonance images
of all cases were reviewed to assess the lateral extension of the
NEUROSURGERY
frontal air sinus. Staying lateral to the supraorbital notch decreases
the risk of entering the frontal air sinus. Cutting through the
lateral extension of the frontal air sinus was anticipated in 7 of
40 cases. In all 7 cases, a hole in the lateral extension of the frontal
air sinus was unavoidable. The frontal air sinus opening was
sealed without difficulty, after the bone flap was elevated, with
a semisolid piece of bone cement. This did not interfere with the
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ABDEL AZIZ ET AL
mucociliary drainage of the frontal air sinus, which is directed
inferomedially toward the frontal air sinus ostium. We did not
scrap the sinus mucosa or obliterate the sinus.
Skin Flap Retraction and Protection
During bony cuts, the skin flap is protected with Desmarres
skin retractors. Plastic rubber-covered blunt fishhooks are used to
protect the skin of the eyelid while the bone cuts are performed
and during the whole procedure. Fishhooks are released intermittently during the case. Two fishhooks are needed: 1 for the
temporalis muscle and 1 for the skin flap. Each fishhook is
encircled in a plastic tube for skin protection.
Dural Opening
Dura is open in a flap fashion on the basis of the periorbita.
Both dura and periorbita are protected with a malleable ½- or 3/4in retractor blade. We apply hardly any significant pressure on the
ocular globe. Occasionally, we place 2 to 3 sutures in the base of
the dural flap and reflect the dura anteriorly on the periorbita.
This allows us to hold back the ocular globe without any significant pressure.
Exposure
After microscopic dissection and opening of the optic cistern,
carotid cistern, and the proximal sylvian fissure (if needed), we
can achieve exposure from the ipsilateral to the contralateral
oculomotor nerve.
Closure
First, dura is approximated in a water-tight fashion. Synthetic
dural graft can be used to optimize dural closure. Second, the
bone flap is secured with 2 to 3 small, low-profile titanium plates
(and low-profile screws) on the frontal bone; plates are not placed
on the supraorbital ridge or the zygomatic processes. Occasionally, we place a plate on the zygomatic processes; in this case, we
create a recess with the drill for the plate placement. The sphenoid
ridge area is reconstructed with a malleable low-profile mesh.
Bone cement is applied over the superior orbital ridge cut and the
zygomatic cut and to fill the gaps of the craniotomy defect. A layer
of bone cement is placed on top of the titanium mesh covering
the sphenoid keyhole to restore the natural contour of the
sphenoid wing area (Figure 6A and 6B). Third, we place 3 or
4 holes at the superior temporal line and the zygomatic process of
the frontal bone using the tack-up drill bit. This allows
approximation and closure of the temporalis muscle with 4-0
Polysorb or Vicryl sutures (Figure 6A). We then place a subperiosteal 10F rounded drain along the superior aspect of the
bone flap and bring the trocar out through the hairline. Temporalis muscle is then pulled forward, and 4-0 Vicryl sutures are
passed through the muscle and predrilled holes to reapproximate
it to the superior temporal line. The frontal periosteum, which
was previously tagged with 2-0 Polysorb sutures, is then
relocated, and the relaxing incisions are repaired with interrupted
4-0 Vicryl. The 2-0 sutures are cut free, and the periosteum is
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FIGURE 6. Operative still images. A, we place 3 to 4 holes at the superior
temporal line and the zygomatic process of the frontal bone using the tack-up
drill bit to allow suturing back the temporalis muscle. B, the sphenoid ridge
area is reconstructed with a malleable low profile mesh. Bone cement is applied
over the superior orbital ridge cut and the zygomatic cut and to fill the gaps of
the craniotomy defect. A layer of bone cement is placed on top of the titanium
mesh covering the sphenoid keyhole to restore the sphenoid wing natural
contour. Printed with permission from Allegheny General Hospital.
