a

b

c

Fig. 8.26  Transfacial butterfly incision to treat a gun-shot injury in the naso-frontal region. (a) Incision outlined. (b) Intraoperative situation demonstrating nasofrontal fracture. (c) Situation after wound closure

•Dural tears in the region of the posterior wall of the frontal sinus are easily accessible after sufficient exposure. They can be well repaired by dural suture using atraumatic, nonabsorbable sutures, as the dura in this area exhibits the necessary consistency (Schwab 1995). In addition, a duraplasty is carried out using alloplastic material or fascia, which is fixated­ with fibrin glue. A drain is placed into the nasal cavity to

assure frontal sinus ventilation and drainage. This type of drainage should be maintained for 3–6 months until total consolidation and reepithelization has taken place.

8.6.4.2  Ethmoid/Cribriform Plate

The intact dura is dissected from the bony rims of the fracture site and a bed formed for the necessary patch. This is then placed between dura and bone and fixed with tissue adhesive. Free pericranial or fascia lata grafts or alloplastic transplants may be used for extradural duraplasty (Schwab 1995; Ernst et al. 2004).

8.6.4.3  Sphenoid

After ethmoidectomy of the posterior ethmoid, the anterior wall of the sphenoid sinus is removed under microscopic control (Delank et al. 1998). When clearing the fragments from the sphenoid sinus, great care must be taken as there is a potential danger of injuring the local vessels. Defects should be covered with a transplant (Landreneau et al. 1998).

If there is a dural fistula in the roof of the sphenoid sinus, the mucous membrane is carefully removed and the entire sphenoid sinus is lined with a transplant, sealed, and filled with fibrin foam. Closure to the nasal cavity is secured and supported by an additional tamponade strip.

The obliteration technique is advocated for covering large sphenoidal sinus defects, i.e., the entire sphenoid cavity is completely filled with a transplant. Fat, muscle, or fascia tissues can be used (Schwab 1995; Schick et al. 1996; Delank et al. 1998; Ernst et al. 2004).

8.6.5  Advantages, Disadvantages,

and Risks Associated with

the Transfacial Approaches

The transfacial butterfly incision can result in an esthetically nonacceptable scar and offers only a limited­ exposure. Simultaneously with this incision, the supraorbital and supratrochlear nerves may be injured. The butterfly incision has the same limiting factors as the approach through penetrating soft tissue