Discussion
Management of Frontal Sinus Fractures
Discussion by Larry H. Hollier, Jr., M.D., and Stephen Higuera, M.D.
Houston, Texas
This article provides an excellent discus-
sion of frontal sinus fractures in general and
their management in particular. The senior
author has extensive experience with these
injuries, and his previously published results
attest to the effectiveness of his treatment
algorithm and his surgical technique. Al-
though the majority of the recommendations
regarding treatment are in keeping with pre-
viously published literature, two aspects are
somewhat divergent. These are the senior
author’s propensity for use of the galeal fron-
talis flap in the majority of cases, and the
relatively infrequent use of sinus cran-
ialization, even in cases with posterior wall
comminution.
The most difficult part of discussing results
of different forms of treatment for frontal
sinus fractures is the fact that everything
seems to work so well. This may be a compo-
nent of the fact that so many complications
from poor frontal sinus management do not
manifest until years after the surgery. The
authors quite appropriately point out that
long-term follow-up for years is necessary to
detect these problems. The authors’ aggres-
sive use of the galeal flap may be one aspect
of their management that is responsible for
minimizing their incidence of complications.
The majority of previous reports on this topic
have focused on the use of nonvascularized
graft material such as fat, bone, and muscle
for sinus obliteration.1–5 However, this goes
contrary to some of the most basic tenets of
plastic surgery. The expectation that a graft
can be placed in any quantity in a relatively
poorly vascularized space with substantial
long-term retention is probably not realistic.
As the authors discuss, Weber et al. demon-
strated by means of magnetic resonance im-
Received for publication November 22, 2004.
DOI: 10.1097/01.PRS.0000161992.64956.1A
94e
aging that less than 20 percent of fat graft
placed for obliteration was retained in half of
the cases treated during a mean follow-up of
approximately 2 years.6 In addition, there is
concern regarding the ability of this necrotic
graft material to drain, as the frontal recess
has been plugged to prevent communication
with the nasal cavity. Just because using fat as
a graft seems to work in the majority of pa-
tients does not necessarily make it the best
option. Indeed, the technique of spontane-
ous osteoneogenesis (i.e., leaving the de-
nuded sinus cavity empty to fill secondarily
with bone and scar tissue) would seem to be
preferable to placement of dead graft mate-
rial.2,3,7 Although this may be the case, it is
difficult to argue against the strong point
made in this article that vascularized galeal
tissue is the best option. Not only is it more
likely to prevent an infection in the frontal
sinus, it also provides a well-vascularized base
for the bone fragments from the anterior
table that have been repositioned and stabi-
lized. This may minimize resorption of the
bone grafts and limit secondary forehead ir-
regularities. However, there is morbidity as-
sociated with harvest of the galeal flap. In
addition to eliminating or diminishing brow
elevation and the requisite sensory distur-
bance, these flaps not infrequently leave
some degree of contour deformity of the
forehead. This can be substantial and require
secondary revision.
Another unique aspect found in this article is
the apparent disinclination of the authors to cra-
nialize the sinuses, even in cases where the pos-
terior wall is comminuted, with or without a du-
ral tear. Certainly, once a craniotomy is required
for repair of a dural laceration, the most prudent
option would seem to be complete removal of
Vol. 115, No. 6 / DISCUSSION
the posterior table of the sinus, where the muco-
sal invaginations lie. This may be the most com-
mon source of postoperative mucocele and po-
tential infection. Even in cases where there is no
dural leak but extensive posterior table commi-
nution, there would seem to be relatively little
benefit in obliterating the sinus rather than cra-
nializing it.
In summary, the authors present a well-
conceived, logical approach to the safe man-
agement of frontal sinus injuries. They are to
be commended for their consistent adherence
to sound plastic surgical principles and their
insistence on careful long-term follow-up to
prevent the insidious complications seen with
these injuries.
Larry H. Hollier, Jr., M.D.
Texas Children’s Hospital
Baylor College of Medicine
6621 Fannin Street, CC 620
Houston, Texas 77030-2399
larryh@bcm.tmc.edu
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REFERENCES
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2. Rohrich, R. J., and Mickel, T. J. Frontal sinus oblitera-
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Frontal sinus obliteration: A comparison of fat, mus-
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model. Plast. Reconstr. Surg. 95: 586, 1995.
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