Transorbital microsurgery (TOMS): Step-by-Step technique, tips and tricks
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https://orcid.org/0000-0002-4504-2277
Gilda Parra
Benjamin Abarca
Cristian Salazar
Jorge Cerda
Andrei Joaquim
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Resumo
Introduction: Transorbital microsurgery (TOMS) represents a transformative innovation in the minimally invasive approach to the anterior skull base. Through an inconspicuous upper eyelid incision and precise orbitofrontal craniectomy , this approach allows direct access to the subfrontal space and critical neurovascular structures without the need for extensive craniotomies or significan brain retraction. The technique combines the principles of classical microsurgery 3D visualization, bimanual control, and operative ergonomics with the efficiency of a natural anatomical corridor, preserving facial aesthetics and minimizing morbidity. Its development responded to the need for surgical Solutions that maintain safety and control while maintaining minimal invasion. In trained hands, TOMS expands the scope of modern neurosurgery, enabling complex interventions with selective access, maximum precision, and minimal invasiveness. Objective: To comprehensively describe the TOMS technique, establish its anatomical foundations, and demonstrate its applicability to orbitocranial pathology through real-life cases, highlighting its ability to replace open approaches in selected scenarios. Methods: The technique is detailed step by step: upper eyelid incision, orbitofrontal craniectomy, wide subperiosteal dissection, and intracranial visualization under a microscope. Three clinical applications (trauma, tumor and vascular) are presented as functional validation of the approach. Results: TOMS provided direct and controlled access to the optic nerve, the carotid artery bifurcation, and the frontal floor, with minimal brain retraction, complete bimanual control, and optimal cosmetic results. No major complications were reported. Recovery was generally rapid, and all patients were discharged without sequelae. Conclusions: Transorbital microsurgery is a useful alternative for some anterior skull base pathologies.. It combines the aesthetic elegance of a transpalpebral approach with the technical rigor of modern microsurgery. In the appropriate setting, TOMS not only complements but can replace traditional approaches to orbitobasal lesions, offering the surgeon precision, visibility, and anatomical mastery in a previously seemingly inaccessible area.
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