April 2020 HSC Section 4 - Plastic and Reconstructive Problems

Facial plastic surgery

extension (mean ¼ 20.9mm) and most limited with far medial extension (mean ¼ 16.1mm). The inves- tigators suggest that injuries above this level could be addressed with percutaneous screw placement. Alinasab and colleagues [9] report a series of six patients undergoing an upper eyelid approach for anterior table fracture reduction, finding that all patients were satisfied (17%) or very satisfied (83%) with their forehead contour. Finally, Park and colleagues [10] described a suprabrow approach for open reduction and internal fixation in 31 patients with anterior table fractures with the advantages of shorter operative time, avoid- ance of complications with a coronal approach, and satisfactory scarring on the Patient and Observer Scar Assessment Scale. Subbrow approaches have been explored with similar results [11]. Since first described by Graham and colleagues’ [12], endoscopic brow approaches have been used for both acute fracture reduction and secondary cam- ouflage [13–15]. The hidden incisions in the hair, accurate visualization, and ability to perform delayed camouflage make this technique highly efficacious. Limitations to this approach include high hairline position, depressed fractures with sig- nificant interfragmentary forces preventing reduc- tion (when attempting an acute repair), and a moderate learning curve in endoscopic equipment and techniques. Transnasal endoscopic approaches are gaining trac- tion with the refinement endoscopic techniques and equipment. Woodworth and colleagues [16 && ] published the largest series on transnasal endo- scopic repair of frontal sinus fractures. In their cohort of 46 patients, six patients with fractures to the anterior table (five with isolated anterior table fractures and one with a combined anterior–poste- rior table fracture) underwent transnasal reduction via a Draf IIa, IIb, or III frontal sinusotomy. All patients were satisfied with their forehead contour. An added advantage of this approach is that the frontal sinus outflow tract (FSOT) obstruction is treated at the same time because of the wide frontal sinusotomy made for endoscopic access to the ante- rior table. Patient selection is critical as fracture severity or location may require adjunct transcuta- neous approaches [17]. Additionally, surgeons must have training in endoscopic sinus and skull base Endoscopic brow approach to the anterior table Transnasal endoscopic approach to the anterior table

KEY POINTS

Observation of anterior table fractures For minimally displaced anterior table fractures, nonoperative management and close observation is preferred, conferring a low risk of long-term con- tour deformity. Kim and colleagues [6] performed a retrospective review of 51 nonoperated frontal sinus anterior table fractures in which patients with frac- ture depth of 4mm or less ( n ¼ 44) did not develop contour deformity. Moe and colleagues report 20 patients with frontal sinus fractures involving the anterior table, of which 65% had improved or resolved deformity, supporting the role of a mini- mally disruptive approach to managing these frac- tures [7 & ]. Given that the assessment of an esthetic deformity is difficult in the face of acute soft tissue edema, observation and reassessment after resolu- tion of edema is warranted. The literature suggests that a minority of these patients will desire surgical intervention. If treatment is required, camouflage of the esthetic deformity can be performed in the subacute setting. The senior authors (E.B.S. and T.T.T.) agree that an observational approach with long-term follow-up is indicated for the majority of these patients. Minimal invasive approaches to the anterior table The anterior table fractures can be accessed by a variety of incisions and approaches. The coronal approach provides unrivaled access to the frontal sinus and remains the work-horse for frontal sinus reconstruction. Unfortunately, the risk of surgical morbidity (i.e., scalp paresthesia, alopecia, scarring, and facial nerve injury) can be significant. The upper blepharoplasty incision can provide direct access to the frontal bone and results in a well- hidden scar. Strong and colleagues [8] performed a cadaveric study and measured access to the frontal bone through an upper blepharoplasty incision. They found access was greatest with far lateral Evidence continues to support the safety of observation for select frontal sinus fractures. Endoscopic sinus surgery has expanded the role of minimally invasive management of frontal sinus outflow tract obstruction both in the primary and salvage setting. All patients with treated and untreated frontal sinus fractures should have long-term follow-up to evaluate for early and late complications.

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Volume 27 Number 4 August 2019

176