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
reapproximated to the periorbita with a running 4-0 Vicryl suture. This closure needs to be very accurate to prevent postoperative scarring and to ensure correct anatomic alignment. The
orbicularis oculi fibers are left to reapproximate, and the skin is
then closed with a 6-0 absorbable suture. We prefer to use 2
separate running sutures. The medial suture is to close the lid
crease, and several deep bites through the orbital septum are made
to help recreate the lid crease. The lateral running suture is to
close the crow’s foot extension with simple skin bites. The incision is dressed simply with antibiotic ophthalmic ointment; no
patch is required. Ice packs are placed over the incision for 15
minutes every hour while the patient is awake for the first 3
postoperative days to minimize tissue edema and eyelid swelling.
OUR EXPERIENCE
We have treated 31 anterior circulation aneurysms (28 unruptured and 3 ruptured), 7 anterior skull base meningiomas, 1
frontal low glioma, and 1 frontal cavernoma using the transpalpebral incision (Tables 1 and 2).
We did not use the eyelid fronto-orbital craniotomy for middle
cerebral artery aneurysms. We preferred to use the less invasive
minipterional approach, which provides better direct exposure
along the entire fissure with minimal brain manipulation.
All surgeries were performed with the neurosurgical microscope. We did not use the neuroendoscope in this series.
Beginning with our fifth case, opening time was about 45 to
60 minutes and closure time from dura to skin was about 45 to
60 minutes. The hospital length of stay was similar to that in our
open similar craniotomy cases, up to 5 days.
Of the 31 anterior circulation aneurysms, 28 were unruptured
and 3 were ruptured aneurysms added after we became familiar
with the approach (Table 1). Five carotid ophthalmic segment
aneurysms required extradural optic foraminotomy and anterior
clinoidectomy (Figure 7B). One posterior communicating artery
required intradural anterior clinoidectomy to achieve proximal
internal carotid artery exposure (Figure 7C). No difficulty was
encountered in performing this step because of the direct exposure and immediate access to the optic canal and clinoid
process after the fronto-orbital craniotomy. Satisfactory exposure
for proximal and distal control was obtained with minimal or no
brain retraction. No residual aneurysm was demonstrated in the
follow-up studies of all 31 aneurysms (Figure 7A through 7E).
Seven anterior cranial fossa meningiomas (2 planum, 1 tuberculum, and 4 olfactory groove) were resected with the eyelid frontoorbital approach. The maximum dimension of the meningiomas in
the magnetic resonance imaging study ranged from 1.5 to 5.8 cm.
The volumes ranged from 2.7 to 219 cm3. Total resection,
Simpson grade I, was achieved in 6 meningiomas (Figure 8A and
8C). In the largest meningioma, tumor was extremely adherent and
infiltrating the right optic nerve, anterior communicating artery
complex, and the pituitary stalk; a small residual tumor, visualized
during our exposure, was left attached to these critical neurovascular structures (Simpson grade IV; Figure 8B).
NEUROSURGERY
Complications (Table 1 and 2) included 1 postoperative eyelid
hematoma that required reoperation without any cosmetic longterm complication and 2 postoperative infections: 1 superficial
skin infection that was cured with oral antibiotics and 1 postoperative deep epidural infection that required further surgery
and intravenous antibiotic treatment without long-term cosmetic
complication. One cerebrospinal fluid leak spontaneously resolved with a lumbar drain placed for 4 days. One patient with
a posterior communicating artery aneurysm developed postoperative radiological evidence of a small perforator stroke at the
genu of the internal capsule and was totally asymptomatic.
The postoperative eye swelling varied from patient to patient.
