TECHNICAL STRATEGY
A Simple Aesthetic Approach for Correction of Frontal Sinus Fracture Nam Hoon Kim, MD and Seok Joo Kang, MD Purpose: Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern. The purpose of this study was to introduce the simple and effective method in the surgical treatment of the anterior wall of frontal sinus fractures. Methods: All 11 patients who presented with anterior wall fractures of the frontal sinus between 2009 and 2013 were included in this study. Two 7-mm stab incisions were made on each side of the fracture, a titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector. One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side. Results: No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results. Conclusion: We obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures. Key Words: Frontal sinus, maxillofacial fractures, minimal invasive
depression of the anterior wall, accounts for approximately one third of cases. Approximately two thirds of cases involve posterior wall or frontonasal duct injury.3 Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern.2 Bicoronal incision is the classic approach to treating the anterior wall after frontal sinus fracture. This technique provides sufficient proximity to the fracture site for visualization during surgery.4 However, this method results in a large scar across the entire scalp and can result in complications such as paresthesia, blood loss, and alopecia. Various less invasive methods have been attempted to reduce the complications associated with the bicoronal approach. These methods include a short forehead incision line, closed reduction using tools such as a K-wire, and the use of an endoscope through a small forehead incision. However, these methods have several disadvantages; they do not provide a sufficient field of view, they have very limited indications because fixation is not possible when too much time has elapsed after the fracture, surgery is feasible for simple fractures only, and the use of endoscopy with these methods prolongs the surgery time. In the current study, we report a simple method for surgery of the isolated depressed anterior wall fracture of the frontal sinus using a minimal incision and a C-arm through which an effect similar to open reduction was achieved.
PATIENTS AND METHODS
(J Craniofac Surg 2014;25: 544Y546)
F
rontal sinus fractures account for approximately 5% to 15% of all maxillofacial area fractures and can be accompanied by neurological injuries as well as other fractures such as orbital, zygomatic, naso-orbitoethmoidal, and maxillary fractures.1 The frontal sinus consists of the anterior wall, posterior wall, and nasofrontal duct and has a close relationship with the orbit, nose, and neurocranium. Because of this complex anatomical structure, the treatment of frontal sinus fractures requires a multifaceted approach.2 The most common type of frontal sinus injury, the isolated
The study included 11 patients who were treated at our hospital for displaced anterior wall fractures of the frontal sinus between January 2009 and December 2012. All 11 subjects were men, and their ages at the time of injury ranged from 17 to 35 years (mean age, 23 years). Patients were excluded from the current study if they had nasofrontal duct damage or a posterior wall fracture. Patients with a history of neurological surgery were also excluded. After each patient’s general condition had stabilized and swelling of the soft tissue of the frontal area had receded, each fracture was approached for reduction.
Surgical Technique From the Department of Plastic and reconstructive Surgery, Baik Hospital, Inje University, Busan, Korea. Received August 17, 2013. Accepted for publication September 16, 2013. Address correspondence and reprint requests to Seok Joo Kang, MD, Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, 75 Bokji-ro, Busan Jin-gu, Busan 614-735, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000469
544
The procedure was conducted under general anesthesia with the patient in the supine position. Local anesthesia should not be used because the extra fluid makes orientation more difficult. The distances between the most prominent area of the lateral orbital rim, midline, and point of fracture were measured on a coronal image of the preoperative facial bone computed tomography (CT) to confirm the fractured area (Fig. 1). The distance between the most prominent area at the edge of the patient’s eyebrow and the midline was then measured. The surgical site was determined though the correlation of this measurement with the value measured on CT (Fig. 2).
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Correction of Frontal Sinus Fracture
FIGURE 1. The fracture area is measured in the surgical planning process.
FIGURE 4. Photographs of the C-arm during surgery. A, Prereduction. B, Postreduction.
DISCUSSION
FIGURE 2. The illustration of surgical process.
