2017-18 HSC Section 4 Green Book

S.W. Delaney

minimal risk of neurovascular injury, and it permits evalu- ation of the NFOT. The complex and variable anatomy of the NFOT, however, renders this approach highly chal- lenging, with risk of iatrogenic cerebrospinal fluid leak if conducted improperly.

fragment is removed through one of the longitudinal in- cisions and plated on the back table. The bony fragment is then replaced in its anatomical position secured with additional screws through the stab incision. 17 Chen et al. 17 successfully performed this technique in seven patients without any need to convert to an open approach. Mensink et al. 18 reported favorable outcomes with their technique of introducing both a 30 endoscope and dissector through a preexisting laceration or a 2-cm incision in a forehead skin crease or above the hairline, with a second peri-brow incision as needed for additional exposure or rigid fixation. Endoscopic reduction is a less invasive means of providing direct magnified visualization of the fracture site, with less risk of neurovascular injury, tissue dissection, blood loss and recovery time, and superior aesthetic outcome compared to coronal or direct brow ap- proaches. 17,18,23 This approach is particularly attractive for patients with alopecia and male-pattern baldness, where further hair loss or an unsightly scar would be unaccept- able. The endoscopic technique is associated with a steep learning curve, increased operative time, and higher equipment cost. 1,9,23 For surgeons proficient in the endo- scopic brow lift, however, this approach may actually be faster than the coronal approach, as there is less tissue dissection and smaller incisions to close. A transnasal endoscopic approach to the frontal sinus may be considered in candidates with simple medial ante- rior table fractures and wide frontal sinus and frontal recess dimensions (anterior e posterior axis) that can accommodate 30 and 70 endoscopes and instrumenta- tion. 24 Reduction of the anterior table fragment can be achieved with the use of a curved frontal sinus instrument or an inflatable balloon. As with frontal sinus surgery, the extent of exposure is limited to the medial sinus. If the fracture site is not readily accessible transnasally, is diffi- cult to reduce, or requires rigid fixation, a peri-brow inci- sion can be performed for access and rigid fixation. 24 Steiger et al. 24 reported that in a series of five patients with anterior table fractures treated with transnasal endoscopic reduction, three patients (60%) required an additional peri-brow incision for rigid fixation. The trans- nasal endoscopic method has the advantage of minimal external scar, decreased blood loss and hospital stay, and

Comminuted depressed fracture

Comminuted fractures of the anterior table are consider- ably more difficult to repair; they require a coronal approach for optimal exposure and access to the bony fragments. As with simple depressed fractures, preexisting lacerations and transcutaneous approaches may be used to access the frontal region. Exposure through these ap- proaches alone is generally insufficient for adequate exposure, which should not replace a coronal approach. The anterior table can be reconstructed using rigid fix- ation with plates or wires. In heavily comminuted fractures, care must be taken to ensure that there is no trapped mucosa within the fracture lines to prevent iatrogenic mucocele formation. This can be avoided through meticu- lous resection of the mucosa around the perimeter of bony fragments. 3 Gaps larger than 5 mm are easily noticeable. 4 Should the degree of comminution prohibit adequate anatomical reduction, a split calvarial bone graft, titanium mesh, or resorbable mesh may be placed over the forehead region at the time of acute repair to camouflage any gaps 11 ( Table 1 ). When acute repair of isolated anterior table frontal sinus deformity within 2 weeks of injury is not possible, delayed contour deformity may be considered after approximately 8 weeks, once the overlying soft tissue edema has resolved and bony fragments have ossified. In fact, Strong et al. 22 suggest that in minor frontal sinus deformities, because endoscopic reduction can be technically challenging and delayed endoscopic camouflage much easier, one may simply observe a patient with an anterior table fracture and reassess the need for camouflage after 8 weeks once the swelling has subsided. The fracture camouflage Delayed contour deformity

Approaches to anterior table frontal sinus fracture.

Table 1

Approach

Ideal candidate

Advantage

Disadvantage

Coronal

Large, comminuted fractures

Excellent exposure and access

Large incision Extensive dissection Risk of large scar and alopecia Prolonged recovery

Direct brow

Deep forehead rhytid

Short operative time Good exposure Minimal incision Technically simple

Unsightly scar

Closed

Simple depressed fracture

Blind manipulation No rigid fixation

Endoscopic brow

Simple depressed fracture

Small incisions

Technically challenging Equipment cost Technically challenging Equipment cost

Endoscopic transnasal

Simple medial fracture

No external incision

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