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Coronal Approaches to the Upper Facial Skeleton

last modified on: Thu, 09/13/2018 - 13:27

Coronal Approach to the Upper Facial Skeleton


return to:Reconstructive Procedures Protocols

  1. GENERAL CONSIDERATIONS
    1. Indications
      1. Access to frontal sinus, nasal root, nasoethmoid compartment, superior orbits, and zygomatic arch for fracture repair or tumor extirpation
      2. Approach to infratemporal fossa, lateral orbital rim, and lateral skull base for tumor extirpation
    2. Contraindications
      1. Baldness or a strong family history of male pattern baldness is a relative contraindication to this approach
    3. Pertinent Anatomy
      1. See Temporoparietal Fascia Flap flap and Galeal flap protocols
      2. Anteriorly, the layers of the scalp include from superficial to deep: skin, subcutaneous tissue, galea or frontalis muscle, subgaleal fascia, periosteum
      3. Laterally over the temporalis muscle, the layers of soft tissue are more complicated
        1. Above the temporal line of fusion, which is at the level of the superior orbital rim and delineates the superior aspect of the temporal fat pad, the layers include: skin, subcutaneous tissue, temporoparietal fascia (cranial nerve VII, and the superficial temporal artery run in this layer), deep temporal fascia, temporalis muscle, periosteum
        2. Below the temporal line of fusion the layers include: skin, subcutaneous tissue, temporoparietal fascia, superficial layer of the deep temporal fascia, temporal fat pad (middle temporal artery runs in this pad), deep layer of the deep temporal fascia, temporalis muscle, periosteum
      4. The term "bicoronal incision" is a misnomer. The appropriate terminology is "coronal incision" or "hemicoronal incision."
  2. PREOPERATIVE EVALUATION
    1. Evaluation
      1. For males, the emphasis appropriately focuses on the status of the hairline. In some cases of mild male pattern baldness, the incision may be placed posteriorly to hide it in the remaining hair. The patient should be aware that the incision may become visible if hairline recession continues.
      2. Ensure that the planned incision will afford adequate exposure for the planned procedure.
      3. If temporoparietal or galeal flaps are planned, see protocols for these procedures.
    2. Potential Complications
      1. Infection
      2. Hematoma requiring evacuation
      3. Alopecia along incision line
      4. Visible scar
      5. Injury to frontal branch of facial nerve
      6. Numbness of the flap tissue (may result if supraorbital or supratrochlear nerves are injured)
      7. Some anesthesia posterior to the incision is anticipated, and the patient should be aware of this.
  3. NURSING CONSIDERATIONS
    1. Room Setup
      1. See Basic Soft Tissue Room Setup
      2. Mayfield headrest
      3. Back table x 2
    2. Instrumentation and Equipment
      1. Standard
        1. KLS Oto Trauma Implant - Instrument Tray or
        2. KLS Free Flap Implant - Instrument Tray or
        3. KLS Maxillofacial Implant/Instrument Tray
        4. KLS Locking Reconstruction Threadlock Instrument Tray or
        5. KLS mandibulectomy tray
        6. Fracture Tray
        7. Bipolar Forceps Trays
        8. Minor Instrument Tray, Otolaryngology x 2
        9. Nasal Sharp Tray
        10. Sinus Tray
        11. Hