 It's a super orbital approach and it's the best due to our history of our department. What's about this is that you really think about your surgery before planning your approach. What do you really want to do? It's not useful to really try to make a small incision or a craniotomy. For example, if your lesion is quite superficial, it won't work. But the deeper the lesion is, you can perhaps choose if it's appropriate a minor craniotomy. But even if you choose a minor craniotomy, it should be tailored. You can't let the job somebody doing, which is not really absolutely informed about the patient, the lesion, how you want to do it. And the Keogh concept says, OK, you choose a certain size of the craniotomy and then you make the craniotomy wider in terms of visualization that you drill the inner, the tabular internal. So that makes the access for visualization and even for handling in the depths. But what we think it's good to deal is that it's the cellar region. It's the planum, it's a tuberculum. The olfactory region, we are not sure about this, we use it less. Because if you go from this position and you have, even if you drill the orbiter, it might be difficult to have total visual control for the olfactory region. And what we do with this approach in general, it's the aneurysms and mainly it's a subfrontal approach. This has to be, don't deal with the lesions you would never do with a subfrontal approach. That's the key topic about it. It replaces in described circumstances the standard frontal approach. And we'll see it later in the video as you see this is the incision. You have to preserve the suprapetal nerve, you should. And it's sufficient if you make one bare hole. What kind of anatomy do we deal? Of course you have to know the supralineal temporalis superior. You will deal with the periobucal muscle. You have to do an incision of the temporal muscle. These are the main landmarks. After we did a skin incision, we mainly detached the temporal muscle on a very short distance and make a kind of U-shaped incision of what may be uncomfortable mobility with this kind of approach is if you make injury to the frontal sinus. And because the approach is so minimized, sometimes you even don't see if you made a slit-like lesion on it. So the patient has CSF rhinorrhea and you can't even imagine that you made it from your credit to me, but it's evident and we really have to care about it. And the most simple, of course, you can use neuronavigation for this, but in general you can palpate the frontal sinus. It's easy and you have to respect it. It's a pity if you make a nice surgery with a minimized approach, but you have to do a reduced surgery because of CSF leakage and a frontal sinus injury. This is where we place the burhole. And this is the first cut. It should be really as low as possible that you really make an osteoplastic run into me and don't have to drill too much of the bone so that you're parallel to the obterufe and we complete it like this. And what's perhaps important is not only the supraorbital nerve, but you have even some motor branches of the facial nerve so that there is a risk with this approach, like with a lot of approaches, that you may cause a facial weakness for the frontal branch. And the preparation is, we talked about planning. You should, in general, for example in our department, the surgeon has to do the positioning himself. And that means, in case of the supraorbital approach, you have to think about what kind of a lesion do you want to tackle. For example, if you want to go for an MCA aneurysm, which is quite lateral, here's the opening and we choose rather a slight rotation, perhaps this 15-20 degrees maximum. So that the surgeon may be really comfortable. So the place of the cranitomy is about here and I want to have a straight vision on it and I want to go to lateral pathology. There's only a slight tilting of the head, but the more I want to go medially, the more I have to tilt the head for a comfortable position. If I don't do it properly, then I have to stand like this to see it right. This is the only thing you can really make wrong about the positioning. What is also important to gain a good visualization is that you have to... You see there are always... the orbital roof is never plain. And there may be sometimes really a severe hypostosis, which may make a straight visualization, for example, of the cellar region or even the planum impossible. And what you have to do is that after you made a really parallel incision of the cranitomy to the orbital roof, you have to drill the orbital roof a bit flat, get off all these bony ridges to have direct access, for example, for the planum. Now, this is essential. If you don't do this, you can't use this approach properly. And it's always done extra-dual. If you don't do this, then you have to do an orbitosagomatic version of this approach. That means extra-dual while holding the suction or even using additional tools. This is here you have the orbital roof, and it's what I said initially. You have to really to make the orbital roof flat. And sometimes you even see some periorbiter. And this is a case of an MCA aneurysm. So in general, you can't stay within the eyebrow. If the patient has no eyebrow, we rarely choose it out. We think it's an ideal approach. And what we always do is draw. That means what do we draw? We draw the incision. We draw the burhole, the linear temporalis. We draw what is the expected size of the craniotomy. And in this case, the craniotomy ends where the frontal sinus has this maximum extension. This is what you need. And you can extend the skin incision a bit laterally In general, the cosmetic results are good if you stay within these folds. It's about a four-centimeter skin incision, four to five centimeters which is planned. We use sutures in general with retractors. The fissure is also okay, but with retractors you take too much space. It's not suitable, very good. You need a temporalis, which is incised. We make a kind of U-shaped muscle incision. You need a temporalis, so we will place the burhole about here. And it's good if you, from that position, it's a small burhole. Just take the kerosene and goes as close as possible to the obter roof. And you need the help of an assistant which really moves the skin so that you can make adequate bony exposure. And again, it's for subfrontal root and it's not for superficial pathologies. At the surface you don't have a good exposure, it's only in the depth. Now this is the step where we try to remove all the, to improve the bony exposure. So you make it really flat to the obter roof. And with a diamond drill you remove the bony ridges of the orbiter. Then you make a, in this case, we made a puncture of the ventricle. It's just perpendicular to the surface if it's not difficult. We try to avoid lumber drainage. I don't know. And you have to take some time with this approach. That means always wait for CSF release. You can't force it. This is optic nerve. And then you get, nicely, the CSF and everything is quite comfortable. The better one. Send it back to the manufacturer. So you see, you have a nice exposure. It's not that you have no place to work, but you have to take some time for CSF release. You have to take your time for the rocknidal dissection. And then you see the aneurysm. You can, you are able to split the sieving fissure from a reverse. You now see now the aneurysm. This should be the temporal branch. And in general we use this standard Sugita clips. We don't use this inverse clipping system from Ponetski. It depends so, only in really small aneurysms. And for control, we are now lucky to have this ICG systems too. But in general we do a Doppler to really control micro Doppler. I think it's quite affordable and it's easy. It's straightforward. ICG is of course nice, but we have only one microscope which is working with that. And sometimes you may even replace. Like in this case there was some compromise ICG. It's only an additional tool. So we make an anoscope be assisted clipping. Yeah. And because you said you make a kind of variation of this approach. So you make just the reconstruction of the dura and just can skip this. Yeah. We take two of these clamps. That's so. But yeah. You have to do a good case selection. And especially it must be a legion which is just appropriate for protecting this. We do most of the aneurysms, ACOM aneurysms with this. Plam spinodala meningiomas are tackled by this approach. You can even see control of the MCA. And this is a standard case which we use it for. Yeah. But to be honest, this would be perhaps today a case we would think about doing transnasal endoscopic because there's some extension to the cellar to bechelum. If it's just behind outside of the line of sight, it may be possible that we today would do it with our endoscopic transnasal root. But we are reluctant in general. The post-op care is much more intensive in doing transnasal resection. So we still use most cases currently to me. Okay. Yeah. Cosmetic results. Of course, after people are like this day two and three, but the cosmetic results are quite good. But what are the associated complications? Frontal numbness. Yeah. Even if you think you preserved the supravitin of even palsy, that incomplete. Yeah. In most cases it's after the surgery, but within some month it's recovering full. What I said about this CSF-Line Rear, really take care about your frontal sinus. Take a desk sector and see if you open it. And if you have to do a redo case, it's not. Of course, it's not nice. Yes. It's quite visible, but it's rare. And I think we talked about that we have to really choose our case quite good. Okay. Thank you.