Surgical Limitations of the Supraorbital “Eyebrow” Approach: From the Anterior Fossa to the Middle Fossa

Background The supraorbital “eyebrow” craniotomy is a popular keyhole approach to various neoplasms and vascular lesions. However, its limitations for lesions extending anteriorly to the anterior fossa or laterally into the middle fossa have not been clearly defined in the literature.

Objectives The aim of this study is to evaluate the anterior and middle fossa limitations of the supraorbital eyebrow approach.

Methods Five silicone-injected cadaveric specimens were used for dissection. The supraorbital approach was performed on both sides of each specimen with the use of a surgical microscope and image guidance.

Results The anterior fossa limit of the supraorbital “eyebrow” approach using a microscope for drilling was the sphenoethmoidal suture. The posterior part of the crista galli was the anterior limit that could be visualized and dissected using the microscope but could not be drilled.

The cribriform plate could not be exposed or drilled to access the olfactory clefts.

The lateral limits of this approach were as follows: inferiorly, the superior orbital fissure extending to the lateral wall of the cavernous sinus at the level of V1, and posteriorly, the lateral corner of the oculomotor triangle (the intersection of the anterior and posterior petroclinoid dural fold).

Conclusion The microscopic supraorbital eyebrow approach offers excellent but limited access for total resection of pure anterior fossa lesions that do not extend anterior to the sphenoethmoidal suture or with limited extension into the middle fossa. Being aware of these surgical limitations will help surgeons choose the most suitable lesions for this approach.