Setting the fracture point as the midpoint, two 7-mm stab incisions were made on each side of the fracture and dissected above the frontal bone to create a sufficient surgical area. During the creation of incisions on the medial side, attention was given to the supratrochlear neurovascular bundle and the supraorbital neurovascular bundle. In addition, any dissection below the cranial incision lines was always made from the lateral side to the medial side to minimize neuronal and vascular injury. A titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector to ensure that the fragment did not enter the sinus cavity (Fig. 3). One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side (Fig. 4). After precise fixation was confirmed, the titanium screw was removed, and an absorbable plate was inserted. Compressive dressings were lightly applied for 2 days after the surgery; no separate external splinting was performed.
RESULTS The elapsed time between the injury and surgery was 7 to 21 days, and the postoperative follow-up duration ranged from 6 months to 2 years. All 11 patients underwent a postoperative CT scan at 7 to 60 days postoperatively, and all showed good alignment of the anterior wall (Fig. 5). No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results (Fig. 6).
FIGURE 3. The surgical process.
The frontal sinus is located within the frontal bone between the naso-orbitoethmoidal region and the anterior cranial fossa. Accordingly, the diagnosis and surgical treatment of frontal sinus fractures must take into account not only the neurocranium, orbit, and nose but also the resulting appearance of the forehead.1 There are a few classifications for frontal sinus fractures, but most are based on anatomical location and are decided according to surgical findings. In anterior wall fracture surgery, which accounts for approximately one third of all frontal sinus fractures, a bicoronal incision is made through the conventional approach. The advantages of this method are that it enables full exposure of the frontal bone and that it makes it possible to operate on lesions within the cranium.4 However, the broad-range dissection involved in a bicoronal incision leaves a distinct scar on the entire scalp and may result in paresthesia, alopecia, gross blood loss, and temporal hollowing of the scalp and forehead.5 Thus, in patients with isolated anterior wall fractures, the surgical scar may cause greater discomfort than that related to the forehead depression that develops in the absence of surgery. Therefore, the use of a minimally invasive technique that does not require the use of a bicoronal incision significantly increases the overall aesthetic outcome of the treatment of frontal sinus fractures. In 1979, McGrath and Smith6 used stainless wires and minimal incisions to operate on the anterior wall of frontal sinus instead of using a bicoronal incision; since then, various less invasive surgical methods have been reported. However, surgeries involving small skin incisions, wires, and screws do not allow for sufficient visualization of the fractured area. Because the degree of fixation cannot be confirmed, fixation is difficult when time has elapsed after an injury is sustained. Creating firm postsurgical fixation is also difficult. Thus, we accounted for several points during the preoperative, intraoperative, and postoperative stages to obtain the effects of an open approach using a minimally invasive approach.
FIGURE 5. Preoperative and postoperative CT of the facial bone.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
545
Kim et al
The Journal of Craniofacial Surgery
FIGURE 6. Facial photographs at 3 months after surgery. A good forehead line is maintained, and the scar is not very visible.
First, we estimated the surgical area as accurately as possible using a preoperative facial CT. Precise knowledge of the surgical area is crucial to the use of minimal incisions rather than a wide incision. Computed tomography is the widely used criterion standard in the diagnosis of facial fractures and is very useful for identifying the location and severity of fractures before frontal sinus fracture surgery.1 We did not use additional scans or equipment. The fracture area was calculated using previously taken CT images, and the surgery was conducted using just 2 or 3 incisions in the appropriate areas. Accordingly, the surgery time, surgical scars, and complications were decreased compared with those of broad-range dissections. Second, titanium screws with attached wires were used intraoperatively to raise the depressed fragment; simultaneously, a C-arm was used to confirm accurate reduction. As such, we addressed the disadvantage of closed reduction. Although 2 or 3 small skin incisions were made, adequate reduction was still possible because wide dissections were performed above the bone. Surgery was also possible in cases in which 2 weeks had elapsed since the injury, whereas the same would be difficult using previous minimal surgical methods. The metal screw used in the fixation process was removed immediately after precise fixation was confirmed. Third, firm postoperative fixation using an absorbable plate expanded the previously limited indications for surgery and
546
& Volume 25, Number 2, March 2014
eliminated the need for a second surgery to remove a metal plate. Patients who undergo secondary surgeries to remove metal plates complain of discomfort associated with the palpable metal plate and screw as well as facial cold intolerance and pain.7 Because the zygomaticofrontal suture area has thin soft tissue and is proximal to the temporalis muscle, patients also commonly complain of discomfort after bicoronal incisive surgery, and undergoing a second surgery further exacerbates their discomfort.8 Although the method proposed here has the above advantages, there was a need to elongate the incision lines in cases in which fractures were widespread or involved several fragments. Another disadvantage is that because adequate visualization during surgery is not possible, the operator must receive extensive training to become familiar with this surgical technique. Here we obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures.
