We evaluated treatment of patients with anterior cranial base lesions with supraorbital keyhole surgery. Limited supraorbital craniotomy through an eyebrow skin incision was performed on 21 adult patients between August 2007 and January 2009 at one institution. Each patient's cosmesis was evaluated after the operation using a visual analog scale for cosmesis (VASC). Thirteen patients were treated for ruptured intracranial aneurysms and eight patients for mass lesions in the anterior cranial fossa. The mean follow-up duration was 16.5 months. No identifiable neurological or vascular complications related to this procedure were noted during follow-up; however, two patients died from causes unrelated to the procedure. Of the 19 patients who were followed-up, 89% of patients, and 84% by physician evaluation, were satisfied with the cosmetic result, noting > 75 mm on the VASC. Anterior cranial fossa lesions can be adequately and safely treated via a minimally invasive supraorbital craniotomy when performed on suitable patients by an experienced surgeon. This approach decreases brain manipulation and results in a pleasing cosmetic outcome while minimizing the likelihood of procedure-related morbidity.