The mucoperiosteal flap in frontal sinus surgery. (The Sewall-Boyden-McNaught operation.).

Abstract

AbstractThe problem with the Lynch operation for frontal sinus disease is the high incidence of failures (30 percent) due to the closure of the nasofrontal communication. It seems to us that the use of permanent (Dacron, described as recently as 1972) or temporary (Portex) indwelling tubes to preserve this communication is unreasonable when there is available an operation that requires no gadgets. This is the mucoperiosteal flap operation. This has several advantages over the osteoplastic flap‐fat obliteration procedure. It is performed through a Killian‐type incision through which surgical treatment of the ethmoid and sphenoid sinuses can also be done (not possible with the osteoplastic approach). It is less formidable and not deforming, and there is no concern about the possibility of developing secondary mucoceles. The incidence of failures is extremely low. The probable reason that it is not used more is that it is not well known.It was demonstrated by Sewall and McNaught that an operative nasofrontal duct remains open if one side is epithelized. Sewall, in 1935, described a medially based mucoperiosteal flap to provide this epithelium. He described a Lynch type approach with a Killian incision. The lateral bony wall of the nose is removed carefully to the underlying mucoperiosteum. When a large enough area of the membrane is exposed, two cuts are made vertically and one horizontally, thus forming a flap, based on the septum, that eventually will be turned up into the frontal sinus after the proper surgery on the frontal sinus, the glabella, the anterior ethmoids and posterior ethmoids and sphenoid sinus, if necessary, is done. The flap is held in place with a Portex tube which is removed in seven days.McNaught, in 1936, described a laterally based mucoperiosteal flap for use in cases with large frontal sinuses with narrow nasal vaults, and particularly those with bilateral involvement. He used Lothrop's operation for removing the interfrontal septum, all the nasal portion of the floor of both frontal sinuses, and the upper part of the anterior portion of the bony nasal septum, thus making a large opening into the nose. The opening is lined unilaterally or bilaterally with mucoperiosteal flaps based from the mucosa under the nasal process of the maxilla and cut from the nasal septum and then turned into the frontal sinus over the periosteum of the orbit after the frontoethmoidal surgery has been completed.We believe that the mucoperiosteal flap operation is the best available for external surgery of the frontal sinus. The exception is in the large osteoma for which the osteoplastic flap operation is better.