Endoscopic versus open resection of pediatric periorbital masses using a novel subcutaneous operative channel: a focus on safety and aesthetic outcomes

Introduction

Pediatric periorbital masses refer to a spectrum of benign or malignant lesions arising from the soft tissues surrounding the orbital cavity. This category encompasses a diverse range of pathological entities, including cysts, neoplasms, and other mass-like lesions, which exhibit varied etiologies, clinical presentations, and requisite management strategies. Studies indicate that dermoid cysts predominantly occur in the pediatric population, typically located in the periorbital region, where they present as avascular, ovoid lesions situated beneath the aponeurotic plane. The presence of nonaggressive bone remodeling, observed in 52% of cases, serves as a key diagnostic clue on imaging. Collectively, these features facilitate radiographic diagnosis (1,2). Supporting their clinical prevalence, the work of Vathsalya Vijay et al. identified dermoid cysts as the most common benign lesions, accounting for 24.5% of all pediatric periorbital tumors (3). Studies have documented that a spectrum of other pathologies can present as periorbital masses in children. For instance, some vascular malformations, such as lymphatic malformations, are congenital benign vascular lesions. Case reports indicate that these lesions may involve the orbit or periorbital region, presenting in children as proptosis or swelling, which can be exacerbated by upper respiratory tract infections or minor trauma (4). Beyond these, numerous other entities have been described in the literature, including molluscum contagiosum, infantile myofibroma, xanthogranulomas, and even infectious processes like cellulitis (5-8). Medical imaging serves as a cornerstone in the diagnostic workup of pediatric periorbital masses, enabling the non-invasive assessment of a lesion’s location, depth, and characteristics without the need for invasive procedures or anesthesia. Ultrasonography stands out as a non-invasive and radiation-free modality that accurately delineates lesion morphology, vascularity, and its relationship to the aponeurotic plane, thereby aiding in differential diagnosis (1). Furthermore, ultrasound guidance is essential prior to sclerotherapy for conditions like lymphatic malformations to confirm the lesion’s extent (9). For lesions that are atypically located, deeply seated, or fixed to underlying structures, advanced cross-sectional imaging such as computed tomography (CT) or magnetic resonance imaging (MRI) becomes indispensable for comprehensive evaluation and guiding subsequent management. To date, the primary management for pediatric periorbital masses remains surgical excision, with the definitive diagnosis established by histopathological examination of the intraoperatively resected specimen. In a subset of cases, this approach is supplemented by condition-specific adjuvant therapies; notable examples include the injection of sclerosing agents for lymphatic malformations and the administration of oral propranolol combined with intralesional triamcinolone injections for hemangiomas (9,10).

Masses protruding from the periorbital region are easily noticed due to their prominent location, and frequently prompt patients to seek surgical removal. However, conventional open surgeries in this region often result in residual scars or tension on surrounding tissues, compromising aesthetics and functionality and potentially necessitating subsequent scar reduction and cosmetic treatments (11,12). In children, postoperative scarring, particularly in the periorbital region, can adversely affect physical and psychological well-being (13-15).

Endoscopy, established as a cornerstone of minimally invasive surgery, has evolved from its early applications in natural cavities (16,17) to become an indispensable tool in neurosurgery (18-22). This progression was propelled by pivotal technical innovations, such as those by Kurt Semm (23), and has expanded into aesthetically sensitive domains. The technique’s paramount relevance for subcutaneous lesions lies in its capacity to minimize visible scarring through concealed incisions, a critical advantage in pediatric patients (24). For example, Fan et al. used hidden incisions for extracapsular resection of benign parotid tumors, achieving both disease eradication and excellent cosmetic outcomes (25).

Previous studies by Deshka Foster et al. and George Chater-Cure et al. have demonstrated that utilizing the subgaleal loose connective tissue layer as an endoscopic surgical approach for the resection of periorbital or facial masses can yield excellent therapeutic outcomes (26,27). Building upon this established anatomical pathway—which is readily dissectible and provides a natural plane for dissection—we have developed a technical modification to enhance this existing surgical corridor. We designed a “subcutaneous channel” (Figure 1) created using a 10 mL sterile syringe. Using this artificial subcutaneous channel, we accessed the loose connective tissue layer beneath the galea aponeurotica to remove masses in the periorbital region of the children. In currently reported cases, clinicians performed endoscopic operations within confined anatomical spaces with significant limitations. To address this, we have modified existing surgical techniques by incorporating our institution’s self-developed ‘subcutaneous channel’ approach. This modification provides surgeons with enhanced operative visualization, enabling more precise surgical maneuvers. In this study, we introduced a method for resecting pediatric periorbital masses using neuroendoscopic assistance and hidden incisions within the hairline, and we compared its outcomes with those of conventional open surgeries. We present this article in accordance with the SUPER reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-354/rc).

Figure 1 Subcutaneous channel. (A,B) Three-dimensional view; (C) lateral view; (D) top-down view.

Methods

Patient selection

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Beijing Children’s Hospital, Capital Medical University (approval No. 2024-E-173-R) and conducted in the Department of Neurosurgery at this tertiary pediatric care center. Written informed consent for this retrospective study was waived, while consent for image publication was obtained from the legal guardians. The investigation was designed as a consecutive case series, which retrospectively enrolled all 46 pediatric patients who underwent resection of a periorbital mass in our department between August 31, 2023, and September 1, 2024. Consequently, the sample size was determined by this consecutive case series design rather than by a predetermined statistical power calculation. The parents or guardians selected the surgical method. Clinical data, including sex, age, surgery and hospitalization duration, mass size, postoperative pathology results, and total hospitalization costs, were collected through an electronic medical record system. Postoperative follow-up was conducted for all patients, with the duration calculated from the surgical date to the date of the final clinical evaluation. The follow-up period for the entire cohort ranged from 5 to 16 months, with a median duration of 10 months (7–14 months). The follow-up assessments specifically evaluated recurrence, the implementation of any anti-scar regimens (including the therapeutic modalities employed and treatment frequency), and the occurrence of postoperative complications, such as surgical site infection, hematoma, or wound dehiscence. This comprehensive follow-up scheme encompassed both the critical proliferative phase and the subsequent maturation phase of scar healing, thereby enabling a robust assessment of long-term cosmetic outcomes and the confirmation of recurrence-free status.

Cost calculation

The total hospitalization costs were retrieved individually for each patient from the hospital’s financial billing system. The analysis encompassed all direct medical expenses incurred during the inpatient stay, including fees for the surgical procedure, anesthesia, operating room use, all disposable materials and equipment (including utilization of the endoscopic system), pharmaceuticals, routine nursing care, and room charges. Costs for any preoperative laboratory tests (e.g., complete blood count, biochemistry) and imaging studies performed prior to admission were excluded as they were completed before the hospitalization. Additionally, expenses related to the management of unrelated pre-existing conditions or subsequent outpatient visits were not included in this analysis.

Outcome measures

The primary outcome measure, aligning with the study’s focus on aesthetic outcomes, was the rate of postoperative anti-scar treatment. This objective surrogate was chosen as it directly reflects clinical dissatisfaction with cosmetic results and the subsequent need for intervention. Secondary outcome measures were selected to evaluate the comparative safety and efficiency profiles of the two techniques, and included operative duration, intraoperative and postoperative complication rates, length of hospital stay, and total hospitalization costs.

Surgical equipment and preoperative preparation

Standard surgical instruments, such as scalpels, ablation electrodes, and sutures, were used for conventional open surgery. For endoscopic-assisted surgery, in addition to traditional instruments, a Johnson & Johnson neuroendoscopy system and a self-fabricated “artificial subcutaneous channel” were employed.

Standard preoperative preparations are routinely implemented, including surgical site preparation (hair removal and skin antisepsis) and intravenous antibiotic prophylaxis administered according to institutional guidelines. Prior to surgery, written informed consent was obtained from each pediatric patient’s legal guardian(s) after comprehensive explanation of the procedure, including its risks, benefits, and alternative treatment options. All pediatric periorbital mass resections—whether performed via neuroendoscopic-assisted or conventional open approaches—are conducted in the dedicated neurosurgical operating room at Beijing Children’s Hospital. This specialized facility is staffed by trained neurosurgical nurses and anesthesiologists. Neuroendoscopic procedures are performed exclusively by attending neurosurgeons at the associate chief physician level or higher, all of whom possess advanced proficiency in neuroendoscopic techniques and have completed structured training programs in endoscopic neurosurgery techniques. These standardized protocols ensure optimal surgical execution and patient safety.

Surgical technique

Preoperatively, the mass location was marked on the skin and a surgical incision (1–3 cm long) was made within the hairline. Tunnel pathways were planned based on mass size, location, and incision design (Figure 2). A 10 mL sterile syringe was modified to create the “subcutaneous channel”, providing support and operating space for the endoscopic system and surgical tools. General anesthesia was used because of the young average age of the patients who could not cooperate with local infiltration anesthesia. The patients were placed in a supine position with the head turned to the healthy side or positioned at the midline. The surgical area was then disinfected and draped. An incision was made along the pre-designed path, cutting through the skin, subcutaneous tissue, and galea aponeurotica. Blunt and sharp dissection techniques were used to navigate the loose connective tissue layer beneath the galea aponeurotica to reach the mass and carefully identify anatomical structures to avoid damage to the blood vessels and nerves. The “artificial subcutaneous channel” was inserted to establish an operating space. The endoscope was introduced, and the procedure was performed under the neuroendoscopic monitor view (Figure 3). Meticulous hemostasis was maintained to ensure a clear surgical field. The mass was closely observed through the endoscope, and the surrounding tissue was dissected using scissors, electric hooks, or electrocautery. Bipolar coagulation was used as necessary for hemostasis, while protecting adjacent structures. The mass was excised entirely (Figure 4). The surgical cavity was irrigated with saline and a thorough inspection was performed to check for bleeding points. After complete hemostasis was achieved, the incision was closed in layers using interrupted sutures. Absorbable sutures were placed on the skin (Figure 5). No drains were placed and the surgical area was compressed using a bandage. All surgical procedures are performed under continuous anesthesiologist supervision with comprehensive physiological monitoring. The excised specimen was sent for pathological examination.

Figure 2 Surgical design. (A) Mass located at the brow ridge; incision within the hairline; dashed lines indicate the tunnel pathway, the right side is shown; (B) tunnel length approximately 3.5 cm, the right side is shown. This image is published with consent from the patient’s legal guardian.

Figure 3 Neuroendoscopic view. (A) Advancing through the loose connective tissue layer beneath the galea aponeurotica; (B,C) complete removal of the mass under endoscopic view; (D) electrocautery for hemostasis.

Figure 4 The mass after excision.

Figure 5 Surgical incision after suturing.

Statistical analysis

The data were organized and categorized using Microsoft Excel 2021. Descriptive statistics, such as the median, mean, and interquartile range (IQR), were calculated. Statistical analysis and visualization were performed using GraphPad Prism 10 (GraphPad Software Corporation, USA) and SPSS 22.0 (IBM Corporation, USA). For continuous variables, analysis of variance (ANOVA) was used if the data followed a normal distribution; otherwise, the Kruskal-Wallis test was applied. For categorical data, the Chi-squared test was used if the theoretical frequencies exceeded 5 and the total sample size was over 40; otherwise, the Fisher’s exact test was employed. Statistical significance was set at P<0.05.

Results

A total of 46 pediatric patients were included in this study, comprising 30 boys and 16 girls, aged 0–14 years, with a median age of 3 years (range, 1–5 years) (Table 1). After introducing the two surgical methods, the parents or guardians chose the surgical approach. Among the patients, 29 underwent conventional open surgery [21 boys, 8 girls; median age, 4 years (1–6 years)], while 17 underwent neuroendoscopy-assisted surgery [9 boys and 8 girls; median age, 1 year (1–3 years)]. The difference in the median age between the two surgical methods was statistically significant (P=0.02).

All 46 surgeries were successfully completed, and all masses were completely excised as confirmed by histopathological examination. The median mass volume was 0.42 cm³ (0.15–1.18 cm³) (Table 2). The median surgery duration for all procedures was 42.5 minutes (28.75–60 minutes). The average surgery duration was significantly longer for the new method (75.59±23.00 minutes) than the traditional method (31.62±13.24 minutes) (P<0.001). Pathological results included dermoid cysts (34 cases), calcified epitheliomas (4 cases), fibromas (2 cases), and one case each of lipoma, cranial fasciitis, Langerhans cell histiocytosis, thrombosed arterial aneurysm, sebaceous cyst, and lipoblastoma. The median length of hospitalization for all patients was 1 day (range, 1–2 days), with no significant difference between the two methods. The average hospitalization cost for all patients was RMB [Renminbi (Chinese Yuan)] 8,540.60. The new method incurred an average cost of RMB 8,223.81, whereas the traditional method incurred an average cost of RMB 8,726.30, with no statistically significant difference.

The median postoperative follow-up duration was 10 months (7–14 months). During this period, no recurrence of masses was observed in any of the 46 patients. Among the 17 patients who underwent the new method, specifically, no instances of edema, ecchymosis, infection, or other complications were observed, and all incisions achieved primary healing. Of the 29 patients who underwent the traditional method, 3 experienced complications: one case each of wound redness, infection, and dehiscence. There were no statistically significant differences in complication rates between the two methods. All 17 patients who underwent the new method had hidden incisions, achieving the expected aesthetic outcomes with good cosmetic effects (Figure 6A). None of the patients required antiscarring treatment. In contrast, 17 of the 29 patients who underwent the traditional method required anti-scar treatment (Figure 6B). Among the 17 patients, 15 received monotherapy with topical silicone gel, while the remaining 2 underwent a combined regimen of silicone gel and fractional carbon dioxide laser. All children were instructed to initiate silicone gel application to their surgical scars within 1–2 weeks postoperatively, consistent with standard preventive care. The two patients requiring laser therapy commenced treatment at 2 and 4 months post-surgery, respectively—timepoints that align with established protocols for managing early hypertrophic scarring. All interventions adhered to evidence-based scar management guidelines. The difference in the use of anti-scar treatment between the two methods was statistically significant (P<0.001).

Figure 6 Postoperative follow-up. (A) Neuroendoscopic excision with a scar hidden in the hairline, achieving good cosmetic outcomes, postoperative appearance of the left side at the 6-month postoperative final follow-up; (B) open excision with a scar located on the brow ridge, leaving visible scarring, postoperative appearance of the right side at the 5-month postoperative final follow-up. This image is published with consent from the patient’s legal guardian.

Discussion

Based on established surgical techniques, this study introduces a modification through a self-developed “subcutaneous operative channel”, formally designated as endoscopic resection of pediatric periorbital masses using a novel subcutaneous operative channel. We analyzed clinical data from 46 pediatric patients with periorbital masses who underwent either this modified endoscopic procedure or conventional open resection. Both techniques achieved complete mass excision with no statistically significant difference in complication rates (P=0.54), confirming the safety and efficacy of our endoscopic approach. Its most notable advantage was superior cosmetic outcomes, achieved at the cost of significantly longer operative time compared to open surgery (P<0.001). In conclusion, this initial single-center experience suggests that the novel endoscopic technique is a minimally invasive, safe, effective, and cost-comparable approach with excellent cosmetic results, warranting further validation through larger, multicenter studies.

As early as the beginning of the 21st century, researchers such as Matthew H. Steele and Jorge Orlando Guerrissi successfully resected periorbital masses in socially sensitive areas in both children and adults through concealed hairline incisions. Despite an inherent risk of nerve injury, their techniques achieved satisfactory aesthetic outcomes (28,29). With the increasing adoption of these methods, more clinicians have applied this approach in clinical practice, consistently achieving the expected cosmetic results, while the overall incidence of complications has shown a declining trend (2,26,27,30). However, in our center’s experience with these procedures, we observed that operating within such confined spaces often made it difficult to balance procedural fluency with adequate surgical field exposure. A review of the existing literature revealed that most studies did not report on this particular challenge, although one publication mentioned the use of “a delicate retractor” to create operational space (29), without providing specific details on its nature. Inspired by this concept, we discovered that a modified 10 mL sterile syringe (Figure 1) could be well adapted to the surgical space, providing effective support and exposure for the operative field, thereby effectively addressing the issue we encountered. Furthermore, given the abundance of important blood vessels and nerves superficial to the subgaleal loose connective tissue layer (31), our self-developed subcutaneous channel not only offers excellent support but also helps protect the overlying tissues and reduce the incidence of complications. Importantly, this channel is constructed from a readily available and low-cost 10 mL sterile syringe. We therefore believe that this modification represents a valuable refinement and enhancement of traditional endoscopic techniques, while also offering useful insights for future technical improvements in this surgical approach.

While the endoscopic resection of periorbital masses through concealed incisions yields excellent cosmetic outcomes, it comes at the cost of a significant prolongation of operative time. In our series, the mean operative time for conventional open surgery was 31.62±13.24 minutes, whereas our modified endoscopic technique required a substantially longer duration of 75.59±23.00 minutes, a difference that was statistically significant (P<0.001). Previous studies have similarly reported considerable operative times for endoscopic resection of periorbital or maxillofacial masses, with means of 41 minutes (range, 17–120 minutes) and 60.36±11.78 minutes, respectively (32,33), although these reports lacked direct comparison to open surgery. In our view, the prolonged duration is attributable to multiple factors, including but not limited to endoscopic equipment setup, construction of the subcutaneous operative channel, the surgeon’s position on the learning curve, and the time required for meticulous endoscopic dissection and instrument exchange. To address these challenges, we have implemented several measures: enhancing surgical proficiency, adopting the “chopsticks technique” to enable simultaneous manipulation of the endoscope, suction, and a third instrument to improve efficiency (34), and coordinating with the operating room to prepare pre-sterilized “self-made subcutaneous channels” in advance to reduce setup time. In summary, although the technique necessitates a longer operative time, the resultant satisfactory safety and superior cosmetic profile are highly encouraging. We anticipate that continued technical refinement and process optimization will further enhance the efficiency of this modified procedure.

Beyond operative duration, another point of interest is the total hospitalization cost. The average cost for conventional open surgery was RMB 8,726.30, compared to RMB 8,223.81 for our modified endoscopic technique, with no statistically significant difference. Interestingly, despite utilizing an endoscopic system and requiring longer operative time, the modified procedure incurred a lower mean cost. This apparent paradox can be explained by several factors. First, the minimal tissue trauma associated with the endoscopic approach often facilitated discharge on the day of surgery, optimizing hospitalization expenses compared to the conventional group. Second, the conventional surgery group routinely received prescription of silicone-based scar management materials during their inpatient stay, the cost of which was included in the total hospitalization fees; these relatively expensive materials constituted a primary driver of higher costs. Furthermore, the subcutaneous channel used in the modified technique, fashioned from a low-cost 10 mL sterile syringe, incurred negligible expense. In summary, the modified endoscopic technique effectively eliminates the cost of subsequent anti-scar interventions without generating additional expenses for specialized access devices, representing another significant advantage of our approach.

While our study confirms the advantages of our modified endoscopic technique, several limitations should be acknowledged. First, as a single-center, retrospective case series, future prospective multicenter studies are essential to more robustly validate the safety, efficacy, and cosmetic outcomes of this approach. Second, the data reflect our initial experience during the first year of implementing the technique, representing its early developmental phase; subsequent studies with larger sample sizes from our center will provide more powerful evidence as the technique matures. Finally, the study lacks objective scar assessment scales and validated patient-reported outcome measures, such as the Vancouver Scar Scale or structured satisfaction surveys. Incorporating such evaluative frameworks in future follow-up will enhance the objectivity and persuasiveness of our findings.

In summary, building upon established endoscopic techniques, our self-developed subcutaneous operative channel represents a meaningful modification. The refined procedure demonstrates favorable safety, efficacy, and cosmetic outcomes without incurring additional costs. Although it entails longer operative time, this drawback is expected to diminish with subsequent technical refinements. In future studies, we plan to conduct prospective, multicenter collaborations to more comprehensively validate the overall outcomes of this modified technique.

Conclusions

In conclusion, our study demonstrates that endoscopic resection of pediatric periorbital masses using a novel subcutaneous operative channel is a promising approach, offering potential advantages in minimal invasiveness, safety, and superior cosmetic outcomes without incurring additional costs. To definitively establish its efficacy and generalizability, future studies—preferably multicenter collaborations with larger sample sizes—are necessary to further validate its feasibility, safety, and cosmetic benefits. Additionally, technical refinements aimed at reducing operative duration represent an important focus for subsequent research.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-354/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-354/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2025-354/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2025-354/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of the Beijing Children’s Hospital, Capital Medical University (approval No. 2024-E-173-R). Written informed consent for this retrospective study was waived, while consent for image publication was obtained from the legal guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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