In a rare through-the-eyelid surgery, neurosurgeon Omar Arnaout, MD of Brigham and Women’s Hospital’s Department of Neurosurgery and collaborators from the Division of Plastic and Reconstructive Surgery recently removed a recurring meningioma from the roof of the orbit. The patient, age 76, bypassed the ICU and was discharged to home the next day, with only non-prescription pain medication.

Growing expertise and interdisciplinary collaboration in keyhole surgery are driving innovation in such minimally invasive surgeries at Brigham and Women’s.

“A keyhole implies that we make the least amount of soft tissue disruption. To do that, we often come up with creative ways to get to the target,” said Dr. Arnaout.

The patient previously had two open craniotomies – in 2001 and 2016 – to resect a meningioma from the interior skull base. Each time, a tumor was removed completely, using a traditional reverse question mark incision. Each time she required several days in the Neuroscience Intensive Care Unit and experienced encephalomalacia and a long recovery.

By spring 2019, her left eye developed progressive ptosis and excessive lacrimation that significantly interfered with activities of daily living, including reading. An MRI showed tumor recurrence, this time with intracranial and intraorbital extension compressing the lachrymal gland and the levator muscles controlling the upper eyelid. But the patient, remembering her challenging recoveries, balked at the possibility of a third invasive surgery.

Collaborating on Creative Ways to Reach the Target

Dr. Arnaout immediately recognized the potential for keyhole surgery. The technique is primarily a set of principles to limit brain exposure and minimize brain retraction; the philosophy of minimal invasiveness results in smaller craniotomies and limited soft tissue disruption. Keyhole surgery fully leverages neuronavigation, advanced hemostatic techniques and the use of neuro-endoscopy.

After his fellowship in complex skull base neurosurgery at Brigham and Women’s Hospital, Dr. Arnaout completed additional fellowship training in minimally invasive and keyhole surgery at Prince of Wales Hospital in Sydney, Australia in 2017.

Since returning to Brigham and Women’s two years ago, Dr. Arnaout has performed approximately 200 keyhole surgeries that make up about half of his surgical practice. Using keyhole principles, he has removed ventricular tumors, meningiomas (including posterior fossa tumors), gliomas and pineal tumors beyond the skull base. Keyhole approaches include those along the convexity, the eyebrow, the mini-pterional, mini-subtemporal, retrosigmoid, interhemispheric and suboccipital.

The move into keyhole techniques at Brigham and Women’s grew naturally from longstanding collaboration between surgeons in the  Center for Skull Base and Pituitary Surgery and the Division of Otolaryngology-Head and Neck Surgery. A growing partnership with craniofacial surgeons from the Division of Plastic and Reconstructive Surgery opened new opportunities.

“It makes a lot of sense, especially at a place like the Brigham, to take advantage of having a super specialist just down the hall,” Dr. Arnaout said. “Collaboration is crucial.”

When the meningioma patient met with Dr. Arnaout and plastic and reconstructive surgeon Edward Caterson, MD, PhD, she noticed immediately their rapport and mutual trust. After what she described as a forthright conversation about her options, she chose to proceed with keyhole surgery.

“No Limitations as to What Technique We Could Use”

Dr. Caterson began with an incision of approximately 3 centimeters in the upper eyelid. Gently pushing down on the globe, Dr. Arnaout exposed the roof of the orbit and the floor of the anterior cranial fossa and was able to reach the target. In this approach, the tumor was tackled upfront, completely eliminating any retraction on the brain.

Using a combination of endoscope and microscope, he was able to achieve a complete resection of the lesion as well as its origin.

Contrary to a common concern that a keyhole is more limiting than an open craniotomy, Dr. Arnaout said, “we had no limitations as to what technique we could use.”

“Once you’ve done that work in exposure, you can use the same microsurgical techniques and principles that you use anywhere,” Arnaout said. “There were up to four instruments working through that incision. I was doing the exact same thing as I would do [with a traditional approach].”

Collaboration with a specialized cranio-facial reconstructive surgeon has the additional benefit of maximizing cosmetic result, particularly when the surgical incision involves the eyebrow or eyelid area. In this case, the incision was hidden within a skin crease in the eyelid.

Patient: “To Me, This Looks Perfect”

This surgery to remove a meningioma through the upper eyelid is believed to be the first of its kind in New England — but is unlikely to be the last at Brigham and Women’s. Interdepartmental collaboration has enabled other keyhole entries through the eyebrow or eyelid and a recent approach through a patient’s forehead wrinkle.

Each keyhole surgery is custom-designed, for the best possible incision and access without compromising complete tumor removal. “You need to be willing to study and plan your own approach, beyond standard approaches to the brain,” said Dr. Arnaout. This generally requires subspecialty neurosurgical training in keyhole techniques and a multidisciplinary team that includes a craniofacial surgeon.

With those elements in place, a secondary advantage of keyhole surgery is speed: In this surgery, opening and closing the wound each were achieved in a few minutes, rather than the time needed for a conventional craniotomy. Dr. Arnaout expects other advantages to be demonstrated as data accrue, including less postoperative pain and discomfort, a shorter hospital stay than the typical 3 to 5 days after conventional craniotomy and fewer infections.

His meningioma patient who underwent eyelid surgery was more than satisfied. “The recovery was so easy, I was on my feet the next day,” she said. Within weeks, she resumed reading, driving, and volunteer work and preparing for cross-country trip.

“I’m kind of a miracle,” said the mother of 8 and grandmother of 37.  “I’ve earned my wrinkles. The stitches blend into my eyelid. To me, this looks perfect.”