Local flap reconstruction techniques after frontal sinus drainage typeII andIII according to Draf

Abstract

Extended endonasal endoscopic frontal sinus surgery is characterized by bone resection beyond the lamellae of the frontal sinus and is currently classified according to Draf as typeIIa, typeIIb, modified typeIII (also referred to as typeIIc), and typeIII. This approach is indicated when the surgical goal cannot be achieved through complete removal of the anterior ethmoidal cells. Numerous studies indicate restenosis rates ranging from 7to 36%, despite creation of maximal openings. Exposed bone, which tends to epithelize slowly with significant crusting and the risk of uncontrolled wound healing depending on the local environment and other factors, is considered acontributing factor. Covering the exposed bone with mucosa can significantly reduce the risk of restenosis. Avariety of flap techniques for frontal sinus drainage in DrafIII procedures are presented, including some variants that were part of presentations at the 2023 Congress of the European Rhinologic Society in Sofia, Bulgaria. These include combinations of free mucosal grafts, pedicled mucosal flaps, and hybrids combining both techniques. Additionally, the results of current studies are presented. The results and achieved opening areas in contemporary DrafIII surgeries are significantly improved and larger compared to the early stages of these procedures. Amultitude of published studies consistently demonstrate that outcomes are markedly improved with mucosal coverage. Depending on the prevailing anatomy, mucosal conditions, and the extent of the surgical intervention, the most suitable technique should be selected. Therefore, proficiency in various methods is crucial. The use of aflap technique (free, pedicled, or combinations thereof) should be defined as the standard when performing extended frontal sinus surgery (Draf IIb, IIc, III, or endonasal frontal sinus surgery [EFSS] 4-6).