Osteoplastic flap for obliteration of the frontal sinus: Five years’ experience

The objective of this retrospective study was to evaluate the osteoplastic flap (OPF) for the obliteration of the frontal sinus in this current era of endoscopic management of frontal sinus disease. A review of consecutive OPF procedures (n = 43) performed by the senior author (J.A.D.) from 1992 to 1997 was carried out. Data were gathered regarding chief symptom, medical history, previous sinus surgery, endoscopic findings in the office and at surgery, CT scan findings, and follow-up results (mean 19.4 months). Previous endoscopic management of frontal sinus disease had failed in 24% of patients; 97% had eventual resolution of frontal sinusitis with OPF. After OPF, 63% also had improvement or resolution of disease in other paranasal sinuses. Statistically significant, positive correlations (P < 0.05) were noted between the resolution of frontal sinusitis and improved or resolved pain, as well as the resolution of frontal sinusitis and improved or resolved infections in other paranasal sinuses. In 1998 OPF remains the standard for treating frontal sinus disease refractory to other methods. OPF can decrease the pain associated with frontal sinus infections and has a positive impact on inflammatory disease in other paranasal sinuses. (Otolaryngol Head Neck Surg 1999;121:731-5.)     

Use of anteriorly based pericranial flap in frontal sinus obliteration.

OBJECTIVE: In an era of endoscopic sinus surgery, frontal sinus obliteration continues to remain an important treatment option in chronic frontal sinus disease. Numerous avascular obliterative materials including fat, muscle, cancellous bone, and hydroxyapatite have been used in this procedure. In this article, we describe a vascularized anteriorly based pericranial flap to obliterate frontal sinus. STUDY DESIGN: Retrospective chart review of patients referred to tertiary care hospital between 1996 and 2003. METHODS: Records of the patients who underwent this procedure were reviewed. Demographics, indications, and immediate and late complications were recorded. A phone questionnaire was used to assess patient satisfaction with the outcome. RESULTS: A total of 12 patients underwent frontal sinus obliteration with this technique. Mean follow-up was 40 months. None of the patients developed recurrent frontal sinusitis. All of the patients were pleased with the outcome. CONCLUSION: Pericranial flap is a highly vascularized flap that is easily harvested and is an effective and viable modality for obliterating frontal sinus. EBM rating: C-4.     

Endoscopic frontal sinus obliteration: a new technique for the treatment of chronic frontal sinusitis.

OBJECTIVES: Patients who fail endoscopic drainage procedures for chronic frontal sinusitis often require obliteration of the frontal sinus with abdominal fat. The purpose of this study was to evaluate an endoscopic technique for frontal sinus obliteration. STUDY DESIGN AND SETTING: Retrospective case-control. Thirty-five patients underwent frontal sinus obliteration using either an endoscopic (n=10) or conventional osteoplastic flap (n=25) technique from 1994 to 2004 at an academic medical center. RESULTS: Patients undergoing endoscopic obliteration had less blood loss (P = 0.006), decreased operative time (P = 0.016), and a shorter hospital stay (P = 0.003) compared to osteoplastic control subjects. All 3 surgical complications occurred in the control group. No patients required additional surgery for frontal sinusitis. CONCLUSIONS: The endoscopic approach to frontal sinus obliteration appears to reduce patient morbidity and should be considered in the surgical management of advanced frontal sinus disease. SIGNIFICANCE: This is the first report of a minimally-invasive technique for frontal sinus obliteration.     

Biomaterials for use in frontal sinus obliteration

Although fractures of the frontal sinus are infrequent (2-15% of victims of facial trauma), because of their proximity to the brain and eyes, the consequences of their management may have a significant impact on the patient. For frontal sinus injuries that affect the nasofrontal ducts or posterior wall, obliteration is indicated. Although frontal sinus surgery has been documented since 1750, a consensus as to the best material for obliteration has not been achieved. The particular autogenous and alloplastic materials for use in frontal sinus obliteration will be the focus of this review, with particular attention paid to assessing their physical properties, advantages, disadvantages, and complications. While numerous new alloplastic materials show promise for frontal sinus obliteration, autogenous fat remains the most popular and most frequently used material with the longest history of use, and it is versatile and reliable.     

Frontal sinus obliteration with the pericranial flap.

BACKGROUND: Frontal sinus obliteration is often accomplished by autologous grafts such as fat, muscle, or bone. These avascular grafts carry an increased risk of resorption and infection as well as donor site morbidity. Vascular regional flaps may be used to obliterate small sinuses with less morbidity. OBJECTIVES: To review our experience with the use of the pericranial flap for obliteration of the frontal sinus. METHODS: The records of 10 patients who underwent obliteration of the frontal sinus with the pericranial flap were reviewed. Demographics, indications for frontal sinus obliteration, immediate and late complications, and long-term outcome were recorded. These results were compared with those in the current literature. RESULTS: Ten sinuses were obliterated with the pericranial flap. Indications included frontal sinus mucocele, mucopyocele, frontal sinus osteomyelitis, and frontal sinus fracture. The median follow-up was 3 years. There was 1 short-term complication of persistent headache for 1 month, and there was asymptomatic recurrence of a neofrontal sinus in 1 case. CONCLUSIONS: The pericranial flap is a vascularized local flap that is easily harvested. The use of the pericranial flap avoids donor site morbidity associated with free fat or cancellous bone grafts. The pericranial flap arms the head and neck surgeon with an effective alternative to other methods of frontal sinus obliteration.     

