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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5226_Библиотеки_им_академика_М_И_Перельмана.pdf
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8 Modied Mini/Hemi/Subtotal/Central Lothrop for Recalcitrant Chronic Frontal…
93
Fig. 8.10 Preoperative coronal (a) and axial (b) CT scan of a patient with proptosis and a right
fronto-orbital mucopyocele causing destruction of the superomedial orbital wall. Note the partition
separating the mucopyocele and the frontal sinus. This lesion was approached via a modied
central- Lothrop procedure (Eloy IIF). (c) Intraoperative endoscopic view of the modied centralLothrop procedure (Eloy IIF) prior to the resection of the dividing partition. (d) Copious mucopurulent extravasation is noted after resection of the partition. (e) Depiction of the opening after
resection of the partition. (f) A silastic splint is used to stent the created opening after adequate
drainage of the mucopyocele
94
Financial Disclosures None.
Conicts of Interest None.
M. S. Hegazin et al.
References
1. Javer AR, Alandejani T.Prevention and management of complications in frontal sinus surgery.
Otolaryngol Clin N Am. 2010;43:827–38.
2. Draf W. Endonasal micro-endoscopic frontal sinus surgery: the Fulda concept. Op Tech
Otolaryngol Head Neck Surg. 1991;2:234–40.
3. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modied transnasal endoscopic
Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg.
1995;113:427–34.
4. Close LG, Lee NK, Leach JL, Manning SC.Endoscopic resection of the intranasal frontal
sinus oor. Ann Otol Rhinol Laryngol. 1994;103:952–8.
5. Eloy JA, Friedel ME, Murray KP, Liu JK. Modied hemi-Lothrop procedure for supraorbital frontal sinus access: a cadaveric feasibility study. Otolaryngol Head Neck Surg.
2011;145:489–93.
6. Eloy JA, Kuperan AB, Friedel ME, Choudhry OJ, Liu JK.Modied hemi-lothrop procedure for
supraorbital frontal sinus access: a case series. Otolaryngol Head Neck Surg. 2012;147:167–9.
7. Friedel ME, Li S, Langer PD, Liu JK, Eloy JA.Modied hemi-lothrop procedure for supraorbital ethmoid lesion access. Laryngoscope. 2012;122:442–4.
8. Liu JK, Mendelson ZS, Dubal PM, Mirani N, Eloy JA.The modied hemi-Lothrop procedure:
a variation of the endoscopic endonasal approach for resection of a supraorbital psammomatoid ossifying broma. J Clin Neurosci. 2014;21:2233–8.
9. Eloy JA, Friedel ME, Kuperan AB, Govindaraj S, Folbe AJ, Liu JK.Modied mini-lothrop/
extended draf IIb procedure for contralateral frontal sinus disease: a cadaveric feasibility study.
Otolaryngol Head Neck Surg. 2012;146:165–8.
10. Eloy JA, Friedel ME, Kuperan AB, Govindaraj S, Folbe AJ, Liu JK.Modied mini-lothrop/
extended draf IIB procedure for contralateral frontal sinus disease: a case series. Int Forum
Allergy Rhinol. 2012;2:321–4.
11. Eloy JA, Liu JK, Choudhry OJ, etal. Modied subtotal lothrop procedure for extended frontal
sinus and anterior skull base access: a cadaveric feasibility study with clinical correlates. J
Neurol Surg B Skull Base. 2013;74:130–5.
12. Eloy JA, Mady LJ, Kanumuri VV, Svider PF, Liu JK.Modied subtotal-Lothrop procedure for
extended frontal sinus and anterior skull-base access: a case series. Int Forum Allergy Rhinol.
2014;4:517–22.
13. Weber R, Draf W, Kratzsch B, Hosemann W, Schaefer SD.Modern concepts of frontal sinus
surgery. Laryngoscope. 2001;111:137–46.
