Supraorbital Eyebrow Approach: A Contemporary Case Series

Introduction: The supraorbital eyebrow approach provides surgical access to a wide range of pathologies and is a useful salvage approach for patients who have undergone prior endoscopic endonasal approaches (EEA). We investigate the indications and outcomes in a series of 49 cases conducted at a single tertiary institution.

Methods: We retrospectively reviewed institutional records of patients who underwent a supraorbital eyebrow craniotomy from 2011 to 2018. Patient demographics, preoperative indications, surgical details, pathology, and postoperative complications were analyzed.

Results: Forty-nine patients (mean age: 51 years, 63.3% female) were included in the analysis. There were 13 left-side and 36 right-side craniotomies utilized for the following indications: meningiomas (n = 14), pituitary adenomas (n = 10), craniopharyngiomas (n = 6), suprasellar Rathke’s cleft cysts (n = 3), chordomas (n = 2), metastases (n = 2), and traumatic frontal sinus fractures (n = 2). Additional miscellaneous lesions included one each of cavernous hemangioma, hematoma, arachnoid cyst, hemangiopericytoma, reactive gliosis, inflammatory tissue, ependymoma, fibrous dysplasia, cerebral cyst, and mucocele. In 49% of cases, the supraorbital approach was used as a salvage operation in patients with prior surgery. Preoperative symptoms included vision loss (81.6%), headache (51.0%), and gait imbalance (10.2%). In nine cases, the surgery was endoscopic-assisted. Fifteen patients (30.6%) underwent gross total resection, 28 (57.1%) subtotal resection, 2 (4.1%) biopsy, 2 (4.1%) cyst fenestration, and 2 (4.1%) fracture repair. Postoperative complications included 1 postoperative CSF leak, 2 cases of intraventricular hemorrhage (1 requiring external ventricular drain placement and 1 requiring evacuation), 2 infections, and 1 case of transient left-sided weakness due to MCA vasospasm. The median length of postoperative hospital stay was 5 days. Vision improved in 42.5% of patients with preoperative vision loss, and headaches improved in 32% of patients with preoperative headache. Over the follow-up period, there were 3 cases of tumor recurrence and 2 with progression; 4 patients required reoperation, 4 were readmitted, and 1 died.

Conclusion: The supraorbital eyebrow approach is effective in the management of a variety of anterior skull base pathologies, including tumors, fractures, as well as cystic, hemorrhagic, and inflammatory lesions. The supraorbital approach can be used as an effective salvage approach for reoperation in patients with complex suprasellar and anterior skull base disease who have undergone prior EEA. Despite this, a significant rate of symptomatic improvement was seen.