Accepted: 29 November 2017
Value of double mucoperiosteal flaps to prevent restenosis in
Draf IIb/III: First clinical report
The frontal sinus is the most challenging of all paranasal sinuses
despite major advances in endoscopic approaches, instrumentations
and image guidance systems.
Draf IIb and III procedures include
extensive bone drilling with resection of the mucosa. Leaving exposed
drilled bone is a major factor that contributes to postoperative failure
because it induces osteitis with subsequent neo-osteogenesis, scarring
and ostium restenosis.
Covering the posteriorly exposed bone with a
single local mucoperiosteal flap was recently proposed to overcome
this issue with promising results.
Vascularised flaps are rapidly inte-
grated to the bony surface allowing a complete epithelialisation that
inhibits the osteitis process. A cadaver study described a double flap
strategy in Draf III procedures covering both the anterior and poste-
rior edges of the frontal cavity.
The objective of this study was to
demonstrate the clinical feasibility of double mucoperiosteal flaps in
Draf IIb and III procedures by reporting the first clinical series and to
evaluate the postoperative healing process.
MATERIALS AND METHODS
The study was approved by the institutional review board at Lari-
boisiere university hospital.
This is a retrospective study from January 2014 to January 2016 at the
otolaryngology-head and neck surgery/endoscopic skull base depart-
ment at Lariboisiere university hospital in Paris, France. Patients’ charts
were reviewed. Inclusion criteria were as follow: Draf IIb or III proce-
dures, double flaps technique to cover the exposed bone and follow-up
superior to 3 months. Draf III was performed in case of recalcitrant CRS
and when a Draf IIb was not enough to expose a benign tumour or to
drain a mucocele with supraorbital extension. During the study period,
a double flap approach was systematically performed unless a technical
limitation was encountered or in the presence of an unhealthy mucosal
flap due to severe polyposis or fibrosis.
All procedures were performed by two senior surgeons in the oper-
ating room under general endotracheal intubation. The flaps were
raised at the beginning of the procedure.
For the Septoturbinal Flap (STF), an inverted U-shaped incision is
made from the leading edge of the middle turbinate, onto the roof
of the nasal cavity and down to the septum. It is important to bend
the septal incision backward in order to allow full rotation of the flap
(Figure 1). The flap is harvested from the incision posteriorly in a
subperiosteal plane until the first olfactory fascicle is reached. A
small emissary vein/nerve running in a lateral direction is usually
seen prior to the first olfactory fascicle. The flap is stored in the
olfactory cleft posteriorly.
The easiest way to define the limits of the Lateral Nasoseptal
Flap (LNSF) is at the roof of the nasal cavity: the posterior limit is at
the level of the axilla of the middle turbinate and the anterior limit
under the nasion. From these landmarks, two vertical septal incisions
are prolonged and joined by an inferior horizontal incision. Laterally,
the posterior incision follows the maxillary line, and a parallel ante-
rior incision is drawn at a distance defined by the width of the pedi-
cle (Figure 2). The flap is elevated in a subperiosteal plane until the
anterior dorsum of the inferior turbinate is reached. It is stored med-
ial to the inferior turbinate down to the nasal floor.
Elevation of the flaps is followed by Draf IIb or III procedure. At
the end of the surgery, the STF and LNSF are unfolded to cover the
posterior and anterior edges of the frontal cavity, respectively. A 5-
mm silicone roll is used to stabilise the flaps and removed after
FIGURE 1 The dark line shows the incision limits of a right
septoturbinal flap. MT, middle turbinate; SP, septum
CORRESPONDENCE: OUR EXPERIENCE