Fig. 12.35  Reconstruction of the anterior sinus wall with titanium mesh (CFFs). (a) The larger bone fragments are used to reconstruct part of the anterior wall of the frontal sinus. Multiple small fragments cannot be fixed resulting in a bone defect. (b) Closure of the defect with a dynamic titanium mesh (0.3 mm).

(c) CT scans 6 months postoperatively demonstrating a symmetric frontal contour and complete re-pneumatization of the frontal sinus. (d) Clinical situation 6 months postoperatively, demonstrating smooth and symmetric contour of the supraorbital region

12.5.5  Fractures of the Anterior and

Posterior Sinus Walls with Anterior

Skull Base Involvement

Basically, the principle aim is always to reconstruct the frontal sinus (Ehrenfeld et al. 1996; Ernst and Lennarz 1996).

In extensive frontal sinus fractures with frontal skull base injuries, the transfrontal/transcranial extradural approach should be favored. Following temporary removal of either the anterior wall of the frontal sinus or a cranio-frontal bone flap, the dura and base are exposed. Alternatively, the affected skull base section can be approached and treated via the subcranial/subdural approach (Raveh and Vuillemin 1988; Raveh et al. 1992).

In the case of extensive comminution, particularly of the dorsal wall, cranialization of the frontal sinus is performed by total removal of the dorsal wall, meticulous removal of the sinus mucosa, following tight closure of

the infundibulum. This results in a functional enlargement of the intracranial space (Kessel et al. 1971; Donald and Bernstein 1978; Luce 1987; Elies 1982; Wallis and Donald 1988; Donald 1994, 1998a, b) (Figs. 12.36–12.39).

•Occlusion of the nasofrontal duct is carried out with a bone or muscle graft and an additional pericranial flap. The ventral sinus wall should be always reconstructed.

12.5.6  Fractures of the Frontal Sinus with Comminution of the Infundibulum

Ventilation and drainage of the frontal sinus may be difficult to restore in fractures with intact posterior sinus wall and simultaneous comminution of the anterior wall and infundibulum. In such cases, obliteration of the sinus with autogenous tissue (bone graft, fat, and muscle) is indicated (May et al. 1970; Stanley and Becker 1987;