Supraorbital Eyebrow Research Articles

Supraorbital eyebrow keyhole approach for microsurgical management of ruptured anterior communicating artery aneurysm.

The mortality and disability rate of patients with ruptured anterior communicating artery (AComA) aneurysm after bleeding is high. Even with the most advanced treatment methods, the incidence of complications remains high. The purpose of the present study was to determine the efficacy of microsurgery via supraorbital eyebrow keyhole approach (SOEK) in clipping ruptured AComA aneurysms. Between September 2010 and October 2018, 543 patients with intracranial aneurysms were admitted to the Department of Neurosurgery of the Third Affiliated Hospital of Sun Yat-Sen University (Guangzhou, China). Among them, 85 patients with ruptured AComA aneurysm and subarachnoid hemorrhage (SAH) underwent microsurgical clipping via the SOEK approach. In those patients, the clipping rate, complications and clinical efficacy of treatment were evaluated. The average age of the patients was 52.69±9.94 years (range, 28-78 years). The proportions of small, medium and large aneurysms were 83.5, 15.3 and 1.2%, respectively. Procedural complications occurred in 9 cases (10.5%). The occlusion rate of the aneurysms was 98.8%. The average follow-up period was 37.9 (±24.5) months. A total of 81.2% of the patients with SAH had a good clinical prognosisat 1 year (modified Rankin scale score, ≤2). In conclusion, for a skilled and experienced surgeon, SOEK was indicated to be a safe procedure for the treatment of ruptured AComA aneurysms; it provided sufficient intra-operative exposure and a high clipping rate.

Factors determining the side of approach for clipping ruptured anterior communicating artery aneurysm via supraorbital eyebrow keyhole approach

PurposeThe purpose of this study was to review the microsurgical anatomy and clipping of ruptured anterior communicating artery (AComA) aneurysms and to plan and avoid complications before operation. MethodsA total of 523 cases of cerebral aneurysms admitted to the neurosurgery department of the Third Affiliated Hospital of Sun Yat-Sen University from September 2010 to October 2018 were analyzed retrospectively. Among them, 85 patients had ruptured AComA aneurysms. This study was limited to 85 of these cases, whose satisfactory preoperative angiographic diagnostic films can be retrieved from the hospital database system because of the need for detailed review. ResultsWe performed supraorbital eyebrow keyhole approach (SOEK) craniotomy in 85 patients to clip 85 AComA aneurysms, in the setting of subarachnoid hemorrhage (SAH). Patients’ mean age was (52.69 ± 9.94) years (range, 28–78 years). The proportions of small, medium and large aneurysms were 83.5%, 15.3%, and 1.2%, respectively. The average size of the aneurysms was (5.07 ± 2.36) mm. There were 77.8% of patients with inferior aneurysms and 81.3% of patients with superior aneurysms achieved good results. There was a significant correlation between A1 dominance and operation method (p < 0.001). There was no significant relationship between surgical approach and aneurysm projection or A2 plane (p = 0.157 &p = 0.318). ConclusionRegardless of whether the A2 plane is open or closed, the A1 dominant side is still a better choice for accessing AComA aneurysms to avoid dangerous premature bleeding.

Surgical Techniques and the Choice of Operative Approach for Cranioorbital Lesions.

Objectives Cranioorbital lesions present a great challenge for neurosurgeons and ophthalmologists. There is no consensus on the choice of surgical approach. The aims of this study were to investigate 49 cases of cranioorbital lesions and evaluate surgical approaches and outcomes. Patients and Methods A retrospective study was done on 49 patients (51 operations) from 2009 to 2018. Information about the lesion was used to decide whether the supraorbital eyebrow approach (SEA) or pterional approach (PA) was performed. Results Twenty-eight patients had surgical resection using SEA, 21 patients received PA, each group included one case of recurrence, who underwent reoperation via the same approach. SEA provided better cosmetic satisfaction, and a shorter incision than PA ( p < 0.05). There was no significant difference in total resection rates, visual outcomes, recovery of ptosis, and other new surgical-related complications between SEA group and PA group ( p > 0.05). Forty-nine cases of proptosis (94.1%, 49/51) were improved. Thirty-three patients (33/37, 89.2%) who underwent follow-up for longer than 12 weeks had a modified Rankin Scale (mRS) score ≤ 3. Conclusion Surgery is the preferred treatment for cranioorbital lesions, but total resection is difficult. SEA may be a more minimally invasive option for some more limited lesions superior to optic nerve. PA may be more reasonable for the lesion with obvious hyperostosis and more extensive lesions.

