Minimally Invasive Eyelid Incision Fronto-Orbital Craniotomy Approach to the Anterior Cranial Fossa: Lessons to Learn in Fifty-Eight Cases

Introduction: The concept of minimally invasive approaches for anterior crania fossa has been evolving during the past two decades. Supraorbital frontal mini-craniotomy with or without including orbital ridge is the commonly utilized approach. The eyelid incision fronto-orbital craniotomy has been recently introduced to neurosurgery skull base literature.

Material and Methods: We describe our experience with a transpalpebral “eyelid” incision, which utilizes the natural upper eyelid crease to obtain access to the anterior cranial fossa through the subfrontal-supraorbital corridor. This approach minimizes the cosmetic problems with the supraciliary or transciliary incisions. The eyelid approach reduces risk of injury to the frontalis branch of the facial nerve.

We will review our experience with 58 cases (40 anterior circulation aneurysms and 18 anterior skull base tumors). In all patients, eyelid layers incision and closure were performed by an oculoplastic neuro-ophthalmologist.

Results: Extracranial drilling of the greater sphenoid wing exposes the frontal dura, temporal dura, and peri-orbital “spheno-orbital keyhole,” which is the starting point for the one-piece eyelid fronto-orbital craniotomy. The bone flap performed in all cases was about 2.5 cm high. Anterior clinoidectomy and optic foraminotomy were performed, when indicated, without any difficulty or side effects. After the dura is opened, a panoramic view of the anterior cranial fossa floor is achieved, extending from the contralateral to the ipsilateral oculomotor nerve. Lumbar draining was encountered in all the 58 patients at the beginning of the procedure and was usually removed on postoperative day three. We will describe the approach and technique in step-by-step fashion, discussing the clinical and cosmetic results of our 58 cases, as well as the advantages of the transpalpebral approach. This is the largest series to be published in the literature utilizing the unique eyelid approach with excellent cosmetic outcome (no noticeable eyelid asymmetry with excellent healing and barely visible lateral edge of the incision, which gradually starts to fade after 3 months) in 56/58 patients. Seven complications were: one radiological stroke without deficit, one eyelid hematoma that required surgical evacuation, one superficial infection treated with systemic antibiotics, one deep infection that required surgical drainage, and three CSF leaks (two resolved with keeping the lumbar drain for total of 7 days postoperatively, and one required re-operation).

Conclusion: The transpalpebral “Eyelid” 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, preserves frontalis muscle fibers, avoids injury to the fronto-temporal facial nerve branches, and heals with excellent cosmetic results.