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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. VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons195 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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. www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons197 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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). ons198 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 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 www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons199 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 ons200 | VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 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. www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons201 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons203 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons205 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 www.neurosurgery-online.com Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited. 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 VOLUME 69 | OPERATIVE NEUROSURGERY 2 | DECEMBER 2011 | ons207 Copyright © Congress of Neurological Surgeons. Unauthorized reproduction of this article is prohibited.