REFERENCES 1. Manolidis S, Hollier Jr LH. Management of frontal sinus fractures. Plast Reconstr Surg 2007;12:32SY48S 2. Molendijk J, van der Wal KG, Koudstaal MJ. Surgical treatment of frontal sinus fractures : the simple percutaneous reduction revised. Int J Oral Maxillofac Surg 2012;41:1192Y1194 3. Sataloff RT, Sariego J, Meyers DL, et al. Surgical management of the frontal sinus. Neurosurgery 1984;15:593Y596 4. Yavuzer R, Jackson IT. Coronal incision extending postauricularly. Plast Reconstr Surg 1993;103:1532 5. Chen DJ, Chen CT, Chen YR, et al. Endoscopically assisted repair of frontal sinus fracture. J Trauma 2003;55:378Y382 6. McGrath MH, Smith CJ. A simple method to maintain reduction of unstable fractures of the frontal sinus. Plast Reconstr Surg 1981;68:948Y949 7. Aziz SR, Ziccardi VB, Borah G. Current therapy: complications associated with rigid internal fixation of facial fractures. Compend Contin Dent 2005;26:565Y571 8. Haug RH, Cunningham LL, Brandt MT. Plates, screws and children: their relationship in craniomaxillofacial trauma. J Long Term Eff Med Implants 2003;13:271Y287
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
A Simple Aesthetic Approach for Correction of Frontal Sinus Fracture Nam Hoon Kim, MD and Seok Joo Kang, MD Purpose: Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern. The purpose of this study was to introduce the simple and effective method in the surgical treatment of the anterior wall of frontal sinus fractures. Methods: All 11 patients who presented with anterior wall fractures of the frontal sinus between 2009 and 2013 were included in this study. Two 7-mm stab incisions were made on each side of the fracture, a titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector. One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side. Results: No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results. Conclusion: We obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures. Key Words: Frontal sinus, maxillofacial fractures, minimal invasive
depression of the anterior wall, accounts for approximately one third of cases. Approximately two thirds of cases involve posterior wall or frontonasal duct injury.3 Frontal sinus fracture management remains controversial and involves preserving function whenever possible or obliterating the sinus and duct as required by the fracture pattern.2 Bicoronal incision is the classic approach to treating the anterior wall after frontal sinus fracture. This technique provides sufficient proximity to the fracture site for visualization during surgery.4 However, this method results in a large scar across the entire scalp and can result in complications such as paresthesia, blood loss, and alopecia. Various less invasive methods have been attempted to reduce the complications associated with the bicoronal approach. These methods include a short forehead incision line, closed reduction using tools such as a K-wire, and the use of an endoscope through a small forehead incision. However, these methods have several disadvantages; they do not provide a sufficient field of view, they have very limited indications because fixation is not possible when too much time has elapsed after the fracture, surgery is feasible for simple fractures only, and the use of endoscopy with these methods prolongs the surgery time. In the current study, we report a simple method for surgery of the isolated depressed anterior wall fracture of the frontal sinus using a minimal incision and a C-arm through which an effect similar to open reduction was achieved.
PATIENTS AND METHODS
(J Craniofac Surg 2014;25: 544Y546)
F
rontal sinus fractures account for approximately 5% to 15% of all maxillofacial area fractures and can be accompanied by neurological injuries as well as other fractures such as orbital, zygomatic, naso-orbitoethmoidal, and maxillary fractures.1 The frontal sinus consists of the anterior wall, posterior wall, and nasofrontal duct and has a close relationship with the orbit, nose, and neurocranium. Because of this complex anatomical structure, the treatment of frontal sinus fractures requires a multifaceted approach.2 The most common type of frontal sinus injury, the isolated
The study included 11 patients who were treated at our hospital for displaced anterior wall fractures of the frontal sinus between January 2009 and December 2012. All 11 subjects were men, and their ages at the time of injury ranged from 17 to 35 years (mean age, 23 years). Patients were excluded from the current study if they had nasofrontal duct damage or a posterior wall fracture. Patients with a history of neurological surgery were also excluded. After each patient’s general condition had stabilized and swelling of the soft tissue of the frontal area had receded, each fracture was approached for reduction.