Draf III: Overall Concepts
andtheMucosal Graft andLaterally
Based Flap Techniques
ShilpaM.Rao andBradfordA.Woodworth
Key Points
• The Draf 3 (or Draf III) technique, also known as the modied endoscopic
Lothrop or the frontal sinus drill-out procedure, has emerged as a vital tool in the
endoscopic era to treat recalcitrant frontal sinus disease.
• This technique is also useful in the treatment of lateral mucoceles, skull base
tumors, anterior/posterior table fractures, and CSF leaks of the frontal sinus.
• The Draf 3 has also decreased the need for aggressive open approaches like
osteoplastic ap with obliteration and frontal sinus cranialization.
• Mucosal grafts and laterally based aps have shown short-term and long-term
efcacy in preventing stenosis and closure of the neo-ostium.
9
Background
Surgical management of frontal sinus disease is one of the most challenging areas
in sinus surgery because of narrow frontal sinus ostia, anatomical variability, proximity to skull-base and orbital structures, and difcult visualization. A gradual
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978- 3- 031- 89191- 5_9.
S. M. Rao
Department of Otolaryngology-Head and Neck Surgery, University of Alabama
in Birmingham, Birmingham, AL, USA
B. A. Woodworth (
Department of Otolaryngology-Head and Neck Surgery, University of Alabama
in Birmingham, Birmingham, AL, USA
Gregory Fleming James Cystic Fibrosis Research Center, Birmingham, AL, USA
e-mail: bwoodwo@uab.edu
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
J. T. Lee et al. (eds.), Advances in Surgical and Medical Interventions for
Recalcitrant Chronic Rhinosinusitis,
https://doi.org/10.1007/978-3-031-89191-5_9
*)
95
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S. M. Rao and B. A. Woodworth
stepwise approach is often suggested for the management of frontal sinus pathology, with endoscopic frontal sinusotomy as the preferred initial surgical intervention in patients that do not respond favorably to medical treatment [1]. Aggressive
open approaches like osteoplastic ap with frontal sinus obliteration are reserved
for severe cases. However, this procedure is associated with a 20% rate of intraoperative complications including, but not limited to, exposure of orbital fat, unintentional fracture of the anterior table, and dural injury, as well as a 10% risk of
long-term complications like mucocele and dissatised esthetic appearance [2].
Surgical techniques have evolved in the endoscopic era to prioritize functional
frontal sinus drainage and minimize complications. Open techniques like the
Lothrop procedure, external Lynch incision, and osteoplastic ap have given way to
extended endoscopic approaches that markedly increase the pathway for frontal
sinus drainage [3]. A minimally invasive technique called the Draf 3 procedure, also
known as the endoscopic modied Lothrop or frontal drill-out procedure, has gained
wide acceptance as the primary alternative to frontal sinus obliteration [4]. The Draf
3 method, initially described by Wolfgang Draf [5] in 1991 and Becker, etal. [4] in
1995, involves surgical resection of the superior nasal septum, inter-frontal sinus
septum, and the oor of the frontal sinus to create a single common frontal sinus
drainage pathway [5]. Wolfgang Draf employed an operating microscope to perform the surgery, but it is now adapted to use of an endoscope. While complications
from the Draf 3 are lower than open approaches, the primary issue in a meta- analysis
of the procedure is a 19% rate of neo-ostium stenosis and closure rate of 4%.
Osteogenesis due to the exposed drilled bone of the anterior neo-ostium is often the
culprit and can lead to narrowing and recurrence of symptoms [6, 7]. The other
causes of Draf 3 stenosis include postoperative adhesions, scarring, and inammation of bare bone causing mucosal edema and hypertrophy [6, 8]. In an effort to
improve stenosis and closure rates, the senior author (BAW) developed the Draf 3
mucosal graft technique with laterally based aps and rst described the technique
with the results of a prospective study in 2012 [6]. This study demonstrated marked
improvement over pooled analyses of Draf 3 results in the literature.