We did not find that swelling correlated to the length of the
surgery. Eye swelling maximized during the second and third
postoperative days. Within 1 week, the swelling subsided and the
mechanical ptosis from postoperative edema started to resolve. In
general, we tell the patient that the eye will be swollen for 1 week
and then will start to subside. Within 2 to 3 months, the cosmetic
advantages are seen. We did not encounter any temporalis muscle
wasting of frontalis muscle asymmetry. Excellent cosmetic outcome (no noticeable eyelid asymmetry with excellent healing and
barely visible lateral edge of the incision that gradually starts to
fade after 3 months) was accomplished in 39 of 40 patients
(Figure 9A through 9C). During our early experience, 1 patient
had an evident nonsatisfactory scar, which required revision of
her eyelid incision.
DISCUSSION
‘‘Surgical approach should be as large as necessary and as small
as possible.’’7 Minimally invasive approaches are widely used by
skull base surgeons. The premier advantages of such approaches
are shorter duration, less surgical trauma, shorter hospitalization,
and less postoperative pain. Achieving an excellent cosmetic
outcome should be added to the goals of minimally invasive skull
base surgery.2
Perneczky7 developed the supraorbital keyhole approach
through an eyebrow incision. His approach has been widely used
by skull base surgeons to access the anterior cranial fossa. The
addition of an orbitotomy by Jho4 increased the extent and angle
of exposure, which provided additional space by retracting
the frontal dura against the periorbital. An anatomical study
predicted more benefit from orbitotomy when the orbital roof
height is above 11 mm from the plane of the nasion (J.T. Keller,
unpublished data).
Transient loss of supraorbital sensation frequently occurs after
eyebrow incisions, attributed to traction on the supraorbital nerve.
In addition, weakness of the eyebrow elevation can result from
interruption of the insertion fibers of the frontalis muscle to the
eyebrow itself or may be due to injury of the frontal branch of the
facial nerve, which will be very close to the incision line if extended
laterally. In 2004, Perneczky6 evaluated the surgical results, complications, and patient satisfaction after supraorbital craniotomy
using an eyebrow skin incision on 223 patients. The results showed
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ABDEL AZIZ ET AL
TABLE 1. Aneurysm Seriesa
Size,
Patient Age, y Sex mm Side Postoperative
a
1
2
3
51
53
48
F
F
F
5
6
6
R
R
L
No residual
No residual
No residual
4
5
6
59
33
51
M
F
M
7
30
7
L
R
L
No residual
No residual
No residual
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
40
67
56
58
70
32
45
47
54
52
57
60
56
64
51
F
F
F
F
F
F
F
F
F
M
F
F
M
M
M
5.6
6
6
10
6
5
5
7
5
6
5
12
7
5
11
L
R
R
R
L
R
L
L
R
R
L
R
L
L
R
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
22
23
24
25
26
27
28
29
30
31
46
60
58
59
60
48
31
45
48
58
F
M
F
F
M
F
F
F
F
M
6
10
5
5
7
12
6
7
8
8
R
L
R
L
L
R
R
L
R
R
No
No
No
No
No
No
No
No
No
No
residual
residual
residual
residual
residual
residual
residual
residual
residual
residual
Location
Pcom
Acom
ICA communicating segment
Complications
Follow-up, mo
30
29
28
L upper lid hematoma
required reoperation
Acom
Pcom
Previously coiled, coil impaction and further
aneurysm growth
ICA communicating segment
Acom
Draining stitch sinus
Acom
Pcom, calcified and partially thrombosed
R upper eyelid cicatrix
Acom
Acom
Pcom
Acom
A1 segement
Pcom
Carotid-ophthalmic
Carotid-ophthalmic
Carotid-ophthalmic
A1-A2 ruptured
Acom
CSF leak resolved with a
lumbar drain for 4 d
Pcom ruptured
Pcom ruptured
Carotid Ophthalmic
Carotid communicating segment
Pcom
Carotid-ophthalmic
Acom
Pcom
Acom
Pcom, calcified neck
Radiological evidence of a small
perforator stroke at the genu of
the internal capsule, asymptomatic
27
26
26
25
22
21
20
18
21
19
17
16
15
13
12
10
10
9
9
8
7
6
6
5
5
4
4
3
Acom, anterior communicating artery; CSF, cerebrospinal fluid; ICA, internal carotid artery; Pcom, posterior communicating artery.
that 141 patients were pain free and 82 patients had postoperative
scar pain, which was severe in 3 patients. Sixty-one patients
developed postoperative frontalis palsy, which was temporary in
47 and permanent in 18 patients. Frontal numbness was noted in
94 patients, temporary in 65 and permanent in 29 patients.
