Johns Hopkins logoTraditional means of entry used in brain surgery is more laborious, physically damaging and invasive, requiring an opening of the top half of the skull. However surgeons present at Johns Hopkins claim to have carefully and successfully operated inside the brains of a dozen patients with a less invasive approach. They made a small cut through natural creases of an eyelid in order to reach the skull and deep brain. Access to the skull and brain through eyelids was formally known as a transpalpebral orbitofrontal craniotomy.

The new approach is said to be convenient for the patients as it abstains from shaving the patient’s hair, pulling up the scalp, opening the top half of the skull, and moving aside whole outer sections of the brain. These methods are employed before operating the organ’s delicate neurological tissue. The Johns Hopkins team explained the effectiveness of this new approach to repair brain fluid leaks, conduct tissue biopsy and remove tumors. These are believed to be the first published case studies of this procedure. It was adopted in patients whose complex illness made the traditional approach too risky or indefensible.

“Going through the eyelid offers a simpler, more direct route to the middle and front regions of the brain than traditional skull-based surgery,” says lead study investigator and facial plastic and reconstructive surgeon Kofi Boahene, M.D. “This minimally invasive approach also avoids the major head trauma typically associated with brain surgery.”

The minicraniotomy through the eyelid requires surgeons to remove half-inch to one-inch-square section of the skull bone which is right above the eyebrow. This is later replaced in order to acquire access to the body’s nervous system control center. Once access to the brain is available a microscope and a computer guided endoscope that is fitted with a camera is used to accurately guide other surgical instruments into the soft tissue. This enables the soft tissue to execute the function, using high-tech maps created by advanced CT and MRI scans of the brain.

Boahene reveals that this new approach takes on average less than two hours as compared to the traditional approach which takes four to eight hours. It also appears to exhibit less risk of infection mainly due to less work carried out in opening the skull. Its recovery may usually take an overnight stay instead of four days or longer in the hospital. The noticeable hints of this surgery are the dissolvable sutures across the eyelid as compared to other brain surgeries which require lengthy cuts of the skins before pulling the scalp.

“This new technique does not even leave a noticeable scar, as we are deliberately cutting across the natural creases in the eyelid,” says Boahene, an assistant professor at the Johns Hopkins University School of Medicine, who has performed 15 such procedures at Johns Hopkins since 2007. Before the procedure, surgeons check by drawing along the eyelid folds with a black marker, making sure the line is not visible when the patient’s eyes are open.

Boahene further shares that minicraniotomy still requires anesthesia as it carries its own risks of complications. It may also need ice packs to reduce swelling around the eyelid. New reports highlighted that the eyelid entry was useful to mend a common postsurgical complication, a cerebrospinal spinal fluid leak into the sinus cavity that had resulted from a previous and more invasive skull surgery. Surgeons feared swelling from additional trauma as it would obstruct the patient’s recovery. Therefore they opted for a less obstructive form of surgery towards the stem flow. In another example surgeons were able to remove potentially cancerous tumor in a baby whose skull and head size was considered too small to undergo physical pain connected with major brain surgery.

“The transpalpebral approach is a very viable and practical option for thousands of surgeries done each year in the United States that involve problems deeply seated behind the eyes or at the front of the brain,” says senior study investigator and neurosurgeon Alfredo Quinones-Hinojosa, M.D.

Quinones-Hinojosa, an associate professor at Johns Hopkins reveals that minicraniotomy can also be used to correct deformities or skull bones broken due to trauma and car accidents. The team’s next steps are to estimate and expand the list of procedures for which a transpalpebral orbitofrontal craniotomy is appropriate. This group considers that aneurysm repair and removal of larger brain tumors cannot be done by traditional skull surgery or by going through the nose and sinus cavities.

These findings feature in a pair of studies, one published in the June issue of the Journal of Otolaryngology Head and Neck Surgery and the another set to appear in the July issue of Skull Base.