Indications fortheDraf 3 Procedure
The Draf 3 procedure is traditionally recommended for patients with chronic frontal
sinusitis who have not experienced successful outcomes with initial conservative
surgical management techniques like endoscopic enlargement of frontal sinus ostia
or Draf 2 or Draf 2b procedure. These techniques are discussed in Chap. 7. The Draf
3 procedure should be considered before choosing aggressive open approaches like
frontal sinus obliteration, because of its minimally invasive nature and decreased
morbidity. The primary intent is to create a common frontal sinus drainage pathway
for maintaining functional mucociliary clearance and adequate ventilation [9].
Anderson and Sindwani [10] reported chronic frontal sinusitis and mucocele as the
most common indications for the Draf 3 in their systematic review and metaanalysis of 18 studies. The technique is usually suggested for patients with chronic
9 Draf III: Overall Concepts andtheMucosal Graft andLaterally Based Flap Techniques
97
rhinosinusitis associated with high risk features like severe sinonasal polyposis,
aspirin intolerance, narrow frontal ostium, and ciliary dysmotility [11]. The Draf 3
is also considered for approaches to benign (i.e., osteoma and inverted papilloma)
and malignant neoplasms involving the frontal sinus or the frontal sinus ostium. In
conjunction with periorbital suspension techniques, access to tumors in the far lateral frontal sinus or narrow supraorbital recess is now possible [12]. It is frequently
used as an approach during endoscopic skull base surgery to mark the anterior limits
of surgical resection and prevent iatrogenic postoperative frontal sinus disease
[13–15]. The approach can also be used to manage frontal sinus trauma and cerebrospinal uid leaks [16–24]. Fractures involving the frontal sinus have been treated in
the past with open approaches such as sinus obliteration or cranialization, with the
objective of preventing complications such as mucoceles and cerebrospinal uid
leak from the posterior table [25]. Recently, clinical management has shifted
towards endoscopic approaches using a Draf 3 (or Draf 2b) for access to reduce
anterior table fractures and repair posterior table fractures and CSF leaks with successful outcomes [26–28]. Other less frequently reported indications include frontal
sinus osteomyelitis and frontal cholesterol granuloma [29–31]. Overall, the Draf 3
allows for better postoperative monitoring, prevents frontal bossing and external
scar, improves cosmetic appearance, and lessens overall morbidity compared to
open approaches [32].
Surgical Techniques
The patient is prepped and draped under general anesthesia. Image guided surgical
navigation may be used to conrm landmarks during surgery. The nasal cavity is
decongested with 1:1000 epinephrine-soaked cotton pledgets and inspected with a
0-degree endoscope for the presence of diseased mucosa. The extent of sinus surgery overall is based on the purpose of the procedure. Patients with isolated frontal
sinus mucoceles or other pathology and no other mucosal disease rarely need more
than maxillary antrostomies and anterior +/− posterior ethmoidectomy to identify
the skull base as a landmark for the surgery. However, CRS patients with diffuse
patchy mucosal inammation or polyps require “full house” endoscopic sinus surgery with wide maxillary antrostomies, and complete sphenoethmoidectomy [33].
The Draf 3 procedure may be carried out in two ways, viz., the “inside-out” and
“outside-in” techniques which were based originally on the diameter of the frontal
recess, as reported by Noller, etal. [11] According to their group, the inside-out
technique was considered when the antero-posterior diameter of the frontal recess
was >4mm, which provides adequate space for instrumentation. The outside-in
technique was performed when the diameter was <4mm, because the restriction
impeded the ability to pass frontal instruments. The other facet of the outside-in
approach was the ability to use a 0 degree endoscope for the entire procedure. The
outside-in method is generally performed in the reverse order in comparison to the
inside-out technique and involves the removal of nasofrontal beak followed by the
frontal recess progressing towards the intersinus septum.