Postoperative cosmetic outcome was determined by a patient’s
satisfaction scale from 1 to 5 (1 = very pleasant and 5 = unpleasant).
Of 223 patients scars, 157 were graded as 1, 36 were graded as
2, 22 were graded as 3, 5 were graded as 4, 3 were graded as 5.19
The transpalpebral approach is widely used by oculoplastic
surgeons to resect orbital tumors and to repair orbital fractures.7,15,19,20,22-26 The camouflage of the incision by the overlying lid fold allows excellent cosmesis. The extremely thin lid
skin in the crease allows rapid healing with a virtually
ons202 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
imperceptible mature scar. In addition, the scar is hidden within
the eyelid while the lid is opened and in a natural crease while the
eyelid is closed.23,24 The lateral extension of our eyelid incision
outside the lateral canthus (crow’s feet skin crease) carries a
minimal risk of injury to the frontal branch of the facial nerve
compared with the lateral extension of the eyebrow, which will be
in the vicinity of the frontal branch.18
One-piece fronto-orbital craniotomy can be performed effectively through the newly introduced transpalpebral approach.
Our standard bone flap extends from the sphenoid keyhole
opening medially to the lateral edge of the supratrochlear notch or
foramen medially; anteroposterior extension is 2.5 cm from the
supraorbital ridge. The addition of an orbitotomy dramatically
improves visualization and the angle of exposure. We were able to
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
TABLE 2. Tumor Series
Patient Age, y Sex Side
Diagnosis
Length, cm Width, cm Height, cm
Complete/Incomplete
Resection
1
2
54
40
F
F
L
R
Planum sphenoidale
Tuburculum sella
3.7
1.5
3.5
1.3
1.8
0.8
Complete
Complete
3
4
5
6
48
53
43
28
M
F
M
M
R
L
L
R
5.5
3.2
3
1
5.8
3.4
3.2
1.1
3.8
1.8
3.3
0.9
Incomplete
Complete
Complete
Complete
7
8
9
45
35
71
M
F
F
L
L
L
Olfactory groove
Planum sphenoidale
Olfactory groove
Glial neoplasm
low grade
Olfactory groove
Cavernoma
Olfactory groove
5
3
4
4.5
3
3.5
44
3
3.5
Complete
Complete
Complete
achieve exposure from the ipsilateral to the contralateral oculomotor nerve. Microscopic dissection and opening of the proximal
sylvian fissure allow further subfrontal dissection with minimal
frontal lobe retraction. This facilitates resection of olfactory
groove meningiomas; the falx is exposed, coagulated, and sharply
cut to allow further exposure and resection of the contralateral
portion of the tumor. The maximum tumor diameter in our series
was 6 cm. We plan to use endoscopic assistance for future cases to
allow resection of larger lesions.
Some skull base surgeons advocate the control of the blood
supply of the olfactory groove meningiomas through cauterizing
Complications
Infection, pseudomeningocele
required reoperation
the ethmoidal vessels at the medial orbital compartment before
starting the actual craniotomy.14,27 This entails the downward
dissection of the bicoronal flap to reach the medial orbital
compartment. With the eyelid incision, the extracoronal medial
orbital dissection can be performed easily before the craniotomy is
made to cauterize the ethmoidal vessels without manipulating the
supraorbital nerves.
