Table 1.

Orbitocranial and cranio-orbital approaches: exposure, advantages, and disadvantages.

Approach	Exposure	Advantages	Disadvantages
ORBITOCRANIAL APPROACHES
Lateral orbitotomy	• Lateral, superior, and inferior intraconal compartments • Orbital apex • Middle fossa and cavernous sinus	• Minimal orbitotomy for lateral orbital lesions • Wide exposure of orbit and orbital apex	• Enophthalmos
Total lateral orbitotomy	• Added exposure of anterior cranial fossa in addition to lateral orbitotomy exposure	• Exposes deep apex tumors • Deep seated orbital apex lesions obviating need for craniotomy	• Postoperative periorbital swelling • Cosmetic deformity • Enophthalmos
Modified lateral orbitotomy	• Sphenoid wing • Orbital apex • Middle fossa and cavernous sinus	• Good cosmetic outcome • Minimally invasive and enhanced recovery after surgery • Surgical exposure similar to pterional craniotomy but smaller opening	• Poor anterior cranial fossa exposure • Limited exposure for treating complex vascular lesions and tumors
Anterior medial micro-orbitotomy	• Medial intraconal compartment • Exposure medial to optic nerve	• Easy access to lesions medial to orbit and optic nerve • Better cosmetic outcome than orbitotomy	• Cannot address lesions at apex and superiorly located lesions • Endoscopic endonasal is useful alternative
Trans-conjunctival	• Inferomedial and lateral intraconal compartments • Can be used for supra-orbital keyhole exposure of anterior fossa	• Excellent cosmetic outcome • Low risk of enophthalmos	• Poor sphenoid wing, middle fossa, and orbital apex exposure
CRANIO-ORBITAL APPROACHES
Pterional	• Versatile approach for superior and lateral orbital compartment and full exposure of orbital apex • Anterior and middle fossa	• Excellent exposure of orbital apex • No damage to intraorbital structures, less risk of enophthalmos • Incision behind hairline	• Requires craniotomy • Risk of temporalis atrophy
Mini-pterional	• Similar exposure as pterional	• Smaller incision behind temporal hair line	• Smaller working corridor • Poor orbital exposure with posterior hair line
Orbitozygomatic	• Removal of orbital roof and wall provides enhanced exposure of orbital apex and suprasellar region • Removal of zygoma provides enhanced exposure of middle fossa and infratemporal fossa	• Enhanced exposure • Less brain retraction	• Added operative time • Periorbital hematoma • Risk of enophthalmos
Lateral supraorbital	• Anterior cranial fossa • Superior orbital compartment	• Minimal disruption to temporalis muscle	• Large pterional incision behind hairline necessary to provide exposure
Supraorbital keyhole	• Anterior cranial fossa • Superior orbital compartment	• Minimally invasive approach through eyebrow incision	• Smaller craniotomy provides limited maneuverability of instruments • Cosmetic outcome affected by thickness of eyebrow
Endoscopic endonasal	• Medial orbital compartment • Medial aspect of orbital apex • Opticocarotid recess	• No visible scar • No orbitotomy or craniotomy • Low risk of enophthalmos	• Limited exposure of orbital apex • Increased risk of CSF leak and infection • Risk of infraorbital hypoesthesia