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Obliteration of the frontal sinus with the pericranial flap
INNOVATIVE TECHNIQUES OBLITERATION OF THE FRONTAL SINUS WITH THE PERICRANIAL FLAP AFSHIN PARHISCAR, MD, GADY HAR-EL, MD, FACS
A host of autogenous and synthetic materials ranging from free fat, muscle, and bone to methylmethacrylate, hydroxyapatite cement, and glass beads have been used to obliterate the frontal sinus. These materials carry an increased risk of donor-site morbidity, as well as the risk of resorption, infection, and local inflammatory reactions. The pericranial flap is a local flap that can be used to obliterate small- and medium-sized frontal sinuses. This vascularized flap is easily and quickly harvested, and it avoids the morbidity associated with free-fat and cancellous bone grafts. Its ease of harvest, vascularity, and low complication rate make the pericranial flap an excellent alternative for frontal sinus obliteration.
Techniques in frontal sinus obliteration have progressed significantly from the radical resections performed in the mid-18th century. Although Runge, Reidel, Killian, and Kuhnt contributed significantly to the techniques used in frontal sinus obliteration, it was not until the late 19th century that Schonberg and Brieger popularized techniques that effectively obliterated the sinus, with concern for aesthetic outcome.1 Marx introduced free-fat grafts for frontal sinus obliteration in the early 20th century.1 The most popular current technique—anterior-wall osteoplastic flap with auologous fat obliteration—was introduced in the mid-20th century by Goodale and Montgomery.2 The pericranial flap has been used for frontal sinus obliteration over the last decade.3-5 In this paper, we describe the technique of using the pericranial flap for obliteration of the frontal sinus. We have found the pericranial flap to be a safe and effective method of frontal sinus obliteration. The pericranial flap is easy to harvest, requires no additional incisions, and does not cause additional morbidity.
TECHNIQUE The frontal sinus is approached through a standard bicoronal incision. The incision is carried through the skin to the level of the loose areolar tissue (Figure 1).6 If needed, dissection in this plane is carried posteriorly to gain more length for the pericranial flap. The pericranium is incised at the most posterior aspect of the dissection. The pericranium is elevated from the skull with a periosteal elevator. This dissection is carried anteriorly to the supraorbital rim in a subperiosteal plane. Although the arcus marginalis From the Department of Surgery, Plastic and Reconstructive Surgery, SUNY-Downstate and the Department of Otolaryngology, SUNY-Downstate, New York, NY. Address reprint requests to Gady Har-El, MD, FACS, Department of Otolaryngology, 134 Atlantic Avenue, Brooklyn, NY 11201. © 2004 Elsevier Inc. All rights reserved. 1043-1810/04/1501-0010$30.00/0 doi:10.1053/j.otot.2003.12.003
50
does not need to be released routinely, it can be done carefully while preserving the supraorbital and supratrochlear neurovascular bundle, if necessary. The flap is then covered with a saline-soaked gauze to prevent dessication. The frontal sinus can then be approached through its anterior wall with an osteoperiosteal flap. The sinus mucosa is removed carefully. The mucosa from the posterior wall should be separated meticulously to remove all remnants that can be trapped in the foramina of Brechet. A thin layer of bone can be removed from the posterior wall with a diamond burr. The mucosa within the frontal sinus outflow tract is then removed, and it can be packed with bone chips and/or fascia. The pericranial flap is then designed on the bicoronal flap. It is then dissected away from the bicoronal flap in the loose areolar plane with blunt and sharp dissection. A small Metzenbaum scissors is usually adequate for this dissection. The dissection is stopped 2 cm above the arcus marginalis to preserve the blood supply of the flap. The flap is then layered into the frontal sinus. The osteoperiosteal flap is then replaced and secured with microplates (Figure 2). If the osteoperiosteal flap is compressing the pedicle of the pericranial flap, then the bone segment can be shortened with a cutting burr. The bicoronal flap is then closed in layers after placement of a Jackson–Pratt drain. Sterile dressing is placed over the wound and the scalp is wrapped with a light pressure dressing. The Jackson–Pratt drain is removed when the drainage is less than 25 mL per 24 hours. Although the pericranial flap is usually based on the supratrochlear and supraorbital artery and vein, this flap can also be designed based on the anterior branch of the superficial temporal artery. This laterally based flap can be designed across the forehead to the contralateral side and used to obliterate the frontal sinus.4 In cases of frontal sinus fracture, the anterior-wall fragments are carefully removed and all mucosa is thoroughly debrided. These fragments can be used to reconstruct the anterior wall of the sinus with miniplates or titanium mesh. In cases of sinus mucopyocele or osteomyelitis of the sinus walls, using a vascularized pericranial flap for sinus
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY—HEAD AND NECK SURGERY, VOL 15, NO 1 (MAR), 2004: PP 50-52
FIGURE 1. The scalp is made of the following 5 layers: skin, subcutaneous tissue, aponeurosis and muscle, loose areolar tissue, and pericranium. The pericranial flap includes the pericranium and the loose areolar tissue.
FIGURE 2. The pericranial flap is layered into the frontal sinus after removal of the mucosa and plugging of the frontal sinus outflow tract. If the anterior-wall bone flap is available, then it is replaced and stabilized. PARHISCAR AND HAR-EL
51
obliteration is an excellent alternative to obliteration with avascular material. In cases where the anterior sinus wall is resorbed, the pericranial flap can be used as a filler, without bony reconstruction of the anterior sinus wall, to provide appropriate forehead contour. The pericranial flap is a reliable technique for frontal sinus obliteration. It is a local flap that can be used to obliterate small- and medium-sized frontal sinuses. This vascularized flap is easily and quickly harvested and avoids the morbidity associated with free-fat and cancellous bone grafts. Its ease of harvest and low complication rate make the pericranial flap an excellent alternative for frontal sinus obliteration.
52
REFERENCES 1. Lawson W: Frontal sinus, in Blitzer A, Lawson W, Friedman WH (eds): Surgery of the Paranasal Sinuses, 2nd ed. Philadelphia, Saunders, 1986, pp 183-184 2. Goodale RL, Montgomery WW: Anterior osteoplastic frontal sinus operation: Five years’ experience. Ann Otol 70:860-863, 1961 3. Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 4. Ducic Y, Stone TL: Frontal sinus obliteration using a latrally based pedicled pericranial flap. Laryngoscope 109:541-545, 1999 5. Parhiscar A, Har-El G: Frontal sinus obliteration with the pericranial flap. Otolaryngol Head Neck Surg 124:304-307, 2001 6. Tolhurst DE, Carstens MH, Greco RJ, et al: The surgical anatomy of the scalp. Plast Reconstr Surg 87:603-614, 1991
OBLITERATION OF THE FRONTAL SINUS WITH THE PERICRANIAL FLAP
A host of autogenous and synthetic materials ranging from free fat, muscle, and bone to methylmethacrylate, hydroxyapatite cement, and glass beads have been used to obliterate the frontal sinus. These materials carry an increased risk of donor-site morbidity, as well as the risk of resorption, infection, and local inflammatory reactions. The pericranial flap is a local flap that can be used to obliterate small- and medium-sized frontal sinuses. This vascularized flap is easily and quickly harvested, and it avoids the morbidity associated with free-fat and cancellous bone grafts. Its ease of harvest, vascularity, and low complication rate make the pericranial flap an excellent alternative for frontal sinus obliteration.
Techniques in frontal sinus obliteration have progressed significantly from the radical resections performed in the mid-18th century. Although Runge, Reidel, Killian, and Kuhnt contributed significantly to the techniques used in frontal sinus obliteration, it was not until the late 19th century that Schonberg and Brieger popularized techniques that effectively obliterated the sinus, with concern for aesthetic outcome.1 Marx introduced free-fat grafts for frontal sinus obliteration in the early 20th century.1 The most popular current technique—anterior-wall osteoplastic flap with auologous fat obliteration—was introduced in the mid-20th century by Goodale and Montgomery.2 The pericranial flap has been used for frontal sinus obliteration over the last decade.3-5 In this paper, we describe the technique of using the pericranial flap for obliteration of the frontal sinus. We have found the pericranial flap to be a safe and effective method of frontal sinus obliteration. The pericranial flap is easy to harvest, requires no additional incisions, and does not cause additional morbidity.
TECHNIQUE The frontal sinus is approached through a standard bicoronal incision. The incision is carried through the skin to the level of the loose areolar tissue (Figure 1).6 If needed, dissection in this plane is carried posteriorly to gain more length for the pericranial flap. The pericranium is incised at the most posterior aspect of the dissection. The pericranium is elevated from the skull with a periosteal elevator. This dissection is carried anteriorly to the supraorbital rim in a subperiosteal plane. Although the arcus marginalis From the Department of Surgery, Plastic and Reconstructive Surgery, SUNY-Downstate and the Department of Otolaryngology, SUNY-Downstate, New York, NY. Address reprint requests to Gady Har-El, MD, FACS, Department of Otolaryngology, 134 Atlantic Avenue, Brooklyn, NY 11201. © 2004 Elsevier Inc. All rights reserved. 1043-1810/04/1501-0010$30.00/0 doi:10.1053/j.otot.2003.12.003
50
does not need to be released routinely, it can be done carefully while preserving the supraorbital and supratrochlear neurovascular bundle, if necessary. The flap is then covered with a saline-soaked gauze to prevent dessication. The frontal sinus can then be approached through its anterior wall with an osteoperiosteal flap. The sinus mucosa is removed carefully. The mucosa from the posterior wall should be separated meticulously to remove all remnants that can be trapped in the foramina of Brechet. A thin layer of bone can be removed from the posterior wall with a diamond burr. The mucosa within the frontal sinus outflow tract is then removed, and it can be packed with bone chips and/or fascia. The pericranial flap is then designed on the bicoronal flap. It is then dissected away from the bicoronal flap in the loose areolar plane with blunt and sharp dissection. A small Metzenbaum scissors is usually adequate for this dissection. The dissection is stopped 2 cm above the arcus marginalis to preserve the blood supply of the flap. The flap is then layered into the frontal sinus. The osteoperiosteal flap is then replaced and secured with microplates (Figure 2). If the osteoperiosteal flap is compressing the pedicle of the pericranial flap, then the bone segment can be shortened with a cutting burr. The bicoronal flap is then closed in layers after placement of a Jackson–Pratt drain. Sterile dressing is placed over the wound and the scalp is wrapped with a light pressure dressing. The Jackson–Pratt drain is removed when the drainage is less than 25 mL per 24 hours. Although the pericranial flap is usually based on the supratrochlear and supraorbital artery and vein, this flap can also be designed based on the anterior branch of the superficial temporal artery. This laterally based flap can be designed across the forehead to the contralateral side and used to obliterate the frontal sinus.4 In cases of frontal sinus fracture, the anterior-wall fragments are carefully removed and all mucosa is thoroughly debrided. These fragments can be used to reconstruct the anterior wall of the sinus with miniplates or titanium mesh. In cases of sinus mucopyocele or osteomyelitis of the sinus walls, using a vascularized pericranial flap for sinus
OPERATIVE TECHNIQUES IN OTOLARYNGOLOGY—HEAD AND NECK SURGERY, VOL 15, NO 1 (MAR), 2004: PP 50-52
FIGURE 1. The scalp is made of the following 5 layers: skin, subcutaneous tissue, aponeurosis and muscle, loose areolar tissue, and pericranium. The pericranial flap includes the pericranium and the loose areolar tissue.
FIGURE 2. The pericranial flap is layered into the frontal sinus after removal of the mucosa and plugging of the frontal sinus outflow tract. If the anterior-wall bone flap is available, then it is replaced and stabilized. PARHISCAR AND HAR-EL
51
obliteration is an excellent alternative to obliteration with avascular material. In cases where the anterior sinus wall is resorbed, the pericranial flap can be used as a filler, without bony reconstruction of the anterior sinus wall, to provide appropriate forehead contour. The pericranial flap is a reliable technique for frontal sinus obliteration. It is a local flap that can be used to obliterate small- and medium-sized frontal sinuses. This vascularized flap is easily and quickly harvested and avoids the morbidity associated with free-fat and cancellous bone grafts. Its ease of harvest and low complication rate make the pericranial flap an excellent alternative for frontal sinus obliteration.
52
REFERENCES 1. Lawson W: Frontal sinus, in Blitzer A, Lawson W, Friedman WH (eds): Surgery of the Paranasal Sinuses, 2nd ed. Philadelphia, Saunders, 1986, pp 183-184 2. Goodale RL, Montgomery WW: Anterior osteoplastic frontal sinus operation: Five years’ experience. Ann Otol 70:860-863, 1961 3. Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 4. Ducic Y, Stone TL: Frontal sinus obliteration using a latrally based pedicled pericranial flap. Laryngoscope 109:541-545, 1999 5. Parhiscar A, Har-El G: Frontal sinus obliteration with the pericranial flap. Otolaryngol Head Neck Surg 124:304-307, 2001 6. Tolhurst DE, Carstens MH, Greco RJ, et al: The surgical anatomy of the scalp. Plast Reconstr Surg 87:603-614, 1991
OBLITERATION OF THE FRONTAL SINUS WITH THE PERICRANIAL FLAP