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S. M. Rao and B. A. Woodworth
Modifications
Our surgical technique has evolved in the last 15years from using an exclusively
inside-out technique to incorporating various aspects of both procedures. The ability
to use the 0 degree endoscope with the outside-in increases operative speed, but can
also be incorporated into an inside-out approach, especially when the frontal sinus has
already been opened with a Draf 2a bilaterally. We also describe our original technique using mucosal grafts from the upper septum (Video 9.1, Figs.9.1, 9.2 and 9.3)
Fig. 9.1 Coronal (a) and sagittal HRCT (b, c) imaging of paranasal sinuses showing small ste-
notic frontal sinus ostia with a poor A/P diameter
ab c
de f
Fig. 9.2 Intraoperative images of Draf 3 mucosal graft and laterally based ap technique for the
patient in Fig.9.1. The upper septectomy is outlined with a beaver blade (a) and the right upper
septal mucosal graft removed (b). A scissor is used to complete the incisions and harvest the left
upper septal mucosal graft. Laterally based aps ending at the nasal vault are incised with a beaver
blade (d) and displaced inferiorly with an elevator (e) to the level of the inferior turbinate head so
that they are out of the way for drilling the Draf 3 (f)
9 Draf III: Overall Concepts andtheMucosal Graft andLaterally Based Flap Techniques
99
ab c
de f
Fig. 9.3 Intra-operative views of the completed Draf 3 with measurement of the A/P diameter (a).
The laterally based aps are placed back into position over the bone that was drilled laterally (b)
and the rst mucosal graft placed over the drilled frontal beak (c). 70 degree endoscopic view of
both mucosal grafts over all the drilled bone and the lateral aps covering the lateral bone (d).
Rolled silastic sheets are placed to cover the grafts (e) and postoperative healing and diameter
show similar diameter at 3months (f)
Fig. 9.4 Incisions along
the lateral nasal wall—
anterior (in blue) and
posterior incision (in red),
in preparation for the Draf
III procedure
as well as a newer modication of the technique that incorporates the upper septal
mucosa with our laterally based aps (Video 9.2, Figs.9.4, 9.5, 9.6 and 9.7).
Starting with a 0 degree scope, the upper septectomy is outlined with an angled
Beaver blade or, more recently, with an extended needle-tip bovie cautery. The
mucosal grafts are harvested, placed on the back table, the perichondrium and submucosa thinned, and placed in saline for later in the case. Alternatively, the posterior
aspect of one or both inferior turbinates can be harvested and thinned out for use if
100
Fig. 9.5 Incisions
depicted in the anterior
nasal view—anterior
incision (in blue), posterior
incision (in green) and
inferior septal incision
(in red)
abc
S. M. Rao and B. A. Woodworth
de f
Fig. 9.6 A lateral nasal wall incision for a complete ap technique (a) is demonstrated using a
needle tip bovie cautery followed by elevation of the upper septal mucosa connected to the lateral
ap (b–d). The Draf 3 is performed (e) and the right ap is placed into the frontal sinus over the
beak (f)
the mucosa is unusable (i.e., polypoid change, already perforated). Next, laterally
based mucoperiosteal aps based on the front portion of the inferior turbinate are
elevated following a lateral incision posterior to the anterior free margin of the middle turbinate extended to the upper nasal septum approximately a half centimeter
posterior to the anterior most middle turbinate attachment. Another lateral incision
9 Draf III: Overall Concepts andtheMucosal Graft andLaterally Based Flap Techniques
101
abc
def
Fig. 9.7 The left ap is then placed into the frontal sinus (a) and both aps positioned over the
exposed bone of the sinus (b). Endoscopic view of the aps in position (c). Mometasone eluting
stents are placed over the aps to tack them down (d) and additional silastic sheets are placed to
cover the aps (e). Endoscopic view at 3months reveals a stable diameter with well healed aps (f)
along the nasomaxillary buttress just posterior to the cartilaginous nose is made
superiorly to the nasal vault under the nasal bones but posterior to the cartilaginous
attachments to avoid exposure of the anterior cartilage. The ap is elevated in the
subperiosteal plane and preserved for later in the procedure. Recently, we have transitioned the majority of the time to elevating one continuous ap on each side that
incorporates the laterally based ap with the upper septal mucosa. This is a difcult
technique to master due to the thin, friable nature of the mucosa that spans the upper
nasal vault. The aps are placed out of the way of the instruments and endoscope on
the nasal oor.
