Frontal Sinus Repair through a Frontalis Rhytid Approach
Mostafa M. Noury, Jr., M.D., Raymond M. Dunn, MD, Janice F. Lalikos, M.D., Gary M. Fudem, M.D., Douglas M. Rothkopf, M.D..
University of Massachusetts Medical Center, Worcester, MA, USA.
Frontal sinus fractures have traditionally been approached through a bicoronal incision. Although this exposure provides a wide surgical field through a largely hidden scar, it requires an extensive incision that is time consuming to close, can be complicated by scar alopecia and is not suitable for the patient with or at risk for hairline recession. We present a series of 14 patients who underwent open reduction and internal fixation of anterior table frontal sinus fractures through a frontalis rhytid forehead incision and their results based on scar appearance, forehead contour, frontalis function, sensation and fracture reduction.
Between 1994 and 2009, a transfrontal approach through a prominent frontalis rhytid was used in 14 patients, age ranging from 17-64 for open reduction and internal fixation of anterior wall frontal sinus fractures. Patients underwent surgery within two weeks of presentation and all had preoperative imaging in the form of computed tomography. Follow up including postoperative photos, appearance of scar, forehead contour, frontalis function, sensation and fracture reduction were documented until an average of six months postoperatively.
A transverse incision through a prominent frontalis rhytid is performed. Following the skin incision and dissection through the subcutaneous tissue, the frontalis muscle is incised. Subperiosteal dissection of the anterior wall of the frontal sinus is performed with preservation of the supraorbital and supratrochlear nerves. The fracture segments are reduced with titanium microplates. Layered closure is performed with absorbable suturing of the periosteum, frontalis muscle and subcutaneous tissues with a running polypropylene used for skin closure.
Twelve male and two female patients with an average age of 27.4 years of age were retrospectively studied in this case series. Fracture types were composed of six isolated frontal sinus fractures, five combined with supraorbital bar or orbital roof fractures and three with combined maxillary wall or nasal fractures. Parasthesias cranial to the incision in the supraorbital or supratrochlear distribution were noted in 11 of the 14 patients with resolution in all except one patient who did not regain sensation at six months follow up. In all patients, satisfactory forehead contour and fracture reduction was achieved as were scar appearance and frontalis function at six months follow up.
Frontal sinus repair through a frontalis rhytid crease offers an alternative approach to open reduction and internal fixation of anterior table frontal sinus fractures. It offers an excellent, inconspicuous aesthetic result, avoiding an extensive, time consuming coronal incision with its attendant risk of scar alopecia. We have used this approach in a series of anterior table frontal sinus fractures ranging from minimal displacement to severe depression with comminution. The frontalis rhytid approach provides for a safe dissection with minimal blood loss. We thus recommend this approach in the treatment of anterior table frontal sinus fractures, with special consideration for the patient with or at risk for anterior hairline recession.
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