The perforation technique: a modification to the frontal sinus osteoplastic flap.

INTRODUCTION Despite impressive advances in endoscopic approaches to the frontal sinus, the osteoplastic flap approach to the frontal sinus remains an important tool for surgically treating frontal sinus pathology. In this approach, the anterior table of the frontal sinus is opened wide while maintaining a hinged attachment to the overlying periosteum and soft tissue along its inferior border. In this manner, surgical access to the entire frontal sinus and recess is achieved, and a blood supply to the bone segment is maintained via the intact periosteum. The frontal sinus may then be left intact or obliterated. The anterior table is then replaced and typically secured with plating. The osteoplastic flap was first reported by Schonborn in 1894 and described in detail by Hoffman in 1904. Abdominal fat obliteration was described by Tato in 1949 and popularized by Goodale and Montgomery in 1956 as a definitive procedure for recalcitrant frontal sinus disease. Subsequently, Montgomery published a large series of osteoplastic flap obliteration of the frontal sinuses for recalcitrant inflammatory disease and tumors of the frontal sinus and is credited with describing today’s “classic” osteoplastic flap procedure. For achieving wide access to all areas of the frontal sinus, the osteoplastic flap is superior to all other approaches, including endoscopic approaches, external trephination, and frontoethmoidectomy. However, it is often considered an approach of “last resort” due to concerns of increased perioperative morbidity and potentially poor cosmetic results. Forehead edema and periorbital ecchymosis are commonly encountered in the immediate postoperative period. Frontal bossing and anterior plate depression are fairly common late complications of this technique. Frontal bossing can be caused by an ill-fitting bone flap that does not contour to its original position. Additionally, osteoneogenesis occurring in the bone gap that is created with sagittal saw cuts through the anterior plate may remodel the anterior plate so that it is anteriorly displaced. Anterior plate depression can also be caused by excessive drilling of bone in creating the flap and poor plating technique; and it can occur as a late complication due to poor healing, bone migration, and bone resorption. Plates that carefully reapproximate the bone flap can occasionally be felt or seen and do not necessarily prevent bossing or depression. To combat these effects, a technique that creates an anterior boney flap with minimal trauma and bone loss without cosmetic changes would be beneficial. The perforation technique was devised with this aim in mind.