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Vascularized anteriorly based pericranial flap for frontal sinus obliteration
Operative Techniques in Otolaryngology (2009) 20, 88-91
Vascularized anteriorly based pericranial flap for frontal sinus obliteration Alex M. Mlynarek, MD, MSc, FRCSC, Hadi Seikaly, MD, FRCS From the Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. KEYWORDS Pericranial flap; Frontal sinus; Obliteration; Chronic sinusitis; Surgical flap
Even with the widespread use of minimally invasive endoscopic sinus surgery, the treatment of complicated frontal sinus disease remains very challenging, and obliteration of the sinus often is indicated. A variety of materials have been used for obliteration of the frontal sinus; however, the search for the ideal technique persists. The well-vascularized anteriorly based pericranial flap, described in this article, is a safe, effective, and viable method of frontal sinus obliteration. © 2009 Elsevier Inc. All rights reserved.
The management of chronic frontal sinus disease remains controversial and challenging. Endoscopic management is appropriate for most frontal sinus disease. Nevertheless, obliteration of the sinus by the use of various materials, such as fat, muscle, bone or hydroxyapatite, is indicated in the difficult-to-treat diseases. Many of these materials have been thoroughly investigated, and controversy persists as to which one is the ideal material. Meticulous removal of the entire mucosal lining is the most important element in successful frontal sinus obliteration. However, permanent occlusion of frontal recess and complete obliteration of the sinus are essential in avoiding recurrence of infections and preventing possible complications.1 We describe a novel method of frontal sinus obliteration that uses a composite flap involving the periosteum of the skull with its overlying loose areolar tissue (subgaleal fascia).
Indications Anterior pericranial flaps have been widely used in anterior cranial fossa repair, reconstruction of the middle third of face defects, full-thickness scalp defects, and orbital floor defects.2-4 Reports5,6 have been published in which the authors used this technique as an adjunct to sinus obliteration in the treatment of complicated frontal sinus infections, Address reprint requests and correspondence: Hadi Seikaly, MD, FRCS, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, 1E4.34 WMC, 8440 112 Street, Edmonton, AB T6G 2B7. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2009.07.002
such as those unresponsive to medical management or endoscopic sinus surgery, mucoceles, mucopyoceles, and osteomyelitis. Indications for frontal sinus obliteration include failure of endoscopic approaches to adequately communicate frontal sinus with the nasal cavity, loss of anterior bony table of the frontal sinus, severe fractures of floor of the frontal sinus, and benign tumors, such as osteomas.7
Technique The standard bicoronal incision is performed through the galea. The loose areolar tissue is then dissected off the posterior galea toward the vertex, extending the length of the pericranial flap. The pericranium is incised as far posteriorly as possible, and a subperiosteal dissection is carried up to the supraorbital rim, preserving the supratrochlear and supraorbital neurovascular bundles (Figure 1). The frontal sinus is outlined by use of either neuronavigation or a radiographic template. The anterior bony table is then removed by the use of a 2-mm burr. Sinus mucosa is meticulously exenterated with a periosteal elevator, and the interior of the sinus is carefully drilled with a medium-sized diamond burr. Frontal outflow tracts (also called nasofrontal ducts or nasofrontal ostiums) are then plugged with tempo parietal fascia and muscle. The anteriorly based pericranial flap is then elevated from the bicoronal scalp flap in a submusculoaponeurotic plane by the use of sharp dissection. The lateral limits of the dissection are the superior temporal lines. Anatomic studies have shown that a 10 ⫻ 12-cm flap can fill a 16-cc cavity (Figure 2).8
Mlynarek and Seikaly
Figure 1
Vascularized Anteriorly Based Pericranial Flap
89
Exposure of frontal sinus after coronal incision and subperiosteal elevation of flap. (Color version of figure is available online.)
Once the pericranial flap is harvested, it is then folded onto itself, obliterating the frontal sinus and augmenting the fascial plug (Figure 3). The anterior table plate is then replaced and plated, leaving a 2- to 3-mm gap inferiorly between the anterior table bone and the frontal bar, preventing any compromise to the blood supply of the flap pedicle (Figure 4). A closed-suction drain is then placed in the subgaleal space, the bicoronal is replaced, and the skin incision closed in a multilayer fashion.
Complications Possible complications of the anteriorly based pericranial flap include potential devascularization of anterior bony table and vascular compromise of the flap when the anterior table is replaced. Even though theoretically possible, neither of these complications has been previously reported. Devascularization and bone resorption is unlikely because well-vascularized tissues, including the pericranial flap internally and the galea, surround the bone externally. Leaving a 2- to 3-mm gap between the anterior bony table and the frontal bar prevents the vascular compromise of the pericranial flap.
