11 Supraorbital Approach The supraorbital approach is a frontal approach, which is suitable for the unilateral exposure of the anterior skull base. The surgical route corresponds to the anatomical corridor seated between the inferior aspect of the frontal lobe and the floor of the anterior cranial fossa. The approach is mainly indicated in case of vascular lesions of the anterior circulation as well as of lesions involving the anterior skull base as well as the parasellar areas. • Anterior circulation aneurysms. • Anterior skull base meningiomas. • Parasellar tumors (e.g., craniopharyngiomas). • Less common: posterior circulation aneurysms, inferior frontal pathology. • Position: Patient is positioned supine in a 20° of reverse Trendelenburg position. • Head: The head is extended 20°, rotated 5°-15° to the contralateral side for most pathology; for anterior lesions near the midline (e.g., olfactory groove meningiomas) rotation may be up to 60°. • The malar eminence is the highest point in the surgical field. • Ipsilateral temporary tarsorrhaphy is performed to protect the cornea. • Slightly curved incision ◦ Starting point: Incision starts just medial to supraorbital notch. Fig. 11.1 Patient positioning. Fig. 11.2 Planned incision through the eyebrow, running from just medial to the supraorbital notch to the edge of the brow. If more medial access is necessary, care should be taken to preserve the supraorbital nerve, which can be found deep to the frontalis muscle. ◦ Course: Incision line runs within hair-bearing skin of the eyebrow. ◦ Ending point: It ends at the lateral edge of the brow (may be extended up to 1 cm). • Supraorbital nerve • Myofascial and muscular layers ◦ The frontal muscle is divided with monopolar electrocautery along the path of the incision. ◦ Usually this does not need to extend medially to the supraorbital notch. Fig. 11.3 Muscle dissection: frontal muscle is divided in the plane of the incision.
11.1 Introduction
11.2 Indications
11.3 Patient Positioning (Fig. 11.1)
11.4 Skin Incision (Fig. 11.2)
Abbreviations: FH = forehead; N = nose; RE = right eye; SN = supraorbital notch.
11.4.1 Critical Structures
11.5 Soft Tissue Dissection (Figs. 11.3–11.5)
Abbreviations: FH = forehead; FM = frontalis muscle; N = nose; RE = right eye.
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