Complications in our aneurysms series are listed in Table 1. One
patient developed postoperative eyelid hematoma and required
reoperation without any cosmetic long-term complication. During
our early experience, 1 patient developed an incision cicatrix, which
FIGURE 7. A, preoperative and postoperative magnetic resonance imaging (MRI) for olfactory groove meningioma, complete resection. B, preoperative and postoperative MRI
for olfactory groove meningioma (World Health Organization grade II), small residual tumor infiltrating anterior communicating artery complex, and pituitary stalk (Simpson
grade IV). C, preoperative and postoperative MRIs for planum sphenoidale meningioma, complete resection. Printed with permission from Allegheny General Hospital.
NEUROSURGERY
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ABDEL AZIZ ET AL
FIGURE 8. A, preoperative angiogram of a 12-mm carotid ophthalmic segment aneurysm. Postoperative angiogram showing
complete clipping (anterior clinoidectomy performed). B, preoperative angiogram of a 5-mm internal carotid artery (ICA)
aneurysm clipped with a fenestrated clip (fenestration around the ICA). Postoperative angiogram showing complete clipping.
C, preoperative computed tomography (CT) angiogram, 9 mm posterior communicating artery aneurysm. Postoperative CT
angiogram showing complete clipping (anterior clinoidectomy performed). D, preoperative angiogram for a recurrent anterior
communicating artery aneurysm after coiling. Postoperative CT angiogram showing complete clipping. E, preoperative angiogram
for an anterior communicating artery aneurysm. Postoperative angiogram showing complete clipping. F, preoperative angiogram
for an anterior communicating artery aneurysm. Postoperative angiogram showing complete clipping. Printed with permission
from Allegheny General Hospital.
ons204 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
FIGURE 9. Postoperative patients’ pictures showing that the camouflage of the incision by the overlying lid fold allows excellent
cosmesis. Printed with permission from Allegheny General Hospital.
required later (at 12 months) incision revision with improved
satisfactory outcome and required makeup to mask the incision
lateral extension, but symmetric eye lid movement was achieved.
Postoperative superficial skin infection (stitch sinus) occurred in 1
patient and was cured with local and oral antibiotics. One patient
developed cerebrospinal fluid leak from the incision; this was
controlled with a lumbar drain for 4 days and elevation of the head
of the bed. Asymptomatic small perforator ischemic stroke at the
genu of the internal capsule occurred in 1 patient. Complications
NEUROSURGERY
in our neoplasm series are listed in Table 2. One patient had an
excellent cosmetic outcome; he started strenuous excises 3 weeks
postoperatively and developed a pseudomeningocele. This was not
resolved with lumbar drain and elevation of the head of the bed for
3 days. The eyelid incision was reopened and bone flap was reelevated, the small dural opening was repaired, and the eyelid
incision was closed. The wound started to heal well; however, 4
weeks later, the patient presented with redness and drainage from
the lateral aspect of the eyelid incision. This required reopening of
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ABDEL AZIZ ET AL
the incision and drainage of a deep wound infection. The bone flap
was healthy; it was irrigated with antibiotics and hydrogen peroxide
and placed in Betadine solution for 30 minutes. The incision was
successfully revised; the patient was placed on antibiotics; and the
incision healed with an excellent cosmetic outcome. We did not
encounter any early or late complications related to the opening
and repair of the frontal air sinus during surgery.
The transpalpebral approach is an excellent option to approach
lesions of the anterior skull base. The minimally invasive access
through an eyelid incision involves dissection in normal tissue
planes with minimal surgical trauma, less postoperative pain, and
excellent cosmetic results.
Disclosure
The authors have no personal financial or institutional interest in any of the
drugs, materials, or devices described in this article.
REFERENCES
1. Czirjak S, Szeifert GT. Surgical experience with frontolateral keyhole craniotomy
through a superciliary skin incision. Neurosurgery. 2001;48(1):145-149.
2. Dare AO, Landi MK, Lopes DK, Grand W. Eyebrow incision for combined
orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of
the anterior circulation: technical note. J Neurosurg. 2001;95(4):714-718.
