Anterior Table Research Articles

The Type I+ Forehead in Facial Feminization Surgery.

Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft. Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques. In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002). The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Posterior Table for Primary Reconstruction of Frontal Sinus Fractures.

Frontal fractures can be associated with major facial defects and present, in some cases, a challenge in bone reconstruction. Due to this challenge, this work aims to describe the use of the posterior table of the frontal sinus as a fragment to reconstruct this region. However, this technique is reserved for cases where the posterior table will be removed due to its fracture and is more intact than the anterior table of the frontal sinus.

Fat Grafting for Forehead Contouring in Facial Feminization.

For gender-diverse individuals assigned male at birth, postpubertal estrogen and testosterone-lowering therapies alone are often inadequate to reverse the testosterone-related facial characteristics projecting a male sex identity. Facial feminization surgery significantly improves quality-of-life outcomes for gender-diverse patients by relieving this gender incongruence of the face. Because the shape of the forehead is so radically different between men and women, feminization of this area is critical for many individuals. Several techniques are typically used in combination, including hairline advancement, browlift, burring of the supraorbital rims, frontal bone contouring, and anterior table setback. This report describes the use of fat grafting as an adjuvant technique to forehead contouring as means to avoid frontal bone osteotomy, which carries a higher complication profile and often requires hardware placement.

A Cadaveric Feasibility Study of the Biportal Endoscopic Transfrontal Sinus Approach: A Minimally Invasive Approach to the Anterior Cranial Fossa.

The trans-sinus transglabellar and bifrontal approaches offer direct access to the anterior cranial fossa. However, these approaches present potential drawbacks. We propose the biportal endoscopic transfrontal sinus (BETS) approach, adapting endoscopic endonasal approach (EEA) techniques for minimally invasive access to the anterior fossa, reducing tissue manipulation, venous sacrifice, and brain retraction. Six formalin specimens were used. BETS approach involves 2 incisions over the medial aspect of both eyebrows from the supraorbital notch to the medial end of the eyebrow. A unilateral pedicled pericranial flap is harvested. A craniotomy through the anterior table of the frontal sinus (FS) and a separate craniotomy through the posterior table are performed. Two variants of the approach (preservative vs cranialization) are described for opening and reconstruction of the FS based on the desired pathology to access. Bone flap replacement can be performed with titanium plates and filling of the external table defect with bone cement. Like in EEA, this approach provides access for endoscope and multiple working instruments to be used simultaneously. The approach allows wide access to the anterior cranial fossa, subfrontal, and interhemispheric corridors, all the way up to the suprachiasmatic corridor and through the lamina terminalis to the third ventricle. BETS provides direct access to the anterior fossa, minimizing the level of frontal lobe retraction and providing potentially less tissue disruption and improved cosmesis. Cerebrospinal fluid fistula risk remains one of the major concerns as the narrow corridor limits achieving a watertight closure which can be mitigated with a pedicled flap. Mucocele risk is minimized with full cranialization or reconstruction of the FS. The BETS approach is a minimally invasive approach that translates the concepts of EEA to the FS. It allows excellent access to the anterior cranial fossa structures with minimal frontal lobe retraction.

Feminization of the Forehead: A Scoping Literature Review and Cohort Study of Transfeminine Patients

BackgroundFacial feminization may be performed to alleviate gender dysphoria among transfeminine patients. The upper third of the face has several characteristics, including hairline shape and position, brow position, and forehead protrusion, that may confer feminine identity. The purpose of this study is to conduct a scoping literature review of techniques performed for forehead feminization and to additionally study clinical outcomes within an institutional cohort.MethodsA systematic literature review was conducted to review articles that discussed techniques and clinical outcomes associated with procedures performed for feminization of the upper third of the face. A retrospective review of patients undergoing such procedures by the senior author was then conducted. Variables collected included demographic factors, operative details, and postoperative outcomes such as complications, revisions, and re-operations.ResultsInitial review yielded sixty-seven articles. Title and abstract review followed by standardized application of inclusion and exclusion criteria resulted in a total of twenty-two studies for analysis. Priorities of forehead feminization entail frontal bossing reduction, frontonasal angle widening, orbital contouring, brow lifting, and hairline advancement. Eighty-five patients were included for analysis. The majority were of Caucasian race (56%) and had type 3 forehead classification (92%). The average planned setback of the anterior table was 4.12 mm.ConclusionsThe core tenets of the feminization of the forehead lie in the overall creation of a harmonic curvature of the forehead with other facial features. Our multi-pronged analysis presents an updated review of these principles, which may help plastic surgeons in performing procedures to feminize the upper third of the face.Level of Evidence IIIThis journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Use of Titanium Mesh During Frontal Sinus Setback in Facial Feminization Surgery: Clinical Outcomes and Perspectives.

