Full-Extension Eyebrow Approach with Supraorbital Nerve Preservation for Frontal Sinus Tumors

by Pedro Plou, MD, Simona Serioli, MD, Alex Y. Alexander, BA, Luciano C. P. C. Leonel, PhD, Maria Peris-Celda, MD, PhD, and Carlos D. Pinheiro-Neto, MD, PhD •

INTRODUCTION

Frontal sinus (FS) surgery still represents a challenge due to its complex and highly variable anatomy. Several tumoral and infective pathologies, as well as traumatic injury, may affect this region, with possible intracranial and orbital involvement. Osteoma is the most common benign tumor that affects this area, followed by the inverted papilloma (Laryngoscope. 2012. doi:10.1002/lary.23275). The malignancy of FS is led by squamous cell carcinoma, representing 40%–60% of the sinonasal malignancies, followed by adenocarcinoma (Laryngoscope. 2015. doi:10.1002/lary.25465).

The endoscopic frontal sinus procedures present several limitations associated with individual anatomy and tumor features, especially in cases of lesions located superior and laterally within the frontal sinus (Ann Otol Rhinol Laryngol. 2012. doi:10.1177/000348941212100802).

Before the endoscopic era, the standard FS surgery involved a bicoronal incision. This technique required a large scalp flap, however, and could result in potential facial palsy, poor cosmetic results, and prolonged recovery.

The eyebrow approach is commonly used because it provides direct access to the frontal sinus with avoidance of an obvious facial scar. Besides the risk of eyebrow alopecia, one limitation is the supraorbital nerve injury, which normally limits the extension of the incision and the access to the frontal sinus. The eyebrow incision is traditionally performed medially or laterally to the supraorbital foramen to avoid injury to the supraorbital nerve (Arch Craniofac Surg. 2016. doi:10.7181/acfs.2016.17.4.186.).

To the best of our knowledge, there is no description in the literature of a surgical technique that utilizes the full extension of the eyebrow with preservation of the supraorbital nerve. In this study, we present a detailed anatomical description of an eyebrow approach that allows full exposure of the frontal sinus with a large osteoplastic bone flap and preservation of the supraorbital nerve. A clinical case is described to illustrate the surgical technique.

METHOD

Three embalmed and latex-injected cadaveric heads were dissected to assess the feasibility and limitations of the approach in documenting key steps. After the dissection, the technique was performed in a patient with an inverted papilloma of the frontal sinus.

Surgical Technique

After palpation of the supraorbital foramen, a skin incision was performed laterally to the foramen in the superior aspect of the eyebrow and extended to the lateral edge of the brow. This incision was performed with a 15-blade oriented in a 45-degree angle to the skin parallel to the hair follicles, decreasing the risk of extensive eyebrow alopecia. After the identification of the orbicularis oculi, the incision was extended medially to find the supraorbital nerve arising from the supraorbital foramen. The neurovascular bundle was dissected and isolated. The nerves were carefully dissected from the surrounding tissue, allowing superior retraction of the incision. The anterior wall of the frontal sinus was exposed medially and laterally to the supraorbital nerve. A navigation system was used to mark the limits of the anterior table of the frontal sinus. An anterior table osteotomy was performed with a bone cutting tip of the Sonopet Omni Ultrasonic Surgical System along the limits of the left frontal sinus. A 1-mm drill bit can be used for the osteotomy as well. The inferior bone cut was placed just superior to the supraorbital rim and the nerve was protected with a retractor. Subsequently, the anterior table was gently elevated and removed to expose the frontal sinus.

Illustrative Case

A 77-year-old male with a history of recurrent left-sidedfrontoethmoidal inverted papilloma underwent a first endoscopic resection in August 2020 and a second endoscopic surgery in June 2022, both performed at another institution. MRI and CT scan showed the recurrent tumor filling the left frontal sinus. Therefore, an open approach through an eyebrow incision was indicated to complete surgical resection.