Eyebrow incision for combined orbital osteotomy and supraorbital minicraniotomy: application to aneurysms of the anterior circulation - Technical note

A modification of the supraorbital keyhole approach, the eyebrow incision-m inisupraorbital craniotomy with orbital osteotomy, is described. Unique to this approach is a one-piece supraorbital craniotomy, measuring 2.5 x 3.5 c m, that incorporates the orbital rim and roof and the frontal process of th e zygomatic bone through an eyebrow incision. The orbital osteotomy facilit ates view of the anterior and middle cranial fossa through the operating mi croscope, as well as the maneuverability of instruments through a small cra niotomy. A pericranial flap is elevated with its base at the orbit and used for closure of the frontal sinus, if necessary. The approach was used succ essfully in elective surgery of 10 aneurysms of the anterior circulation. T he mean aneurysm size was 5.9 mm, with a range of 4 to 10 mm. Advantages of this approach include minimal disruption and exposure of normal brain tiss ue, reduced frontal lobe retraction, and an excellent postoperative cosmeti c result. The approach is performed quickly by virtue of a limited skin inc ision with minimal temporalis muscle dissection and a small bone flap. The neuroendoscope, although helpful at times, is not essential and no special instruments or intraoperative image guidance is required. Relative contrain dications include the presence of a large frontal sinus, severe brain edema , and recent subarachnoid hemorrhage. In addition, this approach has not be en used for the treatment of giant intracranial aneurysms.