J Neurosurg 77:959-961, 1992
A two-step supraorbital approach to lesions of the orbital apex Technical note ROBERTO DE1,FINI, M.D., ANTONINO RACO, M.D., MARCO ARTICO, M.D., MAURIZIO SALVATI, M.D., AND PASQUALE CIAPPETTA, M.D. Department (~/ Neuro/ogica/ Sciences. Neurosurgerv, and Chair ~?/Human Anatomy, Faculty of Pharmao,, University (~["Rome "La Sapienza, ""Rome, lta@
~" A two-step supraorbital approach to lesions of the orbital apex is described. This technique is easy and allows a satisfactory exposure of the region. In addition, the reconstruction resulting from the procedure is anatomically perfect. The authors report the operative results obtained in 20 patients and compare this twostep supraorbital procedure with similar surgical techniques described previously. KEY WORDS bone flap 9 orbit 9 orbitotomy supraorbilal approach ' surgical approach
HE range of surgical approaches to the orbit currently available includes Iateral orbitotomy and its modifications 34~ and the anterior approach devised by Knapp 7 and popularized by Benedict;-" despite these, standard transcranial orbitotomy ~2 still retains its value for deep lesions of the medial part of the orbit, for the orbital apex, and for lesions extending intracranially. We propose an alternative technique with two bone flaps (Fig. 1), the first in the frontal bone and the second in a segment comprising the supraorbital rim and the orbital roof. The orbital roof is then removed en bloc and replaced. We describe this technique and report the results obtained in 20 patients treated with this method between June, 1985, and April, 1990.
T
9 reconstructive surgery
'
from the supraorbital notch using either a Kerrison rongeur or a high-speed microdrill. The periorbita is freed from the orbital roof and depressed with the aid of a large brain spatula. Two cuts are then made with a high-speed microdrill through the medial part of the
Operative Technique
A standard bicoronal incision is made and the scalp is elevated together complete with the pefiosteum down to the orbital rim. Four burr holes are drilled in the frontal bone; of the lower two, one is placed over the orbital rim and the other anteriorly in the temporal fossa near the temporal crest. The Gigli saw is used to connect the four burr holes. When the frontal sinus is invaded, which is a frequent occurrence in this procedure, it is exenterated, packed with muscle, and sealed with a layer of pericranium and fibrin glue. The supraorbital neurovascular bundle is identified and freed J. Neurosurg. / Volume 77/December, 1992
FIG. I. Photograph showing a frontal view of the osteotomy lines used during the two-step supraorbital approach. 1 = The first bone flap made via a right frontal craniotomy, with the burr holes and saw cuts clearly indicated; 2 = the second bone flap. 959
R. Delfini, el aL
Fie;. 2. Photograph showing an intracranial view of the osteotomy line used in creating the second bone flap, which includes a good portion of the right orbital roof.
FIG. 3. Photograph showing a frontal view of the second bone flap and clearly illustrating the extension of the osteotomy into the right orbital roof.
frontal rim and through the zygomatic process of the frontal bone. The microdrill is used from a superior direction after the first bone plate has been removed and the dura overlying the orbit has been retracted. The osteotomy line is continued posteriorly toward the orbital apex in the anterior cranial fossa with a microspeed air drill (Fig. 2) while the orbital content is being protected with a spatula. Osteotomy is completed by means of a scalpel. This second bone flap is removed en bloc (Figs. 3 and 4). At this point, the entire roof of the orbit up to the apex is exposed, giving the surgeon a choice of access. Once the lesion has been removed, the osseous segments are replaced and easily joined with silk sutures placed in the external orbital rim. Reconstruction by this method is anatomically perfect.