The septal mucosa of the posterior aspect of the septectomy is elevated to
identify the rst olfactory lia on both sides. The procedure then continues using
15-degree cutting and diamond burrs to thin the nasolacrimal area and lateral
bone to improve width. While we may proceed with a classic outside-in approach
depending on the circumstances (i.e., osteoma lling the frontal sinus recess),
more commonly we use the 0 degree view and 15-degree bur to drill anteriorly
from the Draf 2a, removing the frontal sinus oor/nasofrontal beak on both sides
and crossing over to create a common cavity. Once the basic cavity is sculpted,
we switch to a 70-degree endoscope and 70-degree diamond burr to polish the
corners of the neo-ostium, as well as remove the remainder of the intersinus septum and any lateral partitions within the frontal sinus to achieve maximal
diameter.
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S. M. Rao and B. A. Woodworth
Next, the laterally based aps are transferred to the lateral and inferior aspect of
the neo-ostium and, if raised attached to the upper septal mucosa, the additional
length covers the anterior aspect of the ipsilateral portion of the Draf 3. Otherwise,
the upper septal or inferior turbinate mucosal grafts harvested earlier are placed
onto the anterior aspect of the neo-ostium and rolled 0.5mm silastic sheeting cut to
t are placed into the frontal sinus to cover the mucosal grafts or aps. Frontal
Propel steroid-eluting stents can also be used to help provide pressure and tack the
grafts or aps down. Nasopore® or other bioabsorbable material can also be placed
into the Draf 3 to provide additional pressure.
Reported Outcomes
Numerous studies describe the benets of the Draf 3 procedure and validate it as the
preferred procedure over an osteoplastic ap. However, it should be noted that closure or stenosis is the most common reason for revision and the most common
complication. Shih, etal. [34] reviewed 29 articles that described the Draf 3in 1205
patients, and identied symptom improvement with an overall rate of 85.6% and an
overall patency rate of 90.7%. This was compared to results of an earlier metaanalysis that had an overall patency rate of 86.1%, but the stenosis rate of the earlier
cohort was 15% with an additional 4% with complete closure [10]. Several groups,
including our own, use the mucosal graft technique which may have contributed to
the improved patency rate in the later cohort [6, 8, 32, 35, 36]. Ting, etal. [37], in
their retrospective study of 204 patients, saw a recurrence rate of 30% due to frontal
sinus restenosis after 10years of follow-up. Eloy, etal. [38], in their retrospective
multi-institutional study of 120 patients who underwent Draf 3 procedure, noticed
stenosis of the neo-ostium in 16 patients (13%) and a complete closure in 15 patients
(12.5%). There was an increased risk of restenosis in patients with aspirin sensitivity, asthma, and cystic brosis [7, 38]. Several studies have shown that the success
rates remain unchanged with short- and long-term follow-up whereas the rates of
revision surgery gradually increase with time [34, 38].
The senior author (BAW) developed the Draf 3 mucosal grafting technique with
laterally based aps in 2008 due to frustration with the prolonged healing time of
the bare bone of the frontal beak and the subsequent decrease in neo-ostial size/
diameter that was observed in the rst 3months postoperatively. We hypothesized
that covering the bare bone with mucosal grafts or aps would minimize postoperative osteoneogenesis, decrease stenosis, and avoid revision surgery. A prospective
study to evaluate the technique was performed with measurement of the intraoperative antero-posterior diameter with a trimmed paper ruler inserted into the Draf 3
cavity at the level of the drilled nasofrontal beak to the anterior aspect of the central
cribriform plate. A ruler was also inserted into the neo-ostium at their clinical follow-up visits and the results recorded. Patients followed up to 3months were
included in the study where we observed excellent results with an average neoostium diameter of 10.8mm at 3 months compared to 11.7mm pre-operatively.
Importantly, no patients developed stenosis (<50% original diameter) and there was
a 100% success rate (no closure >50% and no revisions) [6]. While overall