3. Jallo GI, Bognar L. Eyebrow surgery: the supraciliary craniotomy: technical note.
Neurosurgery. 2006;59(1)(suppl 1):ONSE157-ONSE158.
4. Jho HD. Orbital roof craniotomy via an eyebrow incision: a simplified anterior
skull base approach. Minim Invasive Neurosurg. 1997;40(3):91-97.
5. Mitchell P, Vindlacheruvu RR, Mahmood K, Ashpole RD, Grivas A, Mendelow AD.
Supraorbital eyebrow minicraniotomy for anterior circulation aneurysms. Surg Neurol.
2005;63(1):47-51.
6. Perneczky A. Surgical results, complications and patient satisfaction after supraorbital craniotomy through eyebrow skin incision. Paper presented at: Joint
Meeting mit der Ungarischen Gesellschaft für Neurochirurgie Deutsche Gesellschaft für Neurochirurgie (DGNC); April 28, 2004; Koln, Germany.
7. Perneczky A, Muller-Forell W, Lindert E, Fries G. Keyhole Concept in Neurosurgery: With Endoscope-Assisted Microsurgery and Case Studies. New York, NY:
Thieme; 1999.
8. Reisch R, Perneczky A. Ten-year experience with the supraorbital subfrontal
approach through an eyebrow skin incision. Neurosurgery. 2005;57(4)(suppl):
242-255.
9. Reisch R, Perneczky A, Filippi R. Surgical technique of the supraorbital key-hole
craniotomy. Surg Neurol. 2003;59(3):223-227.
10. Sanchez-Vazquez MA, Barrera-Calatayud P, Mejia-Villela M, et al. Transciliary
subfrontal craniotomy for anterior skull base lesions: technical note. J Neurosurg.
1999;91(5):892-896.
11. Velimir L, Sajko T, Beros V, Kudelic N, Velimir L Jr. Advantages and disadvantages of the supraorbital keyhole approach to intracranial aneurysms. Acta
Clin Croatica. 2006;45(2):91-94.
12. Figueiredo EG, Deshmukh P, Nakaji P, et al. The minipterional craniotomy:
technical description and anatomic assessment. Neurosurgery. 2007;61(5)(suppl
2):256-264.
13. Figueiredo EG, Deshmukh V, Nakaji P, et al. An anatomical evaluation of the
mini-supraorbital approach and comparison with standard craniotomies. Neurosurgery. 2006;59(4)(suppl 2):ONS212-ONS220.
14. Hentschel SJ, DeMonte F. Olfactory groove meningiomas. Neurosurg Focus.
2003;14(6):e4.
15. Ohjimi H, Taniguchi Y, Tanahashi S, Era K, Fukushima T. Accessing the orbital
roof via an eyelid incision: the transpalpebral approach. Skull Base Surg. 2000;
10(4):211-216.
16. Kersten RC. The eyelid crease approach to superficial lateral dermoid cysts.
J Pediatr Ophthalmol Strabismus. 1988;25(1):48-51.
17. Andaluz N, Romano A, Reddy LV, Zuccarello M. Eyelid approach to the anterior
cranial base. J Neurosurg. 2008;109(2):341-346.
ons206 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011
18. Schmidt BL, Pogrel MA, Hakim-Faal Z. The course of the temporal branch of the
facial nerve in the periorbital region. J Oral Maxillofac Surg. 2001;59(2):178-184.
19. Bergeron CM, Moe KS. The evaluation and treatment of upper eyelid paralysis.
Facial Plast Surg. 2008;24(2):220-230.
20. Richter DF, Stoff A, Olivari N. Transpalpebral decompression of endocrine
ophthalmopathy by intraorbital fat removal (Olivari technique): experience and
progression after more than 3000 operations over 20 years. Plast Reconstr Surg.
2007;120(1):109-123.
21. Seiff SR, Seiff BD. Anatomy of the Asian eyelid. Facial Plast Surg Clin North Am.
2007;15(3):309-314.