roof is far from easy, certainly more difficult than methods involving the removal of the orbital roof alone (without removal of the superior orbital arch). The advantage of methods like the one currently reported, which involves removal of the arch as well as the orbital roof, is wider exposure of the orbital contents. In our early cases of orbital lesions, we used the technique of Jane, et al.,6 but in our hands it sometimes proved troublesome. We had difficulty inserting the Gigli saw guide between the frontal and temporal burr holes. There was also the risk of tearing the dura mater, which often complicated this procedure, and the exposure obtained was at times still inadequate, necessitating
Discussion The desirability of gaining wider access to lesions of the orbital apex via a transcranial route j5-7'9'11'~3 with simultaneous reconstruction of the orbital roof has been propounded in many reports published in the past few years. In the past, several authors saw no point in reconstructing the orbital roof after it was removed. Today, however, it is common practice to reconstruct the roof in order to avoid transmission of the pulse wave of the cerebrospinal fluid to the eyeball, to prevent postoperative cicatricial adhesions between the periorbita and the dura mater that might cause problems in a second surgical operation, and to avoid an iatrogenic enophthalmos. Materials used for this purpose include acrylic cement and metal plates 4 as well as bone autografts obtained from the frontal bone flap, as suggested by Marchac, et al. ~o Both types of material have drawbacks, however. Acrylic cement and metal plates are heterologous materials and, when possible, we avoid them. On the other hand, the grafting procedure described by Marchac, el al., is laborious and time-consuming. In addition, the fixation of plastic prostheses or of bone autografts to the bone margins of the orbital 960
FIG. 4. Upper."Photograph showing a frontal view of the isolated second bone flap, including the anterior wall (arrows) and a part of the lateral wall (arrowheads) of the right orbit. Lower: Photograph showing an overhead view of the second bone flap, including the anterior wall (arrows) and a part of the lateral wall (arrowheads) of the fight orbit. A portion of the orbital roof (asterisk) is clearly visible. J. Neurosurg. / Volume 77/December, 1992
Supraorbital approach to orbital lesions removal of the remainder of the orbital roof with bonecutting forceps. We therefore developed the technique described here and have been using it since 1985. A not dissimilar technique had been published in 1974. 5 Although we cut two bone flaps, our procedure has several advantages over other recently proposed techniques. It is easier to perform than the operations of Jane, et al./' or AI-Mefty, ~in which the maneuvers for raising the single bone flap are always laborious, the insertion of the Gigli saw guide is awkward, tears in the frontal dura mater are frequent, and the exposure is insufficient, needing to be enlarged via removal of the remainder of the orbital roof with a Kerrison ronguer or with bone-nibbling forceps. The reconstruction resulting from our procedure is anatomically perfect, because the entire roof of the orbit is replaced and easily fixed with two sutures applied to the external margin of the orbital arch. The only drawback to the approach described here is the need for two bone flaps, one in the vault and the other including the orbital roof, which sometimes requires a longer operation. We have used this technique in the treatment of a variety of orbital lesions but mostly for lymphomas, cavernous angiomas, and meningiomas. Conclusions
The two-step supraorbital approach described is simple and effective. Morbidity and complications related to the surgical technique are negligible. Reconstruction leaves no unsightly marks and, most important, the exposure is excellent. References
l. AI-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21:474-477, 1987
J. Neurosurg. / Volume 77/December, 1992
2. Benedict WL: Surgical treatment of tumors and cysts of the orbit: eleventh de Schweinitz lecture. Am J Ophthalmo[ 32:763-773, 1949 3. Berke RN: A modified Kronlein operation. Trans Am Ophthalmol Soc 51:193-231, 1953 4. Brihaye J: Neurosurgical approaches to orbital tumours. Adv Tech Stand Neurosurg 3:103-121, 1976 5. Cophignon J, Clay C, Marchac D, et al: Abord sousfrontal +largi des tumeurs de l'orbite. Neuroehirurgie 20: 161-167, 1974 6. Jane JA, Park TS, Pobereskin LH, eta[: The supraorbital approach: technical note. Neurosurgery 11:537-543, 1982 7. Knapp H: Extirpation ether Schnerven-Geschwulst mit Erhaltung des Augapfels. Klin Monatsbl Augenheilk 12: 439-447, 1874 8. Kronlein RU: Zur Pathologic un operative BehandIung der dermoid-Zysten der Orbita. Beitr Klin Chir 4: 149-163, 1888 9. Leone CR Jr, Wissinger JP: Surgical approaches to diseases of the orbital apex. Ophthalmology 95:391-397, 1988 10. Marchac D, Cochignon J, Clay C, et al: La r6fection du toit de l'orbite par d6doublement du volet frontal. Nouv Presse Med 2:2413-2414, 1973 11. Maroon JC, Kennerdell JS: Surgical approaches to the orbit. Indications and techniques. J Neurosurg 60: 1226-1235, 1984 12. McArthur LL: An aseptic surgical access to the pituitary body and its neigbbourhood. JAMA 58:2009-2011, 1912 13. Pozzati E, Giuliani G, Gaist G: Orbital surgery: repair of the frontal fossa by "on bloc" removal and self-replacement of the orbital roof. Technical note. Surg Neuro130: 159-161, 1988
Manuscript received October 8, 1991. Accepted in final form May 18, 1992. Address reprint requests to: Marco Artico, M.D., Via Edgardo Negri 64, 00128 Rome, Italy.
