4.2. Surgical approach
The objective of treatment is to create a safe sinus and restore aesthetic unity. The procedure begins with a bicoronal incision or incision through existing cuts in the forehead. The borders of the sinus are marked and an osteotome is used for trephination of the frontal sinus. All bony fragments should be collected and orientated on the table to help fixation and for replacement at the end of the operation. Any drainage compromise requires frontal sinus obliteration. Mucosa should be fastidiously removed, including from the vascular crypts of Breschet. Nasal communication should be eliminated and the sinus filled with graft tissue (Metzinger and Metzinger, 2009). This approach has been challenged based on the current understanding of osteoneogenesis. It is suggested that filling the sinus with non-vascularised material such as fat has no advantage over not filling it at all (Rohrich and Mickel, 1995). Any posterior displacement of posterior table fractures requires cranialisation, in which the posterior table is removed and the brain is allowed to expand into the site previously occupied by the sinus.
The use of an endoscopic approach has not been discussed in detail here because it still has a minimal role in the management of frontal sinus fractures in most trauma centres; however, scarring and swelling may be reduced via an endoscopic brow lift, allowing a faster recovery (Simmons and Manson, 2009).