Quality-of-life outcomes after osteoplastic frontal sinus obliteration.

Frontal sinusitis and its treatment remain controversial. Although several authors have evaluated the results of traditional endoscopic sinus surgery, few have assessed patient outcomes and quality of life after osteoplastic frontal sinus obliteration. This retrospective study evaluates these outcomes in a postoperative review and questionnaire of 39 patients treated at the University of Washington from 1991 to 1994. Most patients were satisfied with the results of this procedure, had significant improvements in their Chronic Sinusitis Survey scores, and reported decreased clinic visits and antibiotic use. However, approximately half thought nonsurgical treatments were more effective and continued to require other medical therapy; 30% required additional surgical intervention. Such outcomes may reflect the ineffectiveness of frontal sinus obliteration to treat the chronic symptoms of patients affected by the refractory underlying disease process of chronic sinusitis; however, despite these mixed results, we found a significant decrease in annual days of lost work or activity in this study group after osteoplastic obliteration.     

Frontal sinus fracture following osteoplastic frontal sinus obliteration

A patient who sustained frontal sinus fracture and who earlier had undergone an osteoplastic fat obliteration procedure is described. The literature is reviewed and recommendations are made for management of this and other cases of frontal sinus fractures with posterior table involvement.     

Evaluation of hydroxyapatite cement for frontal sinus obliteration after mucocele resection

OBJECTIVES: To retrospectively evaluate our experience with frontal sinus obliteration using hydroxyapatite cement (BoneSource; Stryker Biotech Europe, Montreux, Switzerland) and compare it with fat obliteration over the approximate same period. Frontal sinus obliteration with hydroxyapatite cement represents a new technique for obliteration of the frontal sinus after mucocele resection. METHODS: Exploration of the frontal sinus was performed using bicoronal, osteoplastic flaps, with mucosal removal and duct obliteration with tissue glue and muscle or fascia. Flaps were elevated over the periorbita, and Silastic sheeting was used to protect the BoneSource material from exposure as it dried. The frontal table was replaced when appropriate. RESULTS: Sixteen patients underwent frontal sinus obliteration with fat (fat obliteration group), and 38 patients underwent obliteration with BoneSource (BoneSource group). Fat obliteration failed in 2 patients, who underwent subsequent BoneSource obliteration, and none of the patients in the BoneSource group has required removal of material because of recurrent complications. Frontobasal trauma (26 patients [68%] in the BoneSource group and 9 patients [56%] in the fat obliteration group) was the most common history of mucocele formation in both groups. Major complications in the BoneSource group included 1 patient with skin fistula, which was managed conservatively, and 1 patient with recurrent ethmoiditis, which was managed surgically. Both complications were not directly attributed to the use of BoneSource. Contour deficit of the frontal bone occurred in 1 patient in the fat obliteration group and in none in the BoneSource group. Two patients in the fat obliteration group had donor site complications (hematoma and infection). Thirteen patients in the BoneSource group had at least 1 prior attempt at mucocele drainage, and no statistical relation existed between recurrent surgery and preservation of the anterior table. CONCLUSION: Hydroxyapatite is a safe, effective material to obliterate frontal sinuses infected with mucoceles, with minimal morbidity and excellent postoperative contour.     

Treatment of frontal sinus mucoceles with the osteoplastic flap technique.

The osteoplastic flap technique for treating frontal sinus mucoceles is described. This procedure has the advantages of: being a direct approach, which allows exposure of the entire sinus, provides complete obliteration of the sinus to prevent recurrence of the sinus disease, and prevents blind curettage of any exposed dura mater; leaving no facial deformity after the operation; being a relatively atraumatic procedure with low morbidity and minimum postoperative care; and allowing simultaneous surgery on both frontal sinuses when indicated.     

Pilonidal sinus: experience with the Limberg flap

A personal series of 162 patients with chronic pilonidal disease was treated by rhombic excision and Limberg transposition flap. Each sinus was totally excised and covered primarily by a fasciocutaneous Limberg flap. Full primary healing was obtained in 161 out of 162 patients. One patient had ischaemia which resulted in necrosis of the flap tips that healed later with a scar. Minor infection occurred in 12 patients (7%). The average hospital stay was 4.2 days, and no patient remained in hospital more than 12 days. The mean follow-up period was 18 months, and three recurrences (2%) have occurred. Surgery for pilonidal sinus should not only eradicate the presenting sinus formation but should also aim to eliminate factors that predispose to formation of another sinus. This can be achieved using a Limberg flap which reduces the depth of the cleft and ensures that all parts of the wound and all suture holes are away from the midline.     

