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Table of Contents    
Year : 2020  |  Volume : 68  |  Issue : 5  |  Page : 1019-1027

Fronto-Orbital Variant of Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms (f-Sokha)

Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication27-Oct-2020

Correspondence Address:
Prof. P Sarat Chandra
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.294827

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 » Abstract 

Objective: The following paper describes the technique and outcomes of fronto-orbital variant of supraorbital key hole approach (f-SOKHA) to clip anterior circulation aneurysms and compares the same with a similar cohort operated through pterional craniotomy (PT).
Material and Methods: Ambispective study (2012–2019); Technique applied for anterior circulation aneurysms. Contraindications included: Large hematomas, tense brain, avoided in poor grade (Hunt and Hess grade III and IV). Large frontal sinus: Relative contraindication. Procedure included a trans-ciliary skin incision, burr hole over key point, cutting of orbital roof via the burr hole, and removal of a single small fronto-orbital flap (1). This was followed by drilling of the inner table of the frontal bone (2). Both 1 and 2 resulted in expansion of the operative space by 60%. Results compared with a similar cohort of PT.
Results: n = 75 cases; most commonly used for ACom (anterior communicating: 43) followed by middle cerebral (16), internal cerebral (13), Posterior communicating (6), anterior cerebral (2), and anterior choroidal (1). Mean age: 47.9 ± 14 years; mean Hunt and Hess grade: 1.96 ± 1.35; duration of surgery: 203 ± 45 minutes, mean size of aneurysm: 6.96 ± 3.65 mm. Both blood loss and surgery duration was less (P: 0.099 and <0.001) when compared with a similar cohort with PT. It also demonstrated better cosmetic results and patient satisfaction.
Conclusions: f-SOKHA provided a larger operating corridor (60% more) as compared with the standard supra-orbital key-hole approaches while preserving the same degree of minimally invasive nature and cosmetic results.

Keywords: Aneurysm, anterior circulation, fronto orbital craniotomy, key hole, orbital rim, supraorbital, trans Ciliary
Key Message: f-SOKHA (fronto-orbital variant of supraorbital keyhole approach) for anterior circulation aneurysms provided an increased surgical corridor by 60%, while preserving the same degree of minimally invasive approach, cosmetic results, and patient satisfaction. It also resulted in equivalent results, lesser surgical time, and lesser blood loss as compared to a similar cohort of patients who underwent pterional craniotomy.

How to cite this article:
Chandra P S, Tej M, Sawarkar D, Agarwal M, Doddamani RS. Fronto-Orbital Variant of Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms (f-Sokha). Neurol India 2020;68:1019-27

How to cite this URL:
Chandra P S, Tej M, Sawarkar D, Agarwal M, Doddamani RS. Fronto-Orbital Variant of Supraorbital Keyhole Approach for Clipping Ruptured Anterior Circulation Aneurysms (f-Sokha). Neurol India [serial online] 2020 [cited 2021 Jun 12];68:1019-27. Available from:

Surgical clipping for aneurysms still forms the most definitive treatment for securing ruptured and un-ruptured aneurysms. The supraorbital keyhole concept in neurosurgery was first advocated by Perneczky in Germany.[1],[2],[3] The main advantages of this procedure include a direct short access to the target and excellent visualization, while preserving the minimally invasive principles. This approach also demonstrated the value of understanding the “reverse cone” or expanding cone concept while tackling intracranial pathologies through a “key hole” approach.[1],[4],[5]

The supraorbital keyhole approach offers equivalent access to the A-com—ACA complex and sellar to parasellar regions compared to the standard pterional craniotomy (PT). The major limitations of keyhole surgeries include: the limited operative field, the reduced working angle, and issues of tackling large frontal sinuses.[1],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] The supra-orbital keyhole craniotomy has been performed through both supraciliary and trans-palpebral incisions.[9],[23]

The fronto-orbital variant of the supra-orbital keyhole craniotomy (f-SOKHA), a modification introduced by the senior author (PSC), incorporates the roof of orbit by creating a single mini fronto-orbital flap. This along with combined technique of drilling the inner table of frontal bone to provide an expansion of the surgical corridor by 60%.

Subjects and methods

This is an ambispective observational study. All patients who underwent “Fronto-orbital variant of supraorbital keyhole approach” (f-SOKHA) for clipping of anterior circulation aneurysms between Jan 2012 and Jan 2019 by the senior surgeon (PSC) have been included.

Indications and contra-indications

We use f-SOKHA for the following indications:

  1. All anterior circulation aneurysms especially ACom, (anterior communicating artery), PCom (posterior communicating artery), and MCA (middle cerebral artery) aneurysms with CT scan showing relatively a lax brain (cisterns open, small sized hematoma, e.g., gyrus rectus hematoma). With gain of experience with this technique, other location aneurysms may also be performed which include superior hypophyseal, supra-clinoid, and paraclinoid aneurysms
  2. Un-ruptured anterior circulation aneurysms apparently constitutes good indication but not included in this cohort
  3. The author prefers to perform f-SOKHA in well preserved patients (Hunt and Hess grade I and II), even though some patients in the early part of the study had poor scores. Following poor outcomes and the potential need to perform large decompressive craniotomies in these patients, f-SOKHA was no longer used for poor grade patients
  4. The contraindications include presence of large hematomas with a full or tense brain. It is also not recommended in poor grade patients as it is felt that a large craniotomy with lax duroplasty along with decompressive craniotomy would be of greater benefit for these patients. Presence of a large frontal sinus is a relative contraindication. An extremely laterally placed MCA aneurysm is again a contraindication, as it is difficult to be accessed via f-SOKHA/SOKHA
  5. The large size of aneurysm is again a relative contraindication. Large sized aneurysms may be attempted once adequate experience and comfort is obtained in this technique.

Operative details (f-SOKHA)

The patient is placed in the supine position, with the head slightly elevated. The head was placed on a horse-shoe holder in neutral position. An incision was made over the eyebrow (preferred to be applied over the lower part of the eyebrow) using a no. 15 scalpel, starting just lateral to the supraorbital foramen, extending laterally to just behind the frontal process of the zygomatic bone [Figure 1]. The entire procedure starting from skin incision was performed using an operating microscope. The supraorbital nerve and artery, the frontal branches of the facial nerve, and the superficial temporal artery were preserved. Subcutaneous dissection was performed from the supraorbital foramen to the fronto-zygomatic suture. The periorbita was separated from the orbital rim. The McCarty key point was exposed. The skin incision was held separated with help of fish hooks. A burr hole was drilled on the “key point” using AM8 Midas Legend drill exposing both the periorbita and the dura. The lateral part roof of the orbit was exposed via the burr hole, the orbital roof was broken using a periosteal elevator and hammer. The lateral part only was broken as the medial part anyway is very thin. Next, a craniotomy was performed using a high-speed drill (B1 Midas Legend). The medial-inferior edge of the craniotomy went around the level of the frontal base and the lateral edge to the sphenoid wing creating a size of approximately 3 × 2.5 cm in size. A small fronto-orbital flap was created and this was removed carefully dissecting it from the peri-orbita. As explained in [Figure 1], removal of the orbital rim expands the operating space by 30%. Following the craniotomy, the inner table of the frontal bone was drilled using a diamond drill [Figure 2]. This technique enhanced the exposure by another 30% [Figure 1]. So, in effect, even though the size of the craniotomy was 2.5–3 cm, the effective space available for performing surgery was around 5–6 cm, which is equivalent to a small standard craniotomy.
Figure 1: The following figure shows the principles of f-SOKHA. [a] shows significantly reduced distance to the target using f-SOKHA. “a” is the distance from the surface to the aneurysms. Removal of the orbital roof (shaded area) allows the distance to be reduced significantly. In contrast a pterional approach (b) demands a greater distance from the surface to the target. [b] shows the direction of trans-ciliary skin incision to be given. The knife has to be cut parallel to the hair follicles rather across them. [c] shows the course of the temporo-facial branch of facial nerve as described by Pitanguy and Ramos. This branch is about 15 mm posterior to the lateral part of eyebrow. Care should be taken to preserve this branch or too much traction should not be applied with the fishhook applied over the lateral part of the incision [d] shows the fronto-orbital craniotomy flap which is removed in the f-SOKHA procedure. As may be seen here, it involves the part of frontal bone as well as the orbital roof. [e] shows the space gained by removal of the orbital rim and roof. (a) shows the space obtained by traditional supra orbital key hole approach. (b) shows the additional space 25-30% obtained by removal of the orbital rim. [f] shows additional space obtained by drilling of the inner table of the frontal bone. (b) shows the space which was obtained by removal of orbital rim as shown in figure E. (c) is the space which additionally obtained by drilling of the inner table of frontal bone. A combination of all these strategies create the inverted cone shaped approach desirable in an ideal minimally invasive approach. [g] shows the standard key hole approach where the orbital rim is not removed or the inner table of frontal bone is not drilled. The main limitation of this approach is that the craniotomy opening is limited in all directions by bony corridors

Click here to view
Figure 2: The following figure collage shows in brief the surgical procedure (see also Video). All the steps right from the skin incision should be performed under the microscope. [a] trans-ciliary skin incision is given on principles as shown in Figure 1b and C. The author (PSC) prefers to give the skin incision through the eyebrow, but more along the lower part. We do this as we feel that an incision given in the lower part of the eyebrow provides better cosmetic outcome. [b] The periosteal elevator is then used to gently dissect the peri-orbital from the roof of the orbit. [c] A burr hole is then placed over the standard “key” position. The burr hole is placed in such a manner, so that part of the burr hole is over the dura and part over the orbit. [d] A periosteal elevator is then used to fracture the lateral part roof of the orbit. [e] Following this, a craniotomy of size 2-3 cm is performed using a B1 (Midas Legend) and the fronto-orbital flap is removed “in toto”. The inner table of the frontal bone is then drilled using a diamond drill (not shown here). The peri-orbita should be preserved carefully. For the same reason, it is to be carefully separated from the roof of orbit using microscope. If there are tears, they must be carefully sutured. The nerve to levator palpabrae (Muller's nerve) is just under the nerve and must be carefully preserved as if damaged may lead to ptosis. [f] The dura is then opened in a curvi-linear manner with the base inferiorly. It is expected that on opening the dura, the brain will be right upto the surface. This is normal. The brain should be now gently elevated using a retractor and the sylvian cistern is then released to let out CSF [f]. Once the brain falls back, the approach to aneurysm is like a traditional microscopic approach. The ACom aneurysm is approached via the gyrus rectus approach (not shown here), the neck is dissected [g] and clipped [h]. The bone flap is replaced back using using mini plate and screws

Click here to view

A large frontal sinus is a relative contraindication to this approach. If the frontal sinus was entered, it was exteriorized by stripping its mucosa. The sinus was then packed with betadine gelfoam and covered with bone wax and periosteal flap during closure. It is important to close and exteriorize the sinus properly before opening the dura. If the peri-orbita was opening inadvertently, it is sutured carefully. The dura was opened in a linear fashion. Next, using a brain retractor, the frontal lobe is gently lifted, and the arachnoid of the sylvian cistern is opened up to let out the CSF following which the brain becomes lax. The arachnoid of the carotid cistern, the sylvian fissure, and suprasellar cisterns were now further opened and the CSF drained, to create enough room for brain retraction and surgical manipulation. Once the brain was lax, the standard procedure was followed using a microscope. For ACom aneurysms, the gyrus rectus approach was generally preferred. For others, again the usual micro-neurosurgical approaches were used. For MCA (middle cerebral artery) aneurysms, careful planning was required preoperatively. Lateral MCA aneurysms placed very close to the sphenoid ridge were not preferred to be operated by f-SOKHA. This procedure provided excellent cosmetic outcomes [Figure 3]. Again, f-SOKHA was used judiciously for selected indications as mentioned above and not for all cases. Once comfortable with standard anterior circulation aneurysms (ACom, PCom, MCA), this was used to clip supra-clinoid and paraclinoid aneurysms [Figure 4]. To increase CSF drainage, lamina terminalis was fenestrated in all cases. At the end of the operation, a watertight dural closure was obtained. Glue was always used to augment the dura to prevent any CSF leak as this complication could cause significant problems in this approach. The bone flap was secured using plate and screw systems. The skin was closed by subcuticular sutures [Figure 1] and [Figure 2], also see video].
Figure 3: [a] shows the surgical site in a patient on day 2 after surgery. The same patient at 3-month follow up [b]. The black dot shows the side of craniotomy. The cosmetic outcomes are also shown in other faces [c-f]. The last patient demonstrates the preservation of temporo-facial branch of facial nerve where the bilateral frontal creases are preserved on looking up [f]

Click here to view
Figure 4: [a] shows a giant para clinoid aneurysm. This was accessed using the f-SOKHA [b]. The anterior clinoid was drilled using the extra-dural corridor. [d and e] Two perpendicular fenestrated clips were used to secure the aneurysm after taking a control of ICA in the neck. Patient had a good neurological and cosmetic outcome. In addition, we found the approach quite suitable and provided an optimal corridor for treating this complex aneurysm

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Video Link:

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Data collection

The hospital records were accessed to collect data with respect to patient's demographic data, clinical details, angiography findings, operative details, hospital stay, complications, post op angiography and post-op CT scan.

The subjective satisfaction data was collected in the form of a questionnaire, which took pain, sensory, cosmetic, eye/mouth complications, and overall satisfaction. Thus, a score was obtained (out of 50) called the subjective satisfaction score. The score was validated in about 50 subjects before being subjected to patients undergoing f-SOKHA.

Postoperative computed tomography (CT) scan of the head was reviewed in all patients. Postoperative angiography was reviewed and analyzed. A P value of <0.05 was considered as significant.

 » Results Top

A total of 75 cases were operated using the f-SOKHA approach for clipping the aneurysms. The average size of aneurysms in the f-SOKHA group was 6.96 ± 3.65 mm. The locations include; ACom (43), MCA (16), ICA (13), PCom (6), ACA (2), and anterior choroidal (1). The location of aneurysms were similar to that compared to a cohort of patients operated through PT except for ACom aneurysms, which were preferred more via the f-SOKHA route [Figure 5]. The mean age of patients was 47.9 ± 14 years (females: 39). The grade of subarachnoid haemorrhage (SAH) as per Hunt and Hess was 1.96 ± 1.35. The clipping time was 5.11 ± 6.1 min and the duration of surgery was 203 ± 45 min. Blood loss was 369 ± 502 ml. The hospital stay was 11.25 ± 11.51 days. The subjective satisfaction score was 41 ± 2.27. To provide a comparison, this cohort was compared with a similar age/sex matched cohort of patients who underwent PT during this period. All parameters were similar except the duration of surgery was significantly less in f-SOKHA and the patient satisfaction in terms of peri-operative discomfort and cosmetic outcome was better for f-SOKHA group [Table 1]. The location of aneurysms was similar in both the groups except for ACom aneurysms which were more frequently operated by f-SOKHA (f-SOKHA: 43 vs PT: 18; [Figure 1]). The operative time and blood loss was less in the SOKHA group compared to the PT group [Table 1]. The subjective satisfaction score was significantly high in the SOKHA group [Table 1].
Figure 5: The following figure shows anatomical location of various types of aneurysms. As can be seen ACom was the most preferred aneurysm

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Table 1: Compares the differences in operative and subjective outcomes between Pterional (PT) and SOKHA groups

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The number of deaths in f-SOKHA were 5, (compared to n = 7 in the PT group), the difference was not significant (P = 0.149, [Table 2]). Of the patients who died, 3 developed severe vasospasm (grade II Hunt and Hess, Fischer grade III), and 2 were in poor grade (Hunt and Hess grade III). Other complications are mentioned in [Table 2]. Briefly, these include vasospasm (14; 18%), hydrocephalus (5, 6.7%), infarcts (13, 17.5%), decompressive craniectomy (4, 5.3%), and meningitis (3, 4%). Vasospasm was treated with triple-H therapy with the blood pressure increased by 25% from baseline using inotropes. They were then shifted for immediate intervention for intra-arterial nimodepine (IAN), which was provided as slow infusion lasting for 30–45 min. The resolution was confirmed postoperatively by DSA. Four patients required IAN more than once. 12/14 patients improved with this therapy, while 2 patients developed prolonged neurological deficits. Hydrocephalus was demonstrated by increased size of the ventricles as seen on CT scan and was communicating in nature in all cases. All patients were treated with a lumbar drain for 3–7 days, and this led to improvement in all cases. Infarcts in most cases were characterized by small lesions. (n = 6). Three developed neurological deficits (paresis) and 4 patients required decompressive craniotomy. Re-bleed occurred in 2 patients, in both cases, re-exploration, and re-clipping performed. Meningitis was treated appropriately. There was no difference in complications when compared with the PT cohort [Table 2]. Minor issues included orbital swelling (n = 9), which resolved with medical therapy in all cases.
Table 2: Complications of f-SOKHA and its comparison with pterional craniotomy (PT) cohort

Click here to view

Postoperative angiogram did not show any residual aneurysm except in 2 cases. Both the cases had complex Acom aneurysm, which was taking up the entire ACom junction. Both had circumferential dilatation, and following clip application, the residual bulge was reported as “residual” neck [Figure 6].
Figure 6: This figure shows clipping of a large circumferential ACom aneurysm. Since the bulk of the aneurysm is pointed posteriorly, a perpendicular fenestrated clip was applied to secure the aneurysm [a]. A 'bulge' was still left anteriorly (arrow). [c] shows the dissector shifting the A1 to demonstrate the complete application of the clip [d] shows the size of the surgical opening which just around 2 cm in height. Despite such a small height, additional space was created by removing the orbital rim and also drilling the inner table of the frontal bone

Click here to view

 » Discussion Top

Several studies of supraorbital keyhole approaches (SOKHA) have been described[1],[4],[7],[8],[9],[10],[11],[12],[14],[15],[16],[17],[20],[21],[22],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60] since the first description by Perneczky et al.[2],[3],[4],[5],[35] Bhatoe et al. from India described this approach for anterior circulation aneurysms.[21] Some authors have also described this technique for posterior circulation aneurysms.[33],[61] While this approach is mostly preferred for unruptured aneurysms, there have been studies which have demonstrated its use also in ruptured aneurysms.[3],[7],[58],[62] In this study, we have described a fronto-orbital variant of supraorbital keyhole craniotomy (f-SOKHA) and its comparison with the standard pterional craniotomy for its application for ruptured anterior circulation ruptured aneurysms. The standard supraorbital keyhole approach was purely a supraorbital approach. We have modified the craniotomy by incorporating the orbital rim and part of the orbital roof in the craniotomy and also drilling the inner table of the frontal bone. This resulted in expansion of the surgical corridor by about 60% without compromising the minimally invasive surgical principles and cosmetic outcome [Figure 1]. Rychen et al.[9],[34] carried out cadaveric dissections and virtual craniotomies and compared the skin incision, craniotomy location and size, the working angles, and the exposure of neurovascular structures achieved through trans-ciliary and trans-palpebral variants of the SOC. The skin incision measured 4 cm for the trans-palpebral and 3 cm for the trans-ciliary variant. The craniotomy size was 2.5 cm × 1.5 cm for both variants, and the trans-palpebral variant included an orbital osteotomy. The bony opening in the trans-palpebral variant was 1 cm more inferior. This alters the available working angles and may impede exposure of key structures during aneurysm surgery.[10] In f-SOKHA, we have used a skin incision similar to the trans-ciliary variant with additional orbital osteotomy making a craniotomy of 3 × 2.5 cm in size, which gives a better exposure craniocaudally and thus better working angles during surgery. As shown in [Figure 1], inclusion of the orbital rim increases the exposure by about 30%. In addition, drilling the inner table of the frontal bone again increases the exposure by another 30%. Thus, by using a craniotomy of size 3 cm, the exposure is enhanced to a size equivalent to about 5–6 cm. Thus, this exposure provides the surgeon the same degree of comfort of a small standard craniotomy. f-SOKHA also provided the access to drill the anterior clinoid process extra-durally to clip ICA aneurysms [Figure 4].

In our study, we found that the duration of surgery and blood loss for the f-SOKHA group was less compared to the pterional group (both groups having age, sex, and location of aneurysms matched). However, the size of aneurysms clipped in the SOKHA group were significantly smaller compared to the PT group. This was expected and has been corroborated by various other studies. Genesan P, et al.[49] in their study noted that the mean operating time for the pterional group was 226 min, compared to supraorbital group, which was 192 min (P = 0.07). Kim Y, et al.[44] in their study of 204 patients noted that the total operative time (P = 0.226), early ambulation time (P = 0.755), length of hospital stay (P = 0.784), Glasgow Coma Scale at discharge (P = 0.325), and Glasgow Outcome Scale scores (P = 0.427) did not show statistically significant differences. The amount of intraoperative blood loss was significantly lower in the supraorbital keyhole approach (P< 0.05). A recent meta-analysis demonstrated a shorter length of stay and operation time and a lower risk of postoperative infection with supraorbital keyhole approaches for aneurysms and have concluded that it seems to be equally effective and safe for clipping aneurysms as compared with pterional approaches.[63] However, “keyhole” approaches should be recommended for surgeons who have acquired sufficient experience with this technique owing to its advantages compared with the pterional approaches. Overall, it is apparent from our study and others in literature that “keyhole” approaches while reducing the operative time, and blood loss, early ambulation may result in the same levels of outcome.

In order to assess, we created a satisfaction score with advice from our clinical psychologist. It is a 10 point scoring system first validated in 50 patients undergoing standard craniotomies. The objective was to create parameters to assess patient satisfaction and comfort. This score was significantly better in f-SOKHA group as compared to the PT group. (41 in f-SOKHA vs. 37.74 in the Pterional group, P < 0.01). Reisch R, et al.[1],[35],[64] in their study of 418 patients of aneurysms, cysts, tumors concluded that supraorbital approach to the anterior, middle, and posterior fossa through an eyebrow incision offers a favorable rate of approach-associated surgical complications and high patient satisfaction with cosmetic outcome. Genesan P, et al.[49] also concluded that the supraorbital group had better cosmetic outcomes and shorter operating times compared to the pterional group. The main issue with the f-SOKHA approach is the likelihood for patients to develop a higher rate of orbit related complications. To avoid this, it is important to use the operating microscope right from the skin incision, perform careful dissection of the orbit, and preserve the periorbita. Using these precautions, we were able to minimize the orbital swelling and were able to provide optimal cosmetic results and patient satisfaction [Figure 2] and [Figure 3]. The complication rates in our series of f-SOKHA were similar to that of PT. The rate of complications were higher than those described in literature. The reason could be that we have used f-SOKHA for ruptured aneurysms as referrals to our center has this as the most common indication for surgery. Unruptured aneurysms mostly present with mass effect (e.g., compression on optic nerve etc) and require craniotomy. While f-SOKHA may be used for giant ICA aneurysms [Figure 4], but again the surgical strategy should be determined by the experience and comfort of the surgeon.

 » Conclusions Top

The following study demonstrated the technique, indications, and results of fronto-orbital variant of supraorbital keyhole approach (f-SOKHA) to ruptured anterior circulation aneurysms. The main limitation of this is that it is a single centre study. The study demonstrated lesser duration of surgery (P< 0.001), lesser blood loss (P 0.099), and better cosmetic results (as compared with a similar cohort of patients operated via pterional approach by the same surgeon). This minimally invasive approach provided 60% more space as compared to the standard supra-orbital keyhole approaches thus allowing greater exposure of the surgical field. The most common indication for performing this surgery was ACom aneurysms.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


We wish to acknowledge Dr Ashima Nehra (Professor, Clinical psychology) for having provided us the patient satisfaction score.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2]


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