Orbitozygomatic Craniotomy via Eyebrow Incision: Management of Opened Frontal Sinus

Background: The eyebrow orbitozygomatic craniotomy is a versatile, minimally invasive approach utilized to access the anterior skull base, basal frontal and temporal lobes, suprasellar region, circle of Willis, and ventral midbrain with no fixed brain retraction. Unintentional breach of the frontal sinus frequently occurs and has been cited as a reason to avoid this approach. Lack of access to a large pericranial graft and the inability to completely cranialize the sinus require alternate techniques of repair. We describe a technique for repairing an opened frontal sinus that includes peeling in local sinus mucosa, packing betadine soaked Gelfoam into the sinus, covering the opening with dural substitute and fibrin glue, and medializing the bone flap.

Methods: All patients who underwent an orbitozygomatic craniotomy via an eyebrow incision by a single surgeon from August 1, 2012, to August 31, 2018, were included in this retrospective analysis of patients’ medical records. Data were collected on patient demographics, pathology treated, operative details, and perioperative and 30 day morbidity.

Results: A total of 47 patients with a wide variety of pathologies underwent analysis. The frontal sinus was breached in 21 patients (42.9%). All patients with an opened frontal sinus were treated as described above. One patient (ruptured aneurysm) had a suspected CSF leak postoperatively treated by a single high volume lumbar puncture. No patient suffered any infection, wound healing problem, complication related to approach or delayed CSF leak.

Conclusion: Breach of the frontal sinus is common during orbitozygomatic craniotomies via an eyebrow incision. Despite reduced options for local repair, these patients have experienced no long-term or delayed CSF problems. Breach of the frontal sinus is not a contraindication to the eyebrow approach nor should it limit the size of the craniotomy to less than what is needed for adequate exposure.