Brow position, hairline shape, and forehead projection may confer cis-feminine identity, and facial feminization surgery (FFS) can improve gender dysphoria among transfeminine patients. Depending on the Ousterhout classification, burring, osteotomy, anterior frontal sinus setback, and augmentation, with subsequent fixation via metal or bioabsorbable plates, can address forehead projection. However, titanium mesh, often used in frontal sinus fracture repair, has not been described for forehead contouring in FFS. The purpose of this study was to study clinical outcomes associated with the use of titanium mesh for the stabilization of bone following anterior frontal sinus setback. A retrospective cohort study of trans-female and nonbinary patients undergoing primary FFS by our senior author between January 2021 and February 2023 was performed. Variables collected include demographics, Ousterhout classification, operative details, complications, and follow-up duration. Patients with prior FFS or facial trauma were excluded. Data were analyzed using SPSS, (IBM, Armonk, NY). Forty-three transfeminine patients were included for analysis. The cohort had an average age of 33.0±8.7 years and a median follow-up time of 3.0 months (IQR = 1.0-7.0). Among our cohort, 26 patients (60.5%) received titanium mesh and 17 patients (39.5%) underwent burring only for forehead contouring. There were no reported complications (ie, infection, hardware extrusion, or mucocele formation) or a need for forehead revisions among the entire cohort regardless of the frontal sinus reconstruction material utilized. Clinical outcomes were favorable among patients receiving titanium mesh anterior table fixation during FFS. Titanium mesh can be considered as an additional technique for frontal bossing reduction and anterior table fixation in FFS.

Incidence, patterns, and management of frontal sinus fractures: A 10-year retrospective study at a tertiary medical center, Saudi Arabia.

To assess the prevalence of various frontal sinus fractures (FSF) and examine the relationships between these fractures, types of treatments, and potential complications. A retrospective study was carried out in King Saud Medical City, Riyadh, Saudi Arabia. The study analyzed the records of patients who were diagnosed and treated with FSF from 2011-2021. Files with missing documents or incomplete treatment were excluded. The retrieved data includes: patients age, gender, types, locations, treatment, and complications of FSF. Data was analyzed by the statistical Package for the Social Sciences Statistics, version 23.0 using descriptive statistics and Chi-square test. A total of 72 cases were included, 94.4% males and 5.6% females. Road traffic accidents were the common cause of trauma (91%). Frontal sinus fractures were unilateral in 59.7% and associated other injuries in 80.6% of cases. Anterior table fractures were the largest proportion (58.3%), followed by anterior and posterior table (37.5%). The carried out surgical procedures were obliteration (23.9%), cranialization and obliteration (23.9%), and fixation only (52.2%). The post-operative complications were categorized into; neurological (22.2%), ophthalmic (15.3%), infection (2.8%), and deformity (16.7%). Anterior and posterior table had the highest percentage among these categories. Frontal sinus fractures were mostly required surgical treatment (63.9%) and post-operative complications occurred especially the neurological and ophthalmic. We recommend studies on the association of complications and different types of obliteration materials.

Comparison of closed percutaneous screw reduction versus open reduction and internal fixation in the treatment of frontal sinus fractures: A retrospective study

The aim of this study was to compare closed percutaneous screw reduction to traditional open reduction-internal fixation (OR-IF) for the treatment of anterior table fractures. Both groups were evaluated in terms of operative variables, complications, and treatment success. Of 32 patients included, 19 patients underwent OR-IF, while 13 underwent percutaneous screw reduction. The median operative time, length of hospital stays, and treatment cost of the OR-IF group were 100 min (range 60-130), 4 days (range 3-9), and $727 (range $642-$1291), respectively. The same variables for the closed reduction group were 30 min (range 20-40), 2 days (range 1-2), and $303 (range $252-$349), respectively. The closed reduction group exhibited a shorter operative time (p< 0.001), reduced length of hospital stays (p< 0.001), lower treatment cost (p< 0.001), and a lower complication rate (p = 0.025) compared to the OR-IF group. Late-term outcomes in both groups showed no visible contour changes or step deformities. In conclusion, the percutaneous screw reduction technique is a safe and effective option with minimal morbidity in the treatment of frontal sinus anterior table fractures. Therefore, traditional OR-IF should be reserved for fractures that are not suitable for reduction using minimally invasive techniques.