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A two-step supraorbital approach to lesions of the orbital apex Technical note ROBERTO DE1,FINI, M.D., ANTONINO RACO, M.D., MARCO ARTICO, M.D., MAURIZIO SALVATI, M.D., AND PASQUALE CIAPPETTA, M.D. Department (~/ Neuro/ogica/ Sciences. Neurosurgerv, and Chair ~?/Human Anatomy, Faculty of Pharmao,, University (~["Rome "La Sapienza, ""Rome, lta@
~" A two-step supraorbital approach to lesions of the orbital apex is described. This technique is easy and allows a satisfactory exposure of the region. In addition, the reconstruction resulting from the procedure is anatomically perfect. The authors report the operative results obtained in 20 patients and compare this twostep supraorbital procedure with similar surgical techniques described previously. KEY WORDS bone flap 9 orbit 9 orbitotomy supraorbilal approach ' surgical approach
HE range of surgical approaches to the orbit currently available includes Iateral orbitotomy and its modifications 34~ and the anterior approach devised by Knapp 7 and popularized by Benedict;-" despite these, standard transcranial orbitotomy ~2 still retains its value for deep lesions of the medial part of the orbit, for the orbital apex, and for lesions extending intracranially. We propose an alternative technique with two bone flaps (Fig. 1), the first in the frontal bone and the second in a segment comprising the supraorbital rim and the orbital roof. The orbital roof is then removed en bloc and replaced. We describe this technique and report the results obtained in 20 patients treated with this method between June, 1985, and April, 1990.
T
9 reconstructive surgery
'
from the supraorbital notch using either a Kerrison rongeur or a high-speed microdrill. The periorbita is freed from the orbital roof and depressed with the aid of a large brain spatula. Two cuts are then made with a high-speed microdrill through the medial part of the
Operative Technique
A standard bicoronal incision is made and the scalp is elevated together complete with the pefiosteum down to the orbital rim. Four burr holes are drilled in the frontal bone; of the lower two, one is placed over the orbital rim and the other anteriorly in the temporal fossa near the temporal crest. The Gigli saw is used to connect the four burr holes. When the frontal sinus is invaded, which is a frequent occurrence in this procedure, it is exenterated, packed with muscle, and sealed with a layer of pericranium and fibrin glue. The supraorbital neurovascular bundle is identified and freed J. Neurosurg. / Volume 77/December, 1992
FIG. I. Photograph showing a frontal view of the osteotomy lines used during the two-step supraorbital approach. 1 = The first bone flap made via a right frontal craniotomy, with the burr holes and saw cuts clearly indicated; 2 = the second bone flap. 959
R. Delfini, el aL
Fie;. 2. Photograph showing an intracranial view of the osteotomy line used in creating the second bone flap, which includes a good portion of the right orbital roof.
FIG. 3. Photograph showing a frontal view of the second bone flap and clearly illustrating the extension of the osteotomy into the right orbital roof.
frontal rim and through the zygomatic process of the frontal bone. The microdrill is used from a superior direction after the first bone plate has been removed and the dura overlying the orbit has been retracted. The osteotomy line is continued posteriorly toward the orbital apex in the anterior cranial fossa with a microspeed air drill (Fig. 2) while the orbital content is being protected with a spatula. Osteotomy is completed by means of a scalpel. This second bone flap is removed en bloc (Figs. 3 and 4). At this point, the entire roof of the orbit up to the apex is exposed, giving the surgeon a choice of access. Once the lesion has been removed, the osseous segments are replaced and easily joined with silk sutures placed in the external orbital rim. Reconstruction by this method is anatomically perfect.
