Brain Surgery Through the Eyebrow (Supraorbital Craniotomy)

Brain surgery through the eyebrow—also known as supraorbital craniotomy—is a minimally invasive “keyhole” technique used to remove select brain and skull base tumors. This approach allows surgeons to access tumors near the frontal lobe, optic nerves, and pituitary region through a small incision hidden within the eyebrow, often resulting in faster recovery and excellent cosmetic outcomes.

An experienced team of outstanding neurosurgeons at Pacific Neuroscience Institute’s Brain Tumor Center has reported on 129 minimally invasive supraorbital (SO) surgeries in a recent paper; the highly encouraging results of a retrospective study are discussed below.

Minimally Invasive Surgery for Removal of Brain and Skull Base Tumors

Neurosurgeons have been exploring the possibility of less invasive craniotomy to access intracranial tumors for over 50 years.

The potential benefits of minimally invasive surgery include faster recovery and less disruption to surrounding brain structures.

These techniques include:

• Endonasal approaches (through the nostrils)
• Supraorbital approaches (through the eyebrow)
• Retromastoid approaches (behind the ear)
• Gravity-assisted keyhole approaches

The PNI neurosurgical and ENT team has a long track record in performing and enhancing these minimally invasive approaches to make them safer and more effective. This paper is another example of the innovative care provided for patients with brain, pituitary and skull base tumors at PNI.

What is eyebrow (Supraorbital) craniotomy?

An eyebrow craniotomy (supraorbital, SO) is a minimally invasive surgical procedure used to remove certain brain tumors located in or beneath the frontal lobes around the optic nerves, and above the pituitary gland.

An incision in the eyebrow allows access to frontal regions of the brain followed by microsurgical tumor removal. In most cases, a high-definition endoscope is used to enhance visualization, allowing maximal safe tumor removal by revealing tumor areas not visible with the operating microscope alone.

During surgery, the patient is positioned to allow optimal access to the eyebrow by the neurosurgical team.

The eyebrow incision technique was developed in the 1990s and early 2000s and offers clear advantages over traditional open craniotomy. It significantly reduces:

• brain exposure
• scalp and muscle manipulation
• the need for brain retraction

In most cases, it also provides an excellent cosmetic outcome.

This approach is especially effective for removing meningiomas, gliomas, and metastatic brain tumors, with improved outcomes when combined with endoscopy.When performed by experienced surgical teams, the supraorbital eyebrow craniotomy is a safe, versatile, and effective option that promotes faster recovery and return to normal activities.

Tumors Commonly Treated With the Eyebrow Approach

The supraorbital eyebrow approach is most commonly used for:

• Meningiomas
• Gliomas
• Metastatic brain tumors
• Select skull base tumors near the optic nerves and frontal lobe

Not all tumors are candidates; suitability depends on tumor size, location, and relationship to critical brain structures.

Clinical Outcomes From a Retrospective Study

In our study by Ansari et al¹, data from 129 supraorbital surgeries performed on 117 patients between 2007 and 2018 were analyzed.

Two primary outcomes were evaluated:

1. The effectiveness of using an endoscope
2. The extent of tumor removal (resection rate)

Key findings included:

• Endoscopy revealed and enabled removal of tumor tissue not otherwise visible in 50% of cases where it was used (38 of 76 cases)
• The most common tumors removed were meningiomas, gliomas, and metastases
• 81.5% of first-time surgeries achieved total tumor removal
• 72% of reoperations achieved total or near-total removal

Major postoperative complications were low

Temporary side effects included:

• Forehead muscle weakness (frontalis paresis)
  
• Temporary forehead numbness (hypesthesia)
  

The study highlighted a modified surgical technique used by the PNI team that preserves more nerve fibers to the frontalis muscle, shortening recovery time for forehead movement.

Conclusions

With a focus on maximal safe tumor removal and quality of life, our approach to all brain, skull base and pituitary tumors is to use the most direct yet least invasive route possible.

For tumors near the optic nerves and chiasm, beneath or within the frontal lobe, and some along the temporal lobe, the eyebrow craniotomy is our go-to approach.

Alternative keyhole options include:

• Mini-pterional craniotomy (side of the head, behind the hairline)
• Endoscopic endonasal surgery (through the nose)

Using these three approaches, we can reach the majority of tumors in the front of the brain and skull base.

Despite this, many institutions still rely on larger traditional craniotomies and do not routinely use endoscopic visualization. We hope this work and ongoing educational efforts encourage wider adoption of less invasive, highly effective brain tumor surgery techniques.

Explore Minimally Invasive Brain Tumor Surgery at Pacific Neuroscience Institute

If you or a loved one has been diagnosed with a brain, skull base, or pituitary tumor, understanding all available surgical options is essential. At Pacific Neuroscience Institute (PNI), our neurosurgical team specializes in minimally invasive keyhole approaches, including supraorbital (eyebrow) craniotomy, designed to maximize tumor removal while preserving neurological function and quality of life.

Our multidisciplinary Brain Tumor Center offers:

• Expert evaluation by experienced neurosurgeons
• Advanced minimally invasive and endoscopic techniques
• Personalized treatment planning and second opinions

To learn more or request a consultation, contact the Pacific Neuroscience Institute Brain Tumor Center or speak with one of our specialists about whether minimally invasive brain surgery may be appropriate for you.

Reference

1. The Supraorbital Eyebrow Craniotomy for Intra- and Extra-Axial Brain Tumors: A Single-Center Series and Technique Modification 
   Shaheryar F Ansari, MD, Amy Eisenberg, NP, Amanda Rodriguez, RN, Garni Barkhoudarian, MD, Daniel F Kelly, MD