Minimally Invasive Transpalpebral “Eyelid” Approach to the Anterior Cranial Fossa: Experience with 58 Cases

Introduction: The concept of minimally invasive approaches for anterior circulation aneurysms has been evolving during the past two decades. A supraorbital frontal mini-craniotomy with or without including the orbital ridge is the commonly used approach.

Material and Methods: We describe our experience with the transpalpebral “eyelid” incision, which uses 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 aneurysms and 18 tumors).

Results: Extracranial drilling of the greater sphenoid wing exposes the frontal dura, temporal dura, and periorbita “spheno-orbital keyhole.” A one-piece fronto-orbital craniotomy is performed in all cases with bone flap approximately 2.5 cm high. 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. We describe the approach and the technique in step-by-step fashion, and we discuss the results of our 58 cases as well as the advantages of the transpalpebral approach. This is the largest series published in the literature on using the unique eyelid approach with excellent cosmetic outcome in 56/58 patients. Seven complications were: one radiological stroke without deficit, one eyelid hematoma, one superficial infection, one deep infection, and three CSF leaks.

Conclusion: The transpalpebral approach provides dissection in natural anatomical planes, preserving frontalis muscle; avoids injury to VII nerve branches; and results in excellent cosmetic outcome.