roof is far from easy, certainly more difficult than methods involving the removal of the orbital roof alone (without removal of the superior orbital arch). The advantage of methods like the one currently reported, which involves removal of the arch as well as the orbital roof, is wider exposure of the orbital contents. In our early cases of orbital lesions, we used the technique of Jane, et al.,6 but in our hands it sometimes proved troublesome. We had difficulty inserting the Gigli saw guide between the frontal and temporal burr holes. There was also the risk of tearing the dura mater, which often complicated this procedure, and the exposure obtained was at times still inadequate, necessitating
Discussion The desirability of gaining wider access to lesions of the orbital apex via a transcranial route j5-7'9'11'~3 with simultaneous reconstruction of the orbital roof has been propounded in many reports published in the past few years. In the past, several authors saw no point in reconstructing the orbital roof after it was removed. Today, however, it is common practice to reconstruct the roof in order to avoid transmission of the pulse wave of the cerebrospinal fluid to the eyeball, to prevent postoperative cicatricial adhesions between the periorbita and the dura mater that might cause problems in a second surgical operation, and to avoid an iatrogenic enophthalmos. Materials used for this purpose include acrylic cement and metal plates 4 as well as bone autografts obtained from the frontal bone flap, as suggested by Marchac, et al. ~o Both types of material have drawbacks, however. Acrylic cement and metal plates are heterologous materials and, when possible, we avoid them. On the other hand, the grafting procedure described by Marchac, el al., is laborious and time-consuming. In addition, the fixation of plastic prostheses or of bone autografts to the bone margins of the orbital 960
FIG. 4. Upper."Photograph showing a frontal view of the isolated second bone flap, including the anterior wall (arrows) and a part of the lateral wall (arrowheads) of the right orbit. Lower: Photograph showing an overhead view of the second bone flap, including the anterior wall (arrows) and a part of the lateral wall (arrowheads) of the fight orbit. A portion of the orbital roof (asterisk) is clearly visible. J. Neurosurg. / Volume 77/December, 1992
Supraorbital approach to orbital lesions removal of the remainder of the orbital roof with bonecutting forceps. We therefore developed the technique described here and have been using it since 1985. A not dissimilar technique had been published in 1974. 5 Although we cut two bone flaps, our procedure has several advantages over other recently proposed techniques. It is easier to perform than the operations of Jane, et al./' or AI-Mefty, ~in which the maneuvers for raising the single bone flap are always laborious, the insertion of the Gigli saw guide is awkward, tears in the frontal dura mater are frequent, and the exposure is insufficient, needing to be enlarged via removal of the remainder of the orbital roof with a Kerrison ronguer or with bone-nibbling forceps. The reconstruction resulting from our procedure is anatomically perfect, because the entire roof of the orbit is replaced and easily fixed with two sutures applied to the external margin of the orbital arch. The only drawback to the approach described here is the need for two bone flaps, one in the vault and the other including the orbital roof, which sometimes requires a longer operation. We have used this technique in the treatment of a variety of orbital lesions but mostly for lymphomas, cavernous angiomas, and meningiomas. Conclusions
The two-step supraorbital approach described is simple and effective. Morbidity and complications related to the surgical technique are negligible. Reconstruction leaves no unsightly marks and, most important, the exposure is excellent. References
l. AI-Mefty O: Supraorbital-pterional approach to skull base lesions. Neurosurgery 21:474-477, 1987
J. Neurosurg. / Volume 77/December, 1992
2. Benedict WL: Surgical treatment of tumors and cysts of the orbit: eleventh de Schweinitz lecture. Am J Ophthalmo[ 32:763-773, 1949 3. Berke RN: A modified Kronlein operation. Trans Am Ophthalmol Soc 51:193-231, 1953 4. Brihaye J: Neurosurgical approaches to orbital tumours. Adv Tech Stand Neurosurg 3:103-121, 1976 5. Cophignon J, Clay C, Marchac D, et al: Abord sousfrontal +largi des tumeurs de l'orbite. Neuroehirurgie 20: 161-167, 1974 6. Jane JA, Park TS, Pobereskin LH, eta[: The supraorbital approach: technical note. Neurosurgery 11:537-543, 1982 7. Knapp H: Extirpation ether Schnerven-Geschwulst mit Erhaltung des Augapfels. Klin Monatsbl Augenheilk 12: 439-447, 1874 8. Kronlein RU: Zur Pathologic un operative BehandIung der dermoid-Zysten der Orbita. Beitr Klin Chir 4: 149-163, 1888 9. Leone CR Jr, Wissinger JP: Surgical approaches to diseases of the orbital apex. Ophthalmology 95:391-397, 1988 10. Marchac D, Cochignon J, Clay C, et al: La r6fection du toit de l'orbite par d6doublement du volet frontal. Nouv Presse Med 2:2413-2414, 1973 11. Maroon JC, Kennerdell JS: Surgical approaches to the orbit. Indications and techniques. J Neurosurg 60: 1226-1235, 1984 12. McArthur LL: An aseptic surgical access to the pituitary body and its neigbbourhood. JAMA 58:2009-2011, 1912 13. Pozzati E, Giuliani G, Gaist G: Orbital surgery: repair of the frontal fossa by "on bloc" removal and self-replacement of the orbital roof. Technical note. Surg Neuro130: 159-161, 1988
Manuscript received October 8, 1991. Accepted in final form May 18, 1992. Address reprint requests to: Marco Artico, M.D., Via Edgardo Negri 64, 00128 Rome, Italy.
961