22. Abouchadi A, Capon-Degardin N, Martinot-Duquennoy V, Pellerin P. Eyelid
crease incision for lateral orbitotomy [in French]. Ann Chir Plast Esthet. 2005;
50(3):221-227.
23. Kung DS, Kaban LB. Supratarsal fold incision for approach to the superior lateral
orbit. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;81(5):522-525.
24. Park AH, Siddiqi F. An approach to pediatric brow dermoids: an upper eyelid
crease incision. Int J Pediatr Otorhinolaryngol. 2006;70(2):349-351.
25. Ruszkowski A, Caouette-Laberge L, Bortoluzzi P, Egerszegi EP. Superior eyelid
incision: an alternative approach for frontozygomatic dermoid cyst excision. Ann
Plast Surg. 2000;44(6):591-594.
26. Wolfley DE. The lid crease approach to the superomedial orbit. Ophthalmic Surg.
1985;16(10):652-656.
27. McDermott MW, Rootman J, Durity FA. Subperiosteal, subperiorbital dissection
and division of the anterior and posterior ethmoid arteries for meningiomas of the
cribriform plate and planum sphenoidale: technical note. Neurosurgery. 1995;
36(6):1215-1218.
COMMENTS
T
he authors describe a series of patients operated on with the eyelid
approach. Minimally invasive neurosurgery constantly struggles to
master the balance between surgical exposure and the amount of tissue
manipulation. Functional, cosmetic, and psychological effects of big
incisions and craniotomies cannot be neglected. Minimally invasive
approaches in skull base surgery are a new frontier in neurosurgery. The
variants of the minisupraorbital craniotomy have proved their value in
achieving adequate and sufficient surgical exposure. However, a ‘‘gold
standard’’ skin incision must be established for the supraorbital frontal
minicraniotomy. The incision must offer sufficient exposure for the
surgeon and a satisfactory cosmetic outcome for the patient. As described
in present article, the eyelid approach is a very interesting alternative and
has the potential to be that gold standard.
Maurı́cio Mandel
Eberval G. Figueiredo
São Paulo, Brazil
T
he authors have provided a very detailed description of this approach
while summarizing the largest case series of its use (at least in the
English literature). This approach has been described on different occasions in the past through the ciliary (eyebrow) or supraciliary incision. The
authors performed an exhaustive data analysis of previous series including
the use of an eyebrow incision1 and even included nonneurosurgical series.
Although the eyelid incision is new to the neurosurgeon’s armamentarium, it is certainly not a completely new description in neurosurgical
literature.2 It is a valuable retrospective study of a series that includes
ruptured aneurysms and intra-axial low frontal lesions. The mastery of
the technique has allowed the authors to expand the indications of the
approach beyond the more conservative cases it had been described for in
the past. The anatomical description is very detailed, but the paucity of
pictures hinders the visual understanding of the approach. Actual step-bystep pictures of cadaveric dissections or real cases could have enhanced the
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TRANSPALPEBRAL ‘‘EYELID’’ APPROACH
explanations but can be found in the Andaluz et al2 article. Additionally,
the amount of subfrontal retraction or tolerable ocular globe pressure
could have been addressed in more detail. Overall, the article is a very
valuable contribution to the literature that could influence today’s and
future neurosurgeons toward more minimally invasive and cosmetically
conscious surgeries. We think it represents a great effort to expand the use
of the approach with great results. It is noted that all surgeries were
performed with an oculoplastic surgeon as part of the team. A multidisciplinary team is paramount in our view to achieve the authors’ results.
This should be emphasized as part of the future application of the
described technique until or unless it becomes a part of the neurosurgeon’s
armamentarium, as occurred with orbitozygomatic osteotomy, another
previously ear, nose, and throat/oculoplastic technique. Emphasis should
also placed on the steep learning curve for this technique and the careful
patient selection, depending not only on the formal indication but also
on the level of confidence of the particular neurosurgeon in minimally
invasive techniques, especially for ruptured aneurysms.
