Brain Surgery through a "Keyhole" Brings Speedy Recovery and a Grandmother's Return to a Full Life

Lois Ence, mother of 8, grandmother of 37 and great grandmother of 9, faced a difficult decision after her left eye began to tear uncontrollably and the lid began to droop.  

An MRI test at Brigham Health confirmed what Ence, 76, suspected:  For the third time, a tumor was growing in the front of her skull, just behind the forehead.

In 2001 and 2016, doctors each time had removed a non-cancerous brain tumor (meningioma). Even with successful surgery, meningiomas may recur. The tumor itself is not deadly, but when it grows in crowded, crucial regions of the skull, it can cause serious health problems.

This time, tests at Brigham Health in Boston, MA showed a new grape-size tumor that likely was pushing on the muscle that holds up the eyelid and on the gland that produces tears.

Omar Arnaout, MD, of the Department of Neurosurgery, explained that she could lose the use of her left eye as the muscle eventually failed to hold up the lid. Or, she could consider surgery to remove the tumor.

After two previous lengthy brain surgeries, followed by challenging recoveries, Ence was willing to risk her left eye to avoid a third invasive surgery.  

Dr. Arnaout, well-aware of the toll that conventional brain surgery takes on a patient, proposed using a new, minimally invasive "keyhole" technique. Working through a small incision in her eyelid he would be able to remove the tumor. "I explained that we could do this through a 'keyhole,' which implies the least intrusive way to get at our target," Dr. Arnaout said.

Still skeptical about any additional brain surgery, Ence met Edward Caterson, MD, PhD, the plastic and reconstructive surgeon who would partner with Dr. Arnaout for the surgery. When he showed her images of children whose cleft palates he had repaired, she began to change her mind.

She liked how both physicians spoke directly and clearly with her about her condition and the benefits of the keyhole approach. Their teamwork and trust in each other were apparent. "They were like peas in a pod," Ence said. "They had my complete confidence after that."

Each keyhole surgery is unique and custom-designed for the individual patient. Dr. Arnaout prepares extensively,  he said, working with colleagues in Brigham Health's Division of Plastic and Reconstructive Surgery to plan the safest route to the tumor, with minimal scarring and tissue disruption.

Ence's surgery was performed in early June. The doctors approached the tumor from below instead of from above, with the plastic surgeon first making a small incision in her upper eyelid. Through this "keyhole" opening, Dr. Arnaout inserted the instruments used to remove the tumor and affected bone. "We were able to sneak in behind the eyeball to the roof of the skull where our target was," he said. 

Dr. Caterson closed the incision, which was not visible within the folds of the eyelid once it healed.

"The surgery took half the time that even the doctors expected," Ence said. Afterward, she was well enough to skip the Neuroscience Intensive Care Unit and so alert that she had a conversation with Dr. Arnaout about what he found and what to expect next. After just one night in the hospital post-surgery, Ence returned to her Massachusetts home with only a non-prescription pain medication.

"The recovery was so easy, I was on my feet the next day," she said. "I immediately started to do word puzzles to stretch my brain and to go for walks." As her eye cleared of excess fluid, she returned to reading. Within weeks, she was back to driving and volunteer work and preparing for a late summer trip to California. "My goal is to go to my granddaughter's wedding, go to Yosemite and see my grandkids," she said.   

"I'm kind of a miracle," she added. "The stitches blend into my eyelid. I've earned my wrinkles. To me, this looks perfect."

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