Persistent Pneumosinus Dilatans Refractory to Endoscopic Frontal Sinus Surgery: A Case Report

Pneumosinus dilatans (PD) is a rare clinical entity involving expansion of the paranasal sinuses. While the pathogenesis of PD is not fully understood, the prevailing theory involves a “ball-valve” mechanism in which obstruction of sinus outflow leads to progressive air cell expansion. Typically, the progression of PD can be halted with endoscopic sinus surgery to relieve any outflow obstruction. In this report, the authors present a case of a patient with progressive expansion of the frontal sinus refractory to endoscopic sinus surgery. The patient ultimately required excision of the anterior table of the frontal sinus and reconstruction with a custom polyetheretherketone implant. This case highlights the variability of PD presentation and how treatment and reconstruction must be tailored to each patient’s unique presentation.

Considerations in Forehead Reduction for Men.

Although frontal prominence is an infrequent benign defect that causes no sequelae, it gives the patient distress due to its unaesthetic visual aspect. Proper surgical recontouring of the forehead can radically change one's appearance. In consequence, different techniques have been proposed for its management and correction. The aim of this study is to describe a surgical algorithm to treat male patients with forehead reduction to soften the "forceful" look. An observational cross-sectional study was conducted at the head and neck surgery ward of a general hospital between 2019 and 2022. We performed 35 forehead reduction operations on male patients. The median age was 29 years (range, 26-32 years). The forehead reduction procedures performed was categorized as follows: 27 anterior table osteotomy and 8 anterior table osteotomy contouring. Median forehead reduction was 2.7 mm (range, 2-3.2 mm). The average medical follow-up for patients was 6 months, with an interval ranging from 4 to 8 months. Surgery of the forehead in properly selected male patients is sufficiently safe that it can be done for entirely aesthetic reasons. The choice of surgical technique depends on the presence or absence of the pneumatized frontal sinus. If the frontal sinus is not pneumatized, an anterior table contouring is performed and if the frontal sinus is pneumatized, an anterior table osteotomy is preferred.

Pott’s Puffy Tumour in Mucormycosis: New Presentation of an Old Disease

Introduction: Pott’s puffy tumour (PPT) is a rare but grave complication of frontal sinusitis. During the second wave of Covid-19, there was rise in rhino-orbito-cerebral mucormycosis (ROCM) cases in India. There is a paucity of literature reporting association of frontal osteomyelitis with rhino-orbital cerebral mucormycosis. This study elucidates the clinico-epidemiological profile and clinical outcomes of management of frontal osteomyelitis in patients with ROCM. Materials &amp; Methods: A retrospective, observational study was conducted at a tertiary hospital from May 2021 to May 2022. 350 patients with covid-19 associated ROCM had reported to the hospital. 12 patients presenting either pre- or post-operatively with doughy swelling over the forehead, with/without oedema of the upper eyelid were clinically diagnosed to have frontal osteomyelitis. Minimal localised defects in the frontal bone were subjected to local excision of granulation tissue, evacuation of pus and biopsy. Cases involving extensive erosions of anterior table of frontal sinus underwent osteoplastic flap with obliteration. Results: 12 patients presented with frontal osteomyelitis. All received systemic antifungals and broad-spectrum antibiotics. It sufficed in only 1 case. 2 required additional local debridement. In 4, endoscopic sinus surgery achieved adequate disease control. 5 with extensive disease required osteoplastic flap with obliteration via either eyebrow or bicoronal incision. Conclusion: A high index of suspicion is warranted in patients with covid-19 associated mucormycosis who present with a forehead swelling because even though PPT is a rare clinical entity it is associated with potentially life-threatening complications.

Balloon Sinuplasty and Stenting in the Management of Complex Frontal Sinus Outflow Tract Fractures.

