The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution

Abstract

In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital "keyhole" approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration.

Figure 1

(a) Preoperative and (b) postoperative MR images of a homogeneously enhancing mass involving the tuberculum sellae and planum sphenoidale. Pathology was meningioma. Gross total resection was achieved.

Figure 2

(a) Preoperative and (b) postoperative MR images of a homogenously enhancing mass involving the planum sphenoidale. Pathology was meningioma. Gross total resection was achieved.

Figure 3

(a) Preoperative and (b) postoperative MR images of a heterogeneously enhancing cystic mass involving the sella and suprasellar region. Pathology was consistent with craniopharyngioma. Near-total resection was achieved. (c) Microscopic images from surgery demonstrate optic nerve (ON) and its relationship to tumor (T). (d) Comparison image from endoscopic view in the same patient now demonstrating both optic nerves (ON) and infundibulum (I) following tumor resection. Note the wider field of view, greater visibility, and contrast at depth. There is also significantly less blur from anatomy obscuring view superficial to focal point as clearly noted in microscopic image (c).

Figure 4

(a) Preoperative image of planned right eyebrow incision and (b) six-week postoperative image in the same patient. (c) Illustration of supraorbital craniotomy through an eyebrow incision. The incision is within the eyebrow (white), lateral to the supraorbital nerve (S) and frontal sinus (FS). The temporalis (T) is separated just posterior to the zygomatic process for the burr hole. Bone flap is approximately 1.5 × 2 cm (B). (d) Illustration after opening demonstrating dural opening (D), retracted frontal lobe (FL). The orbicularis oculi muscle (M) is reflected inferiorly with the pericranium.