Radiographic evaluation and diagnosis of the failed frontal osteoplastic flap with fat obliteration

In the absence of evidence of suppurative disease, clinical assessment of the symptomatic patient after frontal osteoplastic flap with fat obliteration is difficult because the cause of the pain is often neuralgic or from chronic vascular headache. Among 59 patients who have undergone this procedure at our institution since 1979, four required revision surgery. These patients were evaluated by computed tomographic and magnetic resonance scans, and the radiographic findings were compared with those present in 20 asymptomatic subjects. On the basis of the results of this study, we believe we can objectively identify those patients with chronic pain in whom the operation has been unsuccessful. A review of our experience with this procedure is presented along with criteria that enable early diagnosis of recurrent disease in the frontal sinus after osteoplastic sinusotomy.     

Sentinel lymph-node biopsy in breast cancer: five years' experience

The authors report on their experience with sentinel lymph-node biopsy in breast cancer. Sentinel lymph-node biopsy was performed in 91 patients with T1-T2 N0 M0 breast cancer using radiocolloid (99mTC radiolabelled colloidal human albumin microaggregate) injected perilesionally in 56 cases and by Blu Patent V alone in 35 cases. The sentinel lymph nodes identified were located in the axilla in 88 cases, in the internal mammary nodes in 2 cases and in a subclavicular site in 1 case. The histological examination was negative in 62 cases and positive in 29; Axillary lymph-node dissection was carried out in node-positive cases. No recurrences were observed in any of the cases treated. Lymphatic mapping and sentinel lymphadenectomy in primary breast cancer is now a feasible and useful method of avoiding routine axillary lymphadenectomy. However, the role of micro- or macrometastases in sentinel lymph nodes and the significance of identification of tumour mRNA have yet to be defined.     

Demineralized bone matrix and fat autograft in a rabbit model of frontal sinus obliteration.

OBJECTIVE: In this study, we investigate the efficacy of demineralized bone matrix (DBM) as a material for frontal sinus obliteration in a rabbit model. STUDY DESIGN AND SETTING: Twenty-four New Zealand White rabbits were divided into four groups, and the study was carried out to two time periods. Twelve rabbits underwent frontal sinus obliteration with fat autograft, and 12 rabbits underwent the procedure with DBM. At 12 weeks, six control and six study rabbits were killed. The remaining 12 rabbits were killed at 36 weeks. All specimens underwent radiologic evaluation with spiral CT followed by histologic examination for evidence of bony growth. RESULTS: Sinuses obliterated with DBM showed replacement of the sinus cavity by trabecular bone. Histology demonstrated significant progressive replacement of DBM by cancellous bone from 12 weeks (53.3%) to 36 weeks (78.8%). There were no complications observed as a result of the materials used. CONCLUSION AND SIGNIFICANCE: DBM is a prospective material for frontal sinus obliteration. Long-term studies and human trials will further elucidate the role of this material.     

Trilucent breast implants: five years' experience from an Italian perspective

In June 2000 the Medical Devices Agency (MDA) issued a Hazard Notice recommending the explantation of Trilucent breast implants (TBP) as a precautionary measure. Following that recommendation, we reviewed our series of 52 patients (71 implants) operated on from 1994 to 1998 to recall and advise those still harboring TBP. We have analyzed all the recorded adverse events in our setting before June 2000 to estimate the adverse reaction frequency and their time relation (review series). We have also recorded the rate of preoperative symptoms and postoperative findings in 23 patients (29 implants) who underwent explantation after the MDA recommendation (explantation series). In addition, some histologic observations have been made. The rates of significant capsular contracture (Baker 3-4) and explantations were estimated using the Kaplan-Meier method of survival analysis, and the rates of wrinkling and palpability were compared at 1 and 5 years of follow-up. Overall, the rate of grade 3-4 capsular contracture was approximately 45% at 6 years of follow-up with no statistically significant difference among the reconstruction and augmentation groups. The analysis of survival curves showed an overall rate of approximately 55% of explantations at 6 years. Preoperatively, capsular contracture and volume modifications were the most frequent findings in the explantation series. Postoperatively, most implants opposed inadequate resistance to the operative stress and ruptured, showing a creamy content. Free oil has never been found in tissue surrounding the periprosthetic capsule. In conclusion, it appears that the TBP-claimed advantages over other available implants seem to be inconsistent and the MDA advice appropriate. The problems related to these implants have had a great impact on public opinion in Europe and have contributed to the implementation of the conformity assessment procedures to be followed for medical devices: on the 4th February 2003 breast implants were in fact reclassified as class 3 products, in order to provide the best guarantee for health protection.The publication of a communication by the European Parliament in November 2001 gives us hope for the future.