The Transpalpebral Versus the Transciliary Variant of the Supraorbital Keyhole Approach: Anatomic Concepts for Aneurysm Surgery

Abstract

BACKGROUND The supraorbital craniotomy (SOC) is classically performed through a skin incision in the patient's eyebrow. A variant with a skin incision in the patient's eyelid has become increasingly popular in recent years. OBJECTIVE To compare the transpalpebral and the transciliary variants of the SOC with regard to their potential role in aneurysm surgery. METHODS We carried out cadaveric dissections and virtual craniotomies on computerized tomography datasets. The skin incision, the craniotomy location and size, the working angles, and the achievable exposure of neurovascular structures were assessed and compared for both variants of the SOC. RESULTS The skin incision measured 4 cm for the transpalpebral and 3 cm for the transciliary variant. The skin could be retracted 1.5 cm upward from the lower edge of the orbital rim with the transpalpebral and 2.5 cm upward with the transciliary variant. The craniotomy size was 2.5 × 1.5 cm for both variants, given that the transpalpebral variant included an orbital osteotomy. The bony opening in the transpalpebral variant was 1 cm more caudal; this restricted the craniocaudal working angles and, thereby, limited the achievable exposure of neurovascular structures in the paraclinoid area and along the sphenoid ridge. CONCLUSION If the orbital rim and the anterior aspect of the orbital roof are removed, then the transpalpebral variant of the SOC enables a bony opening that is just as large as that of the transciliary variant. Nonetheless, the more caudal location of the bony opening alters the available working angles and may impede exposure of key structures during aneurysm surgery.

Cosmetic Outcomes of Supraorbital Keyhole Craniotomy Via Eyebrow Incision: A Systematic Review and Meta-Analysis

“…In a cadaveric study by Rychen and colleagues, the authors found that addition of orbital rim osteotomy to a trans-eyebrow approach increased the vertical extent of the craniotomy from 1.5 to 2.5 cm. 132 Cavalcanti and colleagues performed supraorbital keyhole craniotomy on cadaveric heads and found that addition of orbital rim osteotomy significantly increased surgical freedom and working angles to common sites of anterior circulation aneurysms, with the greatest increases for anterior communicating artery and posterior communicating artery targets. 135 Rychen and colleagues reported that the transpalpebral approach requires removal of the orbital rim, because without orbital osteotomy the skin can be retracted superiorly to provide only 0.5 cm of vertical working space, but a trans-eyebrow approach without additional orbital rim osteotomy affords wider working angles toward the anterior clinoid process compared with the transpalpebral approach with orbital rim osteotomy.…”

“…135 Rychen and colleagues reported that the transpalpebral approach requires removal of the orbital rim, because without orbital osteotomy the skin can be retracted superiorly to provide only 0.5 cm of vertical working space, but a trans-eyebrow approach without additional orbital rim osteotomy affords wider working angles toward the anterior clinoid process compared with the transpalpebral approach with orbital rim osteotomy. 132 Despite the increased working angles afforded by this modification, orbital osteotomy is infrequently used and was reported in only 8.1% of cases. In our recent systematic review of supraorbital keyhole craniotomy via eyebrow incision, an 83.6% technical success rate, defined as gross total tumor resection or complete aneurysm obliteration via clipping, was achieved despite rare inclusion of orbital osteotomy.…”

“…131 An orbital osteotomy can be added to the supraorbital craniotomy to increase the angle of exposure, and is necessary if using an eyelid incision. 132 In patients with prominent frontal sinuses, the craniotomy can purposefully enter the sinus and a soft tissue graft is often needed to obliterate the lateral sinus and maintain its patency/function. Once intradural, the primary variation described is the use of an endoscope.…”

The Supraorbital Approach via an Eyebrow Incision: Analysis of Cosmetic Outcomes Using the Scar Cosmesis Assessment Rating Scale

“…33,34 This approach, often performed with the expertise of an oculoplastic or craniofacial surgeon present, offers good cosmetic outcomes with the scar hidden in the eyelid crease. 32,33 Rychen et al 35 compare the transpalpebral and supraciliary approach with the use of cadavers and virtual craniotomies, finding that the transpalpebral approach restricts the craniocaudal working angle during surgery. This study reported excellent cosmetic outcomes with both approaches but mentioned that the transpalpebral approach may have superior outcomes in older patients with thinning eyebrows and more pronounced supratarsal folds.…”

Anatomic and Surgical Considerations in the Management of a Sellar and Suprasellar Arachnoid Cyst: 2-Dimensional Operative Video

“…By going through a transcranial route, we circumvented these problems and were able to achieve wide fenestration into multiple basal cisterns. [7][8][9] In this video, we discussed how the goal of surgery, the particular characteristics of the lesion, and anatomic features of the patient should dictate the surgical approach. The patient consented to the procedure and to the publication of her images.…”