Surgical Technique From the Department of Plastic and reconstructive Surgery, Baik Hospital, Inje University, Busan, Korea. Received August 17, 2013. Accepted for publication September 16, 2013. Address correspondence and reprint requests to Seok Joo Kang, MD, Department of Plastic and Reconstructive Surgery, Busan Baik Hospital, Inje University School of Medicine, 75 Bokji-ro, Busan Jin-gu, Busan 614-735, Korea; E-mail: [email protected] The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000469
544
The procedure was conducted under general anesthesia with the patient in the supine position. Local anesthesia should not be used because the extra fluid makes orientation more difficult. The distances between the most prominent area of the lateral orbital rim, midline, and point of fracture were measured on a coronal image of the preoperative facial bone computed tomography (CT) to confirm the fractured area (Fig. 1). The distance between the most prominent area at the edge of the patient’s eyebrow and the midline was then measured. The surgical site was determined though the correlation of this measurement with the value measured on CT (Fig. 2).
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 2, March 2014
Correction of Frontal Sinus Fracture
FIGURE 1. The fracture area is measured in the surgical planning process.
FIGURE 4. Photographs of the C-arm during surgery. A, Prereduction. B, Postreduction.
DISCUSSION
FIGURE 2. The illustration of surgical process.
Setting the fracture point as the midpoint, two 7-mm stab incisions were made on each side of the fracture and dissected above the frontal bone to create a sufficient surgical area. During the creation of incisions on the medial side, attention was given to the supratrochlear neurovascular bundle and the supraorbital neurovascular bundle. In addition, any dissection below the cranial incision lines was always made from the lateral side to the medial side to minimize neuronal and vascular injury. A titanium screw with an attached wire was fixed to the fractured fragment, and an elevator was used to apply force in the opposite vector to ensure that the fragment did not enter the sinus cavity (Fig. 3). One titanium screw was also fixed to the firm normal frontal bone, and the reduction was conducted by observing the C-arm until the fractured fragment reached the height of the normal side (Fig. 4). After precise fixation was confirmed, the titanium screw was removed, and an absorbable plate was inserted. Compressive dressings were lightly applied for 2 days after the surgery; no separate external splinting was performed.
RESULTS The elapsed time between the injury and surgery was 7 to 21 days, and the postoperative follow-up duration ranged from 6 months to 2 years. All 11 patients underwent a postoperative CT scan at 7 to 60 days postoperatively, and all showed good alignment of the anterior wall (Fig. 5). No patients showed any recurrent displacement or infection during the follow-up period, nor did any patient complain of or demonstrate forehead paresthesia. The surgical scar was less than 3 cm in all 11 patients, and all of them reported satisfaction with the results (Fig. 6).
FIGURE 3. The surgical process.
The frontal sinus is located within the frontal bone between the naso-orbitoethmoidal region and the anterior cranial fossa. Accordingly, the diagnosis and surgical treatment of frontal sinus fractures must take into account not only the neurocranium, orbit, and nose but also the resulting appearance of the forehead.1 There are a few classifications for frontal sinus fractures, but most are based on anatomical location and are decided according to surgical findings. In anterior wall fracture surgery, which accounts for approximately one third of all frontal sinus fractures, a bicoronal incision is made through the conventional approach. The advantages of this method are that it enables full exposure of the frontal bone and that it makes it possible to operate on lesions within the cranium.4 However, the broad-range dissection involved in a bicoronal incision leaves a distinct scar on the entire scalp and may result in paresthesia, alopecia, gross blood loss, and temporal hollowing of the scalp and forehead.5 Thus, in patients with isolated anterior wall fractures, the surgical scar may cause greater discomfort than that related to the forehead depression that develops in the absence of surgery. Therefore, the use of a minimally invasive technique that does not require the use of a bicoronal incision significantly increases the overall aesthetic outcome of the treatment of frontal sinus fractures. In 1979, McGrath and Smith6 used stainless wires and minimal incisions to operate on the anterior wall of frontal sinus instead of using a bicoronal incision; since then, various less invasive surgical methods have been reported. However, surgeries involving small skin incisions, wires, and screws do not allow for sufficient visualization of the fractured area. Because the degree of fixation cannot be confirmed, fixation is difficult when time has elapsed after an injury is sustained. Creating firm postsurgical fixation is also difficult. Thus, we accounted for several points during the preoperative, intraoperative, and postoperative stages to obtain the effects of an open approach using a minimally invasive approach.