Classical management of complex fractures involving the frontal sinus outflow tract (FSOT) favors obliteration or cranialization to avoid delayed complications. We aim to exhibit success with a novel application of balloon sinuplasty and frontal stenting in the management of complex injuries disrupting the FSOT, which might have otherwise required more invasive interventions. Retrospective review. Single institution, level 1 trauma center. Retrospective review of patients presenting to a level 1 trauma center with fractures involving the FSOT. Outcomes include patency of the FSOT on imaging and endoscopy, rate of complications, degree of residual tabular displacement, and need for revision surgery. Twenty-five patients met inclusion criteria, with complete FSOT obstruction seen in all cases on computed tomography. All patients underwent balloon sinuplasty with frontal sinus stenting; 48% underwent concurrent anterior table repair, and 36% open repair of nasoorbitoethmoidcomplexfractures. The mean follow-up length was 13.9 months, at which time 91.3% of patients demonstrated radiographic and endoscopic FSOT patency. No residual sinus opacification or pneumocephalus was observed. Balloon sinuplasty with frontal sinus stenting is a straightforward and minimally invasive technique that can create a safe sinus in complex fractures disrupting the FSOT while avoiding the need for more invasive procedures.

Frontal Bone Cranioplasty for Facial Feminization in Gender-Affirming Surgery: Can Fewer Screws Fixate Bone and Avoid Nonunion?

Background: Facial feminization surgery can include forehead feminizing cranioplasty (FFC). The reshaped bones are fixated together with titanium plates and screws. Objective: To define the authors' preferred plating patterns and measure complications of bony nonunion when less hardware is applied. Methods: A 7-year retrospective review of patients who underwent FFC was conducted. Data collection included cranioplasty technique, fixation patterns, and complications. Traditional fixation (≥2 screws on each side of the osteotomy) was compared with conservative fixation (<2 screws). Results: A total of 483 patients were identified with a median of 241 days of follow-up (interquartile range: 8-528 days). Most patients (77.8%) had frontal bone fixation with microplates and screws. The most common combination was placement of two plates with four screws in total, comprising two screws on each plate, with one screw on each side of the fracture line (305/483, 63.1%). No signs or symptoms of bone flap mobility were noted on examination. Conclusion: Conservative fixation of the anterior table does not appear to increase signs of nonunion in forehead reshaping gender-affirming surgery.

Facial Gender-Affirming Surgery: Frontal Bossing Surgical Techniques, Outcomes and Safety.

Facial gender-affirming surgery (FGAS) is described as a set of surgical procedures done to feminize the soft tissue and the facial skeleton, allowing for transfeminine individuals to be recognizable as women to others. It is established in the literature that the most significant facial area for determination of gender is the forehead (Spiegel in Laryngoscope 121:250-261, 2011). This article describes the author's three main surgical techniques used in forehead feminization and reports on the results. The type of surgery performed is based on the patient's anatomy. Type one FGAS consists of burring the anterior table of the frontal bone and is done when frontal bossing is very minimal. Type two FGAS includes burring and applying hydroxyapatite to contour the forehead and is done when frontal bossing is moderate. Type three surgery includes anterior table osteotomy, repositioning and fixation with a non-resorbable titanium plate and is performed for more severe frontal bossing. We present three techniques to feminize the forehead based on patient anatomy, modifying Ousterhout's methods with the use of hydroxyapatite and titanium plates. Complications were rare and consisted of hematoma (1%), chronic sinusitis (1%), cicatricial alopecia (3%), hardware palpability (5%) and delayed wound healing (6%). Ninety-five percent of patients reported being satisfied/highly satisfied with their cosmetic outcome. FGAS plays an important role in the treatment for gender dysphoria, offering transfeminine individuals an improvement in their self-esteem and quality of life. In our series of 100 cases, we demonstrate good esthetic outcomes with a low complication rate. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Algorithms for the management of frontal sinus fractures: A retrospective study

The aim of this study was to evaluate the long-term results and to evaluate the validity of the treatment algorithm that can be safely applied in dfrontal sinus fractures. All patients were evaluated in terms of late-term contour deformity and further craniometric analysis for measurement of maximum amount of displacement, fracture surface area (mm2) and the maximum angulation of the fracture (degree) were done. 125 patients (101 male, 24 female) with frontal sinus fractures with an average age of 22.4 years (range,17–66 years) were reviewed. All patients with isolated anterior table fractures without displacement were followed up on conservative basis. 33 patients with anterior table fractures with displacement and 39 patients with anterior and posterior table fractures were also followed on conservative basis without surgical intervention. The cut-off value of the maximum amount of displacement was confirmed to be 4.5 mm in prediction of late-term contour deformities (p < 0.001). The maximum amount of displacement was decreased by an average of 1.8 mm at late-term. Apart from the standard protocols, within the limitations of the study it seems that isolated anterior table fractures with a maximum amount of displacement of less than 4.5 mm can be treated conservatively without leading to contour deformities. CSF leakage in the acute setting might not always require cranialization and this may spontaneously resolve within 10 days. Cranialization should be considered whenever CSF leakage lasts longer than 10 days.