Discussion The anteriorly based pericranial flap has been used with significant success in the repair of frontal sinus fractures, anterior
skull base surgery, and major head and neck reconstructive surgery to separate the intracranial from extracranial contents.2-4 This versatile flap has been reported in the treatment of complicated frontal sinus disease as an adjunct to sinus obliteration,5,6 as well as cranialization.9 The scalp consists of 5 layers: skin, subcutaneous tissue, aponeurosis and muscle, loose areolar tissue (subgaleal fascia), and pericranium. The subgalial fascia is a trilaminar structure consisting of a central dense fibrous layer in between 2 layers of loose areolar tissue.10 It is this layer that receives the rich blood supply from the peripheral arteries as well as perforating braches from the overlying galea. The pericranial flap is composed of the skull periosteum and the subgaleal fascia. The rich vascularity of the pericranial flap allows it to be designed based on 2 different axial pattern blood supplies. The anteriorly based flap receives its blood supply from the branches of supraorbital and supratrochlear arteries. Branches of the superficial temporal artery supply the laterally based flap.8,11 In contrast to all other avascular grafts used for sinus obliteration, such as fat, muscle, bone or hydroxyapatite, the anteriorly based pericranial flap is composed of a well-vascularized material. The high vascularity makes this flap less prone to infections and turns it into an ideal material for obliteration of an already infected cavity in a contaminated surgical field. Moreover, the blood supply to the flap does not rely on the frontal bone vessels, which is important when treating a chronically infected frontal sinus.
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Figure 2 Elevation of pericranial flap (10 ⫻ 12 cm) from the coronal flap. Frontal sinus has been exposed by removal of anterior table of frontal sinus. (Color version of figure is available online.)
Figure 3 Obliteration of the frontal sinus and frontal recess by folding pericranial flap onto itself and filling the frontal sinus. (Color version of figure is available online.)
Mlynarek and Seikaly
Figure 4 online.)
Vascularized Anteriorly Based Pericranial Flap
91
Osteoplastic flap is replaced and secured to the frontal bone by the use of miniplates. (Color version of figure is available
Aside from being a well-vascularized endogenous material, this flap has many other advantages.12 It is uncomplicated to harvest, and its size can be easily modified according to need. Moreover, the use of this flap avoids a second donor site and its associated morbidity. The authors of 2 case series have reported the use of this flap for treatment of chronic sinus infections and have found it to be safe and effective. At our institution we have reported on 12 patients with a 5-year average follow-up.5 There were no complications, and none of the patients required further treatment. Parhiscar and Har-El6 reported on 10 patients and found only 1 patient with an asymptomatic recurrence of a neofrontal sinus. Although there are no reports of significant immediate or late complications, theoretically this technique allows easy access for possible revision surgery. In conclusion, the anteriorly based pericranial flap is an easily harvested, well-vascularized endogenous material that is a safe, effective, and viable method of frontal sinus obliteration.
References 1. Kennedy DW, Bolger WE, Zinreich SJ: Diseases of the Sinuses: Diagnosis, and Management. Hamilton and London, BC Decker, 2001
2. Noone MC, Osguthorpe JD, Patel S: Pericranial flap for closure of paramedian anterior skull base defects. Otolaryngol Head Neck Surg 127:494-500, 2002 3. Smith JE, Yandranko D: The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 130:704711, 2004 4. Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 5. Moshaver A, Harris JR, Seikaly S: Use of anteriorly based pericranial flap in frontal sinus obliteration. Otolaryngol Head Neck Surg 135: 413-416, 2006 6. Parhiscar A, Har-El G: Frontal sinus obliteration with the pericranial flap. Otolaryngol Head Neck Surg 124:304-307, 2001 7. Mendians AE, Marks SC: Outcome of frontal sinus obliteration. Laryngoscope 109:1495-1498, 1999 8. Potparic Z, Fukuta K, Colen LB, et al: Galeo-pericranial flaps in the forehead: A study of blood supply and volumes. Br J Plast Surg 49:519-528, 1996 9. Donath A, Sindwani R: Frontal sinus canalization using the pericranial flap: An added layer of protection. Laryngoscope 116:15851588, 2006 10. Tolhurst DE, Carstens MH, Greco RJ, et al: The surgical anatomy of the scalp. Plast Reconstr Surg 87:603-614, 1991 11. Ducic Y, Stone TL: Frontal sinus obliteration using a laterally based pedicled pericranial flap. Laryngoscope 109:541-545, 1999 12. Argenta LC, Friedman RJ, Dingman RO, et al: The versatility of pericranial flaps. Plast Reconstr Surg 76:695-702, 1985
Vascularized anteriorly based pericranial flap for frontal sinus obliteration Alex M. Mlynarek, MD, MSc, FRCSC, Hadi Seikaly, MD, FRCS From the Division of Otolaryngology-Head and Neck Surgery, University of Alberta, Edmonton, Alberta, Canada. KEYWORDS Pericranial flap; Frontal sinus; Obliteration; Chronic sinusitis; Surgical flap
Even with the widespread use of minimally invasive endoscopic sinus surgery, the treatment of complicated frontal sinus disease remains very challenging, and obliteration of the sinus often is indicated. A variety of materials have been used for obliteration of the frontal sinus; however, the search for the ideal technique persists. The well-vascularized anteriorly based pericranial flap, described in this article, is a safe, effective, and viable method of frontal sinus obliteration. © 2009 Elsevier Inc. All rights reserved.
The management of chronic frontal sinus disease remains controversial and challenging. Endoscopic management is appropriate for most frontal sinus disease. Nevertheless, obliteration of the sinus by the use of various materials, such as fat, muscle, bone or hydroxyapatite, is indicated in the difficult-to-treat diseases. Many of these materials have been thoroughly investigated, and controversy persists as to which one is the ideal material. Meticulous removal of the entire mucosal lining is the most important element in successful frontal sinus obliteration. However, permanent occlusion of frontal recess and complete obliteration of the sinus are essential in avoiding recurrence of infections and preventing possible complications.1 We describe a novel method of frontal sinus obliteration that uses a composite flap involving the periosteum of the skull with its overlying loose areolar tissue (subgaleal fascia).
Indications Anterior pericranial flaps have been widely used in anterior cranial fossa repair, reconstruction of the middle third of face defects, full-thickness scalp defects, and orbital floor defects.2-4 Reports5,6 have been published in which the authors used this technique as an adjunct to sinus obliteration in the treatment of complicated frontal sinus infections, Address reprint requests and correspondence: Hadi Seikaly, MD, FRCS, Division of Otolaryngology-Head and Neck Surgery, University of Alberta, 1E4.34 WMC, 8440 112 Street, Edmonton, AB T6G 2B7. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2009.07.002
such as those unresponsive to medical management or endoscopic sinus surgery, mucoceles, mucopyoceles, and osteomyelitis. Indications for frontal sinus obliteration include failure of endoscopic approaches to adequately communicate frontal sinus with the nasal cavity, loss of anterior bony table of the frontal sinus, severe fractures of floor of the frontal sinus, and benign tumors, such as osteomas.7
Technique The standard bicoronal incision is performed through the galea. The loose areolar tissue is then dissected off the posterior galea toward the vertex, extending the length of the pericranial flap. The pericranium is incised as far posteriorly as possible, and a subperiosteal dissection is carried up to the supraorbital rim, preserving the supratrochlear and supraorbital neurovascular bundles (Figure 1). The frontal sinus is outlined by use of either neuronavigation or a radiographic template. The anterior bony table is then removed by the use of a 2-mm burr. Sinus mucosa is meticulously exenterated with a periosteal elevator, and the interior of the sinus is carefully drilled with a medium-sized diamond burr. Frontal outflow tracts (also called nasofrontal ducts or nasofrontal ostiums) are then plugged with tempo parietal fascia and muscle. The anteriorly based pericranial flap is then elevated from the bicoronal scalp flap in a submusculoaponeurotic plane by the use of sharp dissection. The lateral limits of the dissection are the superior temporal lines. Anatomic studies have shown that a 10 ⫻ 12-cm flap can fill a 16-cc cavity (Figure 2).8
Mlynarek and Seikaly
Figure 1
Vascularized Anteriorly Based Pericranial Flap
89
Exposure of frontal sinus after coronal incision and subperiosteal elevation of flap. (Color version of figure is available online.)
Once the pericranial flap is harvested, it is then folded onto itself, obliterating the frontal sinus and augmenting the fascial plug (Figure 3). The anterior table plate is then replaced and plated, leaving a 2- to 3-mm gap inferiorly between the anterior table bone and the frontal bar, preventing any compromise to the blood supply of the flap pedicle (Figure 4). A closed-suction drain is then placed in the subgaleal space, the bicoronal is replaced, and the skin incision closed in a multilayer fashion.
Complications Possible complications of the anteriorly based pericranial flap include potential devascularization of anterior bony table and vascular compromise of the flap when the anterior table is replaced. Even though theoretically possible, neither of these complications has been previously reported. Devascularization and bone resorption is unlikely because well-vascularized tissues, including the pericranial flap internally and the galea, surround the bone externally. Leaving a 2- to 3-mm gap between the anterior bony table and the frontal bar prevents the vascular compromise of the pericranial flap.
Discussion The anteriorly based pericranial flap has been used with significant success in the repair of frontal sinus fractures, anterior
skull base surgery, and major head and neck reconstructive surgery to separate the intracranial from extracranial contents.2-4 This versatile flap has been reported in the treatment of complicated frontal sinus disease as an adjunct to sinus obliteration,5,6 as well as cranialization.9 The scalp consists of 5 layers: skin, subcutaneous tissue, aponeurosis and muscle, loose areolar tissue (subgaleal fascia), and pericranium. The subgalial fascia is a trilaminar structure consisting of a central dense fibrous layer in between 2 layers of loose areolar tissue.10 It is this layer that receives the rich blood supply from the peripheral arteries as well as perforating braches from the overlying galea. The pericranial flap is composed of the skull periosteum and the subgaleal fascia. The rich vascularity of the pericranial flap allows it to be designed based on 2 different axial pattern blood supplies. The anteriorly based flap receives its blood supply from the branches of supraorbital and supratrochlear arteries. Branches of the superficial temporal artery supply the laterally based flap.8,11 In contrast to all other avascular grafts used for sinus obliteration, such as fat, muscle, bone or hydroxyapatite, the anteriorly based pericranial flap is composed of a well-vascularized material. The high vascularity makes this flap less prone to infections and turns it into an ideal material for obliteration of an already infected cavity in a contaminated surgical field. Moreover, the blood supply to the flap does not rely on the frontal bone vessels, which is important when treating a chronically infected frontal sinus.
90
Operative Techniques in Otolaryngology, Vol 20, No 2, June 2009
Figure 2 Elevation of pericranial flap (10 ⫻ 12 cm) from the coronal flap. Frontal sinus has been exposed by removal of anterior table of frontal sinus. (Color version of figure is available online.)
Figure 3 Obliteration of the frontal sinus and frontal recess by folding pericranial flap onto itself and filling the frontal sinus. (Color version of figure is available online.)
Mlynarek and Seikaly
Figure 4 online.)
Vascularized Anteriorly Based Pericranial Flap
91
Osteoplastic flap is replaced and secured to the frontal bone by the use of miniplates. (Color version of figure is available
Aside from being a well-vascularized endogenous material, this flap has many other advantages.12 It is uncomplicated to harvest, and its size can be easily modified according to need. Moreover, the use of this flap avoids a second donor site and its associated morbidity. The authors of 2 case series have reported the use of this flap for treatment of chronic sinus infections and have found it to be safe and effective. At our institution we have reported on 12 patients with a 5-year average follow-up.5 There were no complications, and none of the patients required further treatment. Parhiscar and Har-El6 reported on 10 patients and found only 1 patient with an asymptomatic recurrence of a neofrontal sinus. Although there are no reports of significant immediate or late complications, theoretically this technique allows easy access for possible revision surgery. In conclusion, the anteriorly based pericranial flap is an easily harvested, well-vascularized endogenous material that is a safe, effective, and viable method of frontal sinus obliteration.
References 1. Kennedy DW, Bolger WE, Zinreich SJ: Diseases of the Sinuses: Diagnosis, and Management. Hamilton and London, BC Decker, 2001
2. Noone MC, Osguthorpe JD, Patel S: Pericranial flap for closure of paramedian anterior skull base defects. Otolaryngol Head Neck Surg 127:494-500, 2002 3. Smith JE, Yandranko D: The versatile extended pericranial flap for closure of skull base defects. Otolaryngol Head Neck Surg 130:704711, 2004 4. Thaller SR, Donald P: The use of pericranial flaps in frontal sinus fractures. Ann Plast Surg 32:284-287, 1994 5. Moshaver A, Harris JR, Seikaly S: Use of anteriorly based pericranial flap in frontal sinus obliteration. Otolaryngol Head Neck Surg 135: 413-416, 2006 6. Parhiscar A, Har-El G: Frontal sinus obliteration with the pericranial flap. Otolaryngol Head Neck Surg 124:304-307, 2001 7. Mendians AE, Marks SC: Outcome of frontal sinus obliteration. Laryngoscope 109:1495-1498, 1999 8. Potparic Z, Fukuta K, Colen LB, et al: Galeo-pericranial flaps in the forehead: A study of blood supply and volumes. Br J Plast Surg 49:519-528, 1996 9. Donath A, Sindwani R: Frontal sinus canalization using the pericranial flap: An added layer of protection. Laryngoscope 116:15851588, 2006 10. Tolhurst DE, Carstens MH, Greco RJ, et al: The surgical anatomy of the scalp. Plast Reconstr Surg 87:603-614, 1991 11. Ducic Y, Stone TL: Frontal sinus obliteration using a laterally based pedicled pericranial flap. Laryngoscope 109:541-545, 1999 12. Argenta LC, Friedman RJ, Dingman RO, et al: The versatility of pericranial flaps. Plast Reconstr Surg 76:695-702, 1985