The surgical approach for clipping anterior communicating artery Aneurysm

Anterior communicating artery (ACoA) aneurysm, accounts for 30%-35% of all the aneurysm making it one of the most common intracranial aneurysms. Although the Pterional approach is considered as the safe and appropriate method in ACoA aneurysm surgery, temporalis atrophy and injury to a frontal branch of the facial nerve are few inexorable complications. With the advancement of minimally invasive surgery several modified approaches, such as the supraorbital eyebrow incision approach, the minipterional approach, the mini-supraorbital approach, and the lateral supraorbital approach has been recently introduced and has been used as an alternative.

Outcomes After Pterional and Supraorbital Eyebrow Approach for Cranio-Orbital Lesions Communicated via the Supraorbital Fissure—A Retrospective Comparison

The pterional approach (PA) has been used to remove cranio-orbital lesions that have communicated via the supraorbital fissure (SOF). The supraorbital eyebrow approach (SEA) has become increasingly popular as a minimally invasive approach. However, few reports have examined the SEA for cranio-orbital lesions. We assessed the relative advantages, disadvantages, and selection criteria for these 2 approaches. The data from all consecutive patients who had undergone removal of a cranio-orbital lesion that communicated via the SOF using the PA or SEA were analyzed. Of the 25 patients, 13 had undergone surgical resection using the SEA and 12 had undergone resection using the PA. The SEA provided better cosmetic satisfaction, resulted in a shorter surgical time, and required a shorter incision (P < 0.05). Proptosis had improved significantly in all the patients. No significant differences were found in the total resection rates, visual outcomes, recovery of ptosis, or other new surgically related complications between the 2 groups (P > 0.05). All the patients were followed up for an average of 21.9 months. One patient in each group had developed recurrence or progression that required radiotherapy. The disease of the other patients with subtotal resection was stable or atrophic. The SEA provided better cosmetic satisfaction, resulted in a shorter surgical time, and required a shorter incision. The SEA might be a more minimally invasive option for lesions communicating via the SOF without obvious hyperostosis. The PA might be more reasonable for lesions with obvious hyperostosis and more extensive lesions in the cavernous sinus.

Extended Lateral Orbital Craniotomy: Anatomic Study and Initial Clinical Series of a Novel Minimally Invasive Pterional Approach.

Background Of the minimally invasive "keyhole" alternatives to the pterional region, the supraorbital eyebrow approach is the most widely adopted. Yet it can prove disadvantageous when a more direct lateral microsurgical trajectory of attack to the Sylvian fissure and anterior middle fossa are needed. Objective The extended lateral orbital (XLO) approach was designed to be direct and minimally invasive, with the sphenoid ridge at the center of exposure. Methods Five injected cadaver heads were used for anatomic study of the XLO approach. The anatomic course of the frontalis branch of facial nerve was studied in relation to the XLO incision. Following XLO incision, the bone exposure was measured. The intracranial microsurgical exposure was assessed subjectively. Application of the technique in representative clinical operative cases is provided. Results The frontalis nerve was protected in the subgaleal fat pad, with an average minimum distance of 2.3 cm from the XLO incision. The mean calvarial area exposure was 4.95 cm 2 and consistently centered on the sphenoid ridge. Excellent access to ipsilateral Sylvian's fissure, perisylvian regions, and supra-/parasellar structures was possible. The main limitations related to exposure of the posterior Sylvian fissure and the expected limitations of microsurgical instrument manipulation from a smaller craniotomy. Conclusions The XLO approach is a minimally invasive keyhole approach to the pterional region that affords a unique lateral trajectory via a craniotomy centered on the sphenoid ridge. Excellent exposure to properly selected lesions is possible. The incision is at a safe distance from the frontalis branch and shows excellent cosmetic healing.

