Alternative Transpalpebral “Eyelid” Approach for Supraorbital Frontal Craniotomy and Access to the Anterior Cranial Fossa

Abstract

PURPOSE: The transpalpebral “eyelid” approach is a novel alternative to the traditional incisions for supraorbital frontal craniotomy and access to the anterior cranial fossa. Using the natural skin folds of the eyelid, the transpalpebral incision mitigates visible scars to improve postoperative esthetic outcomes. Although this type of approach has been described in the neurosurgery literature, this is the first report of such a surgical technique in the plastic and reconstructive surgery literature for accessing the anterior cranial fossa. Herein, we elucidate our unique surgical technique and results for this approach to the anterior cranial fossa. METHODS: A retrospective review was performed of patients who underwent supraorbital frontal craniotomy using an anterior skull base approach with transpalpebral exposure over 7 years by a single plastic surgeon (D.A.S.). Surgical techniques, medical comorbidities, intraoperative complications, and long-term complications were assessed. Pre- and postoperative imaging were evaluated. RESULTS: Nineteen patients (mean age, 52 ± 12 years, 52% male, 48% female) underwent supraorbital frontal craniotomy using an anterior skull base approach with upper transpalpebral exposure. In terms of operative indications, 80% (15) had anterior communicating aneurysms with a mean aneurysm size of 5.36 ± 1.91 mm, 10% (2) had meningiomas, 5% (1) had a dural fistula, and 5% (1) had an orbital hemangioma. Notably, 58% (11) had a smoking history. No intraoperative complications were encountered, and no cases were converted to traditional open approaches. Mean length of hospital stay was 3.3 ± 1.5 days. Postoperative imaging revealed no residual or recurrent aneurysms, meningiomas, fistulas, or hemangiomas. Mean follow-up time was 47.1 ± 28.4 months. Long-term complications were limited to 2 patients requiring reoperation for esthetic considerations related to palpable hardware with no further sequelae. Specifically, 1 patient had removal of right cranial hardware and cranioplasty with bone paste and temporalis muscle flap advancement, and 1 patient had removal of left cranial hardware and cranioplasty with bone cement. No long-term neurologic complications or infections occurred. CONCLUSION: In conclusion, this transpalpebral technique is an excellent, minimally invasive, and innovative alternative to approach lesions of the anterior cranial fossa. This transpalpebral approach provides dissection in well-defined anatomical planes, affords preservation of the frontalis muscle, avoids injury to the facial nerve branches, and yields superior esthetic outcomes to traditional craniotomy incisions. Furthermore, this novel approach does not limit neurosurgical access or results and led to no neurosurgical complications.