Supramuscular upper blepharoplasty approach to orbital roof and/or lower anterior table frontal sinus fractures: A meta-narrative review

BackgroundAn approach to orbital roof fractures (ORFs) and/or lower anterior table frontal sinus fractures (LATFSFs) is a challenging task. The conventional coronal approach (CCA) appears to suit multiple/complex fractures of the upper face, while periorbital transcutaneous incisions (PTIs), e.g. gull wing, open sky, butterfly, and Lynch incisions, often impair aesthetic outcomes. The aims of this paper were to provide an overview of the supramuscular upper blepharoplasty approach (SUBA) to ORFs/LATFSFs. MethodsUsing a meta-narrative review study design, the investigators enrolled published data extracted from PubMed/Medline, Embase, Cochrane Library, and Google Scholar concerning SUBA to ORFs/LATFSFs. Only publications with the highest and most recent level of evidence (LoE) in English, French or German available until 6 May 2022 were included. The LoE were evaluated using the 2011 Oxford Centre for Evidence-Based Medicine (OCEBM)’s classification. ResultsIn total, 70 articles were included; however, most contained low LoE. Under general and local anaesthesia, SUBA to ORFs/LATFSFs can be performed safely and appeared to be superior to its submuscular counterpart in terms of fewer risks of adjacent tissue injuries, and speedy operative time (maximal 5 min. in experienced hands). ConclusionsIn contrast to CCA and PTIs, the SUBA is a minimally invasive approach to the ORF/LATFSF with favourable aesthetic outcomes, direct visualisation of the fracture, quick operative time, rare complications, and easy learning.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Point of Care Virtual Surgical Planning and Three-Dimensional Printing for Feminizing Foreheadplasty.

Evaluation and treatment of facial feminization surgery: part I. forehead, orbits, eyebrows, eyes, and nose.

Facial feminization surgery (FFS) incorporates aesthetic and craniofacial surgical principles and techniques to feminize masculine facial features and facilitate gender transitioning. A detailed understanding of the defining male and female facial characteristics is essential for success. In this first part of a two-part series, we discuss key aspects of the general preoperative consultation that should be considered when evaluating the prospective facial feminization patient. Assessment of the forehead, orbits, hairline, eyebrows, eyes, and nose and the associated procedures, including scalp advancement, supraorbital rim reduction, setback of the anterior table of the frontal sinus, rhinoplasty, and soft tissue modifications of the upper and midface are discussed. In the second part of this series, bony manipulation of the midface, mandible, and chin, as well as soft tissue modification of the nasolabial complex and chondrolaryngoplasty are discussed. Finally, a review of the literature on patient-reported outcomes in this population following FFS is provided.

Point of care VSP and 3D printed model for anterior table setback mock surgery.

Point of care VSP and 3D printed model for anterior table setback mock surgery.

Frontal Sinus Fractures: 10-Year Contemporary Experience at a Level 1 Urban Trauma Center.

Frontal sinus fractures account for 5% to 15% of all facial fractures, and have traditionally been associated with high kinetic energy blunt injury. Surgical management is largely focused on minimizing potentially serious sequelae including frontal sinus dysfunction, CSF leak, and significant cosmetic deformity. An institutional database of 1944 patients presenting with maxillofacial fractures over a 10-year period was queried. Demographics, mechanism of injury, yearly trends, surgical approaches, and follow-up data were examined. A total of 160 (8.3%) patients presented with at least 1 fracture of the frontal sinus anterior table, posterior table, or frontal sinus outflow tract during the study period. The average annual number of cases was 15.9 ± 5.7 per year with a peak of 21.5 ± 4.0 cases during the 2014 to 2015 period and a decline to 8.5 ± 1.5 cases/year from 2016 to 2017. Among those patients with falls, 61.5% (n = 40) were a result of tripping or fainting at a height of <6 ft. 55.6% of fracture types were isolated to the anterior table, but fracture location was not significantly associated with operative intervention. Cases of operative fracture type had a higher rate of both displacement and comminution compared to nonoperative fractures (P < 0.00001). Of all patients presenting with frontal sinus fractures, 75% of cases were managed nonoperatively. However, many patients presented with falls and other seemingly low energy injuries which are not traditionally associated with frontal sinus trauma. These results highlight the need for continued follow-up even in otherwise low-risk urban populations in order to avoid long term sinus dysfunction.