Raul Olivera
Harry van Loveren
Tampa, Florida
1. Perneczky A. Surgical results, complications and patient satisfaction after supraorbital craniotomy through eyebrow skin incision. Paper presented at: Joint
Meeting mit der Ungarischen Gesellschaft für Neurochirurgie Deutsche Gesellschaft für Neurochirurgie (DGNC); April 28, 2004; Koln, Germany.
2. Andaluz N, Romano A, Reddy LV, Zucarello M. Eyelid approach to the anterior
cranial base. J Neurosurg. 2008;109(2):341-346.
T
he aim of modern neurosurgery is to achieve maximum satisfaction
among patients according to the best possible operative result and
minimal operation-related harm. Axel Perneczky, a pioneer of minimally
invasive neurosurgery, realized this goal with the use of limited keyhole
craniotomies.1 Van Lindert et al2 described the supraorbital minicraniotomy through an eyebrow skin incision in 1998; Steiger et al3 in
2001 reported a basal-placed limited transorbital approach through
a frontotemporal hairline incision, both operating on vascular lesions of
the anterior fossa. The innovative technique presented here offers
a similar minimally invasive concept but uses a special eyelid incision that
allows cosmetically favorable results. A precondition of this technique is
surgical skill in skull base surgery, thus avoiding intracranial complications, and interdisciplinary cooperation for minimal approach-related
traumatization of the orbital content.
Robert Reisch
Zurich, Switzerland
NEUROSURGERY
1. Perneczky A, Fries G. Endoscope-assisted brain surgery, part 1: evolution, basic
concept and current technique. Neurosurgery. 1998;42(2):219-224.
2. van Lindert E, Perneczky A, Fries G, Pierangeli E. The supraorbital keyhole
approach to supratentorial aneurysms: concept and technique. Surg Neurol.
1998;49(5):481-489.
3. Steiger HJ, Schmid-Elsaesser R, Stummer W, Uhl E. Transorbital keyhole approach
to anterior communicating artery aneurysms. Neurosurgery. 2001;48(2):347-351.
T
he authors describe their experience with a minimally invasive
approach to the anterior skull base through a transpalpebral eyelid
incision. The approach achieves somewhat wider access than the eyebrow
minicraniotomy, particularly to the medial anterior fossa floor, with the
skin incision placed in the eyelid rather than the eyebrow. This kind of
approach is becoming increasingly popular with the trend toward more
minimally invasive procedures, but it poses a dilemma. It involves
replacing a longer incision located behind the hairline and well away
from eloquent structures with a shorter one but on the face and close to
eloquent structures. At the other end of the spectrum lies the more
invasive but well-tolerated bicoronal scalp flap favored by many neurosurgeons and maxillofacial surgeons for approaching the anterior skull.
Between are variations on the single-sided pterional craniotomy. The
present authors and others who have published on the eyebrow approach
have demonstrated that minimally invasive approaches can be done safely
with good cosmetic results. No one can be dogmatic about the relative
merits of the different strategies; the choice between them depends many
factors including these 3 points.
1. Minimally invasive anterior skull base approaches provide restricted
surgical access. This is perfectly adequate for safe and effective surgery,
but only if the approach has been carefully matched to the pathology
with preoperative planning. The value of this article is a minimally
invasive approach to the anteriomedial skull base. Conventional
approaches are less demanding of the accuracy of this preoperative
planning.
2. Such approaches can be done safely and with excellent cosmetics
but are demanding of skill, experience, and attention to detail and are
unforgiving of complications, more so than conventional approaches.
3. These approaches tend to have a greater reliance on specialized
equipment, and the skills to use it effectively, than more conventional
approaches.
These approaches deserve consideration by surgeons involved in this
area, but whether to adopt them depends on locally available skills,
teams, and facilities and is a matter for careful individual judgment.
Patrick Mitchell
Newcastle, United Kingdom
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