FIGURE 5. Preoperative and postoperative CT of the facial bone.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
545
Kim et al
The Journal of Craniofacial Surgery
FIGURE 6. Facial photographs at 3 months after surgery. A good forehead line is maintained, and the scar is not very visible.
First, we estimated the surgical area as accurately as possible using a preoperative facial CT. Precise knowledge of the surgical area is crucial to the use of minimal incisions rather than a wide incision. Computed tomography is the widely used criterion standard in the diagnosis of facial fractures and is very useful for identifying the location and severity of fractures before frontal sinus fracture surgery.1 We did not use additional scans or equipment. The fracture area was calculated using previously taken CT images, and the surgery was conducted using just 2 or 3 incisions in the appropriate areas. Accordingly, the surgery time, surgical scars, and complications were decreased compared with those of broad-range dissections. Second, titanium screws with attached wires were used intraoperatively to raise the depressed fragment; simultaneously, a C-arm was used to confirm accurate reduction. As such, we addressed the disadvantage of closed reduction. Although 2 or 3 small skin incisions were made, adequate reduction was still possible because wide dissections were performed above the bone. Surgery was also possible in cases in which 2 weeks had elapsed since the injury, whereas the same would be difficult using previous minimal surgical methods. The metal screw used in the fixation process was removed immediately after precise fixation was confirmed. Third, firm postoperative fixation using an absorbable plate expanded the previously limited indications for surgery and
546
& Volume 25, Number 2, March 2014
eliminated the need for a second surgery to remove a metal plate. Patients who undergo secondary surgeries to remove metal plates complain of discomfort associated with the palpable metal plate and screw as well as facial cold intolerance and pain.7 Because the zygomaticofrontal suture area has thin soft tissue and is proximal to the temporalis muscle, patients also commonly complain of discomfort after bicoronal incisive surgery, and undergoing a second surgery further exacerbates their discomfort.8 Although the method proposed here has the above advantages, there was a need to elongate the incision lines in cases in which fractures were widespread or involved several fragments. Another disadvantage is that because adequate visualization during surgery is not possible, the operator must receive extensive training to become familiar with this surgical technique. Here we obtained the results of an open reduction while using a less invasive method in the surgical treatment of the anterior wall of frontal sinus fractures.
REFERENCES 1. Manolidis S, Hollier Jr LH. Management of frontal sinus fractures. Plast Reconstr Surg 2007;12:32SY48S 2. Molendijk J, van der Wal KG, Koudstaal MJ. Surgical treatment of frontal sinus fractures : the simple percutaneous reduction revised. Int J Oral Maxillofac Surg 2012;41:1192Y1194 3. Sataloff RT, Sariego J, Meyers DL, et al. Surgical management of the frontal sinus. Neurosurgery 1984;15:593Y596 4. Yavuzer R, Jackson IT. Coronal incision extending postauricularly. Plast Reconstr Surg 1993;103:1532 5. Chen DJ, Chen CT, Chen YR, et al. Endoscopically assisted repair of frontal sinus fracture. J Trauma 2003;55:378Y382 6. McGrath MH, Smith CJ. A simple method to maintain reduction of unstable fractures of the frontal sinus. Plast Reconstr Surg 1981;68:948Y949 7. Aziz SR, Ziccardi VB, Borah G. Current therapy: complications associated with rigid internal fixation of facial fractures. Compend Contin Dent 2005;26:565Y571 8. Haug RH, Cunningham LL, Brandt MT. Plates, screws and children: their relationship in craniomaxillofacial trauma. J Long Term Eff Med Implants 2003;13:271Y287
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
