Contouring

The standard approach is a coronal incision. However, previous craniotomy incisions may also be utilized.

An alternative approach is via a limited exposure upper-eyelid approach.

Subperiosteal dissection of the affected rim is performed. The supraorbital nerve is visualized and protected.

The supraorbital rim is reshaped with a burr.

During the contouring care is taken not to:

• Communicate with the frontal sinus or anterior cranial fossa. Detailed radiological preoperative evaluation of the sinus anatomy is therefore mandatory.
• Injure the supraorbital and/or supratrochlear neurovascular bundles.

Head of bed elevation may significantly reduce edema and pain.

The patient's neurological status should be evaluated as soon as it is feasible. Regular postoperative neurological checks should be performed.

Evaluation of the patient’s vision is performed as soon as they are awakened from anesthesia and then at regular intervals until they are discharged from the hospital.

Nose-blowing should be avoided for at least 3 weeks following frontal sinus and skull base repair.

The use of some of the following perioperative medication is controversial.

Analgesia as necessary

Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.) The spectrum should be according to the existing bacterial flora, especially in the combined intra and extra cranial procedures.

Corticosteroids may help with postoperative edema.

Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.

The following signs and symptoms are usually evaluated:

• Vision
• Extraocular motion (motility)
• Diplopia
• If the patient complains of eye pain, a thorough ophthalmological evaluation should be performed.

A head CT scan is obtained postoperatively to provide a patient baseline and evaluate for intracranial bleeding, dead space, and pneumocephalus.

Remove sutures from skin after approximately 7 days if non resorbable sutures have been used. Moisturizing lotion should be used on the skin wounds to minimize excessive scarring after sutures are removed.
Avoid sun exposure and tanning to skin incisions for several months.

Regular patient follow-up after discharge including periodic imaging is recommended.