Letter to the Editor Regarding “Minimally Invasive Approaches for Anterior Skull Base Meningiomas: Supraorbital Eyebrow, Endoscopic Endonasal, or Combination of Both? Anatomic Study, Limitations, and Surgical Application”

Letter to the Editor Regarding “Minimally Invasive Approaches for Anterior Skull Base Meningiomas: Supraorbital Eyebrow, Endoscopic Endonasal, or Combination of Both? Anatomic Study, Limitations, and Surgical Application”

From above or from below? That is the question. Comparison of the supraorbital approach with the endonasal approach. A cadaveric study

Background: Nowadays the endoscopic endonasal approach is increasingly being used to remove craniopharyngiomas, tuberculum sellae meningiomas and other presellar and parasellar lesions and its value in anterior skull base surgery is undisputed. Herein, we assess the relative advantages, disadvantages and feasibility of the keyhole eyebrow approach and the endonasal endoscopic approach in four cadaveric heads for the removal of presellar and parasellar lesions.Methods: We used four cadaveric heads for 12 surgical dissections. The specimens were embalmed with two different techniques. Two bilateral supraorbital endoscopic assisted approaches and one transnasal expanded endonasal approach were performed for each head. We evaluated the feasibility, maneuverability and safety of each approach. We measured the operating room obtained with each approach and the distance from the main structures we reached.Results: The technical feasibility of the endoscopic endonasal transphenoidal approach and the supraorbital eyebrow approach was reproduced in all four cadaveric heads. The transnasal approach gave us a good operating field medial to the two optic nerves and the two carotid arteries anteriorly until the frontal sinus and, posteriorly, the basilar artery, the emergence of the superior cerebellar arteries and posterior cerebral arteries. After performing the supraorbital approach, we viewed a wider field of the anterior skull base and we were able to reach the ipsilateral carotid artery, the optico-carotid recess, the pituitary stalk, the lamina terminalis until the contra lateral optic nerve and carotid artery, keeping a wider angle of maneuverability.Conclusions: Although the endoscopic transnasal approach has developed in leaps and bounds in the last decade, other transcranial approaches maintain their value. The supraorbital endoscopic approach is a minimally invasive approach and seems to be optimal for those lesions wider than 2 cm in the lateral extension and for all the paramedian lesions.

Eyebrow Incision for Combination Supraorbital Minicraniotomy with Orbital Osteotomy: Application to Cranio-Orbital Lesions.

A pterional-orbital or subfrontal-orbital approach is recommended as a surgical treatment in cranio-orbital lesions. We describe a less invasive approach through an eyebrow incision combined supraorbital minicraniotomy and orbital osteotomy for treating some selected cranio-orbital lesions. Sixteen patients with different cranio-orbital lesions were treated using this less invasive approach. Postoperative outcomes were evaluated to shed light on specific parameters related to this approach. The 16 patients with cranio-orbital lesions underwent 17 operations. A total resection was achieved in 11 lesions. All the patients were followed up for 3-54 months. Postoperative proptosis improved in all cases. Five cases of visual impairment were improved, but 4 patients with blindness did not recover. One patient with bitemporal hemianopia recovered. Three patients with ocular dyskinesia did not recover. Two patients had transient cranial nerve III palsy, and 2 patients had cranial nerve VI palsy. One had delayed hydrocephalus. One died 1 year later as a result of pulmonary metastases. One recurred and the patient underwent a second operation. All the patients had a modified Rankin Scale score ≤1 at 12 weeks follow-up. Some selected cranio-orbital lesions can be treated through a supraorbital eyebrow approach with orbital osteotomy. The presence of retro-ocular fat allows the orbital lesions to be classified as a lesion of the intraretro-ocular or extraretro-ocular fat. It is safe to resect the lesion of extraretro-ocular fat from the retro-ocular fat interface. However, the lesion with optic nerve and extraocular muscles involved should be removed from the intermuscular septae.

Minimally Invasive Approaches for Anterior Skull Base Meningiomas: Supraorbital Eyebrow, Endoscopic Endonasal, or a Combination of Both? Anatomic Study, Limitations, and Surgical Application.

Minimally invasive accesses to the anterior skull base include the endoscopic endonasal approach (EEA) and the supraorbital eyebrow approach. These 2 are often seen as competing approaches, not alternative or combinatory approaches. In this study, we evaluated the anatomic limitations of each approach and the combined approach for accessing the anterior skull base. Ten neurovascular injected cadaver heads were used for the study. The supraorbital approach to the anterior skull base was performed on 5 heads, and EEA was done on the other 5 heads. Then, the supraorbital approach was added to the 5 heads receiving EEA. Visualization and surgical limitations were recorded by the ability to perform resection of the crista galli, anterior clinoid, cribriform plate, and planum sellae. The maximal lateral extension of EEA for anterior skull base was the midorbit line anteriorly but narrowing down toward the orbital apex. The limitation of the supraorbital approach was found mostly medial and anterior. Drilling of anterior skull base was impossible medially between the sphenoethmoidal suture and the posterior aspect of the crista galli. The combined approach showed complementary areas of visualization and surgical maneuverability. Three clinical cases were presented to illustrate the indications for the stand-alone supraorbital approach, EEA, and combined approach. The limitations of the EEA when dealing with lateral extension of anterior skull base meningiomas, and the limitations of the supraorbital eyebrow approach for medial skull base drilling and reconstruction, can be overcome by a judicious, anatomically based combination of both approaches.

Role of Endoscopic Skull Base and Keyhole Surgery for Pituitary and Parasellar Tumors Impacting Vision.

Significant advances over the last 2 decades in imaging technology, instrumentation, anatomical knowledge, and reconstructive techniques have resulted in the endonasal endoscopic approach becoming an integral part of modern skull base surgery. With growing use and greater experience, surgical outcomes continue to incrementally improve across many skull base pathologies, including those tumors that impact vision and ocular motility. The importance of the learning curve and use of a multi-disciplinary approach is critical to maximizing success, minimizing complications, and enhancing quality of life in these patients. Realizing the limits of the endonasal route and reasonable use of transcranial approaches such as the supraorbital eyebrow craniotomy, it may br appropriate to consider nonsurgical therapy including various forms of radiotherapy [corrected] and medical treatment options.

The supraorbital eyebrow approach in children: clinical outcomes, cosmetic results, and complications.

The supraorbital eyebrow approach utilizes an eyebrow skin incision to fashion a supraorbital craniotomy for exposure of the subfrontal corridor. This provides anterolateral access to surgical lesions in the anterior cranial fossa, parasellar regions, brainstem, and medial temporal lobe. With use of the endoscope, further areas can be accessed. This approach has been applied effectively in adults, but questions remain about its use in children-specifically with regard to adequate working space, effectiveness for achieving the desired results, cosmesis, and complications. The authors conducted a retrospective review of more than 450 cases involving patients of all ages who had undergone a supraorbital eyebrow approach performed by the senior author (C.T.) from 1995 to 2013. Only cases involving patients younger than 18 years with a minimum follow-up of 6 weeks were included in this study. All inpatient and outpatient records were retrospectively reviewed and clinical/operative outcomes, cosmetic results, and complications were recorded. In the present article, the authors briefly describe the surgical approach and highlight any differences in applying it in children. Fifty-four pediatric patients who had undergone a supraorbital eyebrow approach met inclusion criteria. The pathological conditions consisted mostly of tumors or other resectable lesions. In a total of 51 resectable lesions, 44 surgeries resulted in a gross-total (100%) resection and 7 cases resulted in subtotal (50%-99%) resection. The endoscope assisted and expanded visualization or provided access to areas not reached by standard microscopic visualization in all cases. Cosmetic outcomes were excellent. In all cases, the incisional scar was barely visible at 6 weeks. In 3 cases a minor bone defect was observed on the forehead. Given the small size of the frontal sinus in children, no frontal sinus breaches occurred. Additionally, no CSF leak or wound infection was identified. The supraorbital eyebrow approach is extremely effective in achieving desired results in properly selected cases in patients of all pediatric age ranges, from infants to teenagers. There is sufficient working space for the endoscope and all instruments, allowing for endoscopic assistance and bimanual surgical technique. Cosmetic results are excellent, and complications related to the approach are minimal.

Evolution of minimally invasive approaches to the sella and parasellar region.

Introduction Given advancements in endoscopic image quality, instrumentation, surgical navigation, skull base closure techniques, and anatomical understanding, the endonasal endoscopic approach has rapidly evolved into a widely utilized technique for removal of sellar and parasellar tumors. Although pituitary adenomas and Rathke cleft cysts constitute the majority of lesions removed via this route, craniopharyngiomas, clival chordomas, parasellar meningiomas, and other lesions are increasingly removed using this approach. Paralleling the evolution of the endonasal route to the parasellar region, the supraorbital eyebrow craniotomy has also been increasingly used as an alternative minimally invasive approach to reach this skull base region. Similar to the endonasal route, the supraorbital route has been greatly facilitated by advances in endoscopy, along with development of more refined, low-profile instrumentation and surgical navigation technology. Objectives This review, encompassing both transcranial and transsphenoidal routes, will recount the high points and advances that have made minimally invasive approaches to the sellar region possible, the evolution of these approaches, and their relative indications and technical nuances. Data Synthesis The literature is reviewed regarding the evolution of surgical approaches to the sellar region beginning with the earliest attempts and emphasizing technological advances, which have allowed the evolution of the modern technique. The surgical techniques for both endoscopic transsphenoidal and supraorbital approaches are described in detail. The relative indications for each approach are highlighted using case illustrations. Conclusions Although tremendous advances have been made in transitioning toward minimally invasive transcranial and transsphenoidal approaches to the sella, further work remains to be done. Together, the endonasal endoscopic and the supraorbital endoscope-assisted approaches are complementary minimally invasive routes to the parasellar region.

Endoscopic supraorbital eyebrow approach for the surgical treatment of extraaxialand intraaxial tumors.

The supraorbital eyebrow approach is a minimally invasive technique that offers wide access to the anterior skull base region and parasellar area through asubfrontal corridor. The use of neuroendoscopy allows one to extend the approach further to the pituitary fossa, the anterior third ventricle, the interpeduncular cistern, the anterior and medial temporal lobe, and the middle fossa. The supraorbital approach involves a limited skin incision, with minimal soft-tissue dissection and a small craniotomy, thus carrying relatively low approach-related morbidity. All consecutive patients who underwent the endoscopic supraorbital eyebrow approach were retrospectively analyzed for lesion location, pathology, length of stay, complications, and cosmetic results. During a 56-month period, 97 patients (mean age 58.5 years) underwent an endoscopic eyebrow approach to resect extra- and intraaxial brain lesions. The most common pathologies treated were meningiomas (n = 41); craniopharyngiomas (n = 22); dermoid tumors (n = 7); metastases (n = 4); gliomas (n = 3); and other miscellaneous frontal, parasellar, and midbrain (n = 23) lesions. The median length of postoperative hospital stay was 2.7 days (range 1-8 days). In 82 patients a total removal of the lesion was performed, while in 15 patients a near-total or subtotal removal was achieved. There were no postoperative hematomas, cerebrospinal fluid leaks, or severe neurological deficits, with the exception of 2 cases of visual deterioration and 1 case each of meningitis, stroke, and third cranial nerve paresis. Other complications directly related to the approach included 2 cases of skin burn as a direct result of heat transmission from the microscope light, 1 case of right frontal palsy, 2 cases of frontal numbness, and 1 case of bone remodeling 1 year after surgery. The endoscopic supraorbital eyebrow approach is a safe and effective minimally invasive approach to remove extra- and intraaxial anterior skull base, parasellar, and frontal lesions, promoting a rapid recovery and short hospital stay. The location of the eyebrow incision demands a meticulous cosmetic closure, but, with proper technique, cosmetic results are excellent.

The Supraorbital Approach for Recurrent or Residual Suprasellar Tumors

Suprasellar tumors can be removed through a variety of approaches including conventional frontotemporal craniotomies, the transsphenoidal route, or the supraorbital (SO) eyebrow craniotomy. Herein we assess the utility of the SO route for recurrent or residual suprasellar tumors previously treated by an alternative route. A retrospective analysis of all consecutive patients who underwent an SO approach for removal of a recurrent/residual tumor was undertaken. Between December 2007 and February 2010, 11 patients underwent an SO craniotomy for a recurrent or growing residual tuberculum sellae meningioma (n=7) or craniopharyngioma (n=4). All 11 patients had prior craniotomies, 5 had transsphenoidal surgery, 6 had radiation treatment, and 1 had chemotherapy. In the last 5 cases, the endoscope was used in addition to the microscope for intraoperative visualization. 3 patients underwent decompression of multicystic craniopharyngiomas and the remaining 8 patients had tumor debulking, all achieving 70% or more tumor removal. Of 9 patients with preoperative visual deterioration, 6 (67%) had improvement and no patient had visual worsening. No new adenohypophysis or neurohypophysis dysfunction was noted. One patient had a postoperative CSF leak requiring reoperation. The SO approach should be considered as a safe and effective alternative route for recurrent or residual suprasellar tumors previously treated by conventional craniotomy or TS surgery. It typically offers a simplified trajectory that minimizes scar tissue from prior approaches and provides excellent access for optic apparatus decompression. Endoscopy is helpful to visualize hidden tumor remnants and maximize safe tumor removal.

Supra-orbital keyhole removal of anterior fossa and parasellar meningiomas

The improvement of surgical techniques as well as the introduction of new surgical instruments promoted the use of keyhole craniotomies in neurosurgery. We evaluated the technical aspects of the supra-orbital keyhole approach considering the indications, limitations, and complications of this approach to treat anterior cranial fossa and parasellar meningiomas. Twenty-four patients (21 females; mean age, 53 + or - 8.6 years) operated on between 2002 and 2006 through a supra-orbital eyebrow approach were studied. Maximal tumor diameter ranged from 1.6 to 6 cm. Gross total resection was done in 20 (83.3%). All tumors were histologically benign. Two patients (8%) experienced CSF rinorhea and another two patients suffered transitory diabetes insipidus (8%). One patient experienced transitory hemiparesis. There was one case of meningitis and one mortality. Follow-up ranged between 6 to 66 months (mean 31.5 + or - 20.1 months), with no recurrence. The supra-orbital keyhole craniotomy is a useful minimally invasive approach to treat selected anterior fossa and parasellar meningiomas.

The Supraorbital Subfrontal Approach through an Eyebrow Skin Incision for Treatment of Anterior Cranial Fossa and Suprasellar Pathologies

We report our experience with a supraorbital eyebrow minicraniotomy. This technique is suitable for lesions situated in the region of the anterior fossa, suprasellar cisterns, parasellar region, and sylvian fissure. We have been using the supraorbital keyhole craniotomy since 1998 and have approached eight various lesions within the anterior cranial fossa and suprasellar space. Of the eight patients, six were treated for cranial base meningiomas, one for craniopharyngioma, and one for chiasmatic glioma. The approach has not been used for vascular pathologies. Except for the case of chiasmatic glioma, the total removal of the lesion was achieved in all cases and has been confirmed with mean 2.5-year follow-up MRI controls. The supraorbital craniotomy offers equal surgical possibilities with less approach-related morbidity owing to limited exposure of the cerebral surface and minimal brain retraction. In addition, the short skin incision within the eyebrow and careful soft-tissue dissection result in a pleasing cosmetic outcome.

Supraorbital eyebrow approach to skull base lesions.

We report our experience with a supraorbital eyebrow minicraniotomy. This technique is suitable to lesions situated in the region of the anterior fossa, suprasellar cisterns, parasellar region and Sylvian fissure. A 50 mm incision in the eyebrow and a supraorbital minicraniotomy is performed. Sixteem patients harboring different lesions were operated on with good postoperative and cosmetic results. We conclude that this approach is safe and useful in selected cases.

口腔内アプローチ法による頬骨骨折手術における術中超音波断層検査法の有用性

Generally, en bloc zygomatic fractures are treated by open reductionwith incisions of theinfraorbital rim and supraorbital eyebrow regions. However this method is associated with postoperativecomplications such as facial scars. An intraoral approach requiring only a maxillary vestibular incision, has been reported in several articles. This method is simple and results in adequate bone reduction and fixation. However, the position of bone fragments in the infraorbital rim cannot be observed. We used anintraoral approach, during intraoperative ultrasonic examination to confirm the condition of infraorbitalfragments in 17 patients who had simple en bloc fractures of the zygoma bone body. Ultrasonographyshowed dynamic bone reduction as distinct real-time images and bone fixation was performed exactly. Inselected patients the intaroral approach during ultrasonography, is recommended for en bloc zygomaticfractures.

眉毛切開と上顎口腔前庭切開を用いた頬骨骨折の治療

The treatment of tetrapod zygomatic fractures is generally preceded by open reduction and fixation by means of supraorbital eyebrow and infraorbital incisions. However, fixation of the infraorbital rim does not produce adequate stability of the fractured zygoma owing to the thinness of this bone. We used open reduction and fixation via a supraorbital eyebrow incision and an intraoral approach in three cases of zygomatic fracture. The advantage of this intraoral approach is that it allows reduction under direct vision and provides sufficient stability after mini-plate fixation. Consequently, satisfactory results were obtained.