The transorbital keyhole approach: early and long-term outcome analysis of approach-related morbidity and cosmetic results

Technical note

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In 2003 the authors introduced a minimally invasive transorbital keyhole approach. Because this approach requires removal of the orbital rim and orbital roof, there have been concerns regarding perioperative morbidity, long-term morbidity, and cosmetic results. The authors evaluated approach-related morbidity and cosmetic results in their patients to determine the rate of complications and compared this to published reports of similar approaches.


Seventy-one patients (41 female, 30 male) underwent operations using this approach between 2004 and 2008. Immediate approach-related morbidity was recorded after the operation. Late morbidity was determined after 7 months by an independent examiner while cosmetic results were self-rated by the patient using a questionnaire.


Fifty-one (72%) of 71 patients had no postoperative complications and 12 (16.9%) had minor complications, the most common of which was subgaleal CSF collection (7.0%). Other minor complications included facial nerve palsy (2.8%), hyposphagma (2.8%), periorbital swelling due to periorbital hematoma (2.8%), and subdural hematoma (1.4%). Major complications requiring surgical revision occurred in 4 patients (5.6%); these were CSF fistulas in 2 patients, pneumocephalus in 1 patient, and a hematoma in 1 patient. Forty-nine (90.7%) of all 54 examined patients rated the cosmetic results as very good or good. Major long-term morbidity was hyposmia or anosmia (14 patients) followed by hypoesthesia around the scar (9 patients).


The transorbital keyhole approach is a feasible approach with a low-risk profile for postoperative or long-term morbidity and excellent cosmetic outcome.

Abbreviations used in this paper: ACoA = anterior communicating artery; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Kerim Beseoglu, M.D., Department of Neurosurgery, Universitätsklinik Düsseldorf, Heinrich-Heine-Universität Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany. email:

Please include this information when citing this paper: published online October 29, 2010; DOI: 10.3171/2010.9.JNS1095.

© AANS, except where prohibited by US copyright law.



  • View in gallery

    Three-dimensional CT reconstructions showing the surgical technique. The frontal view (A) shows the medial aspect of the craniotomy where the bur hole is placed just lateral to the supraorbital nerve exit. The more lateral view (B) shows the position of the lateral or pterional bur hole. The view from below (C) shows the almost triangular-shaped part of the anterior orbital roof that is part of the bone flap.

  • View in gallery

    Examples of very good (1a and b), good (2a and b), moderate (3a and b), and poor (4a and b) cosmetic results as rated by the patients approximately 7 months after surgery. The adjacent graph shows the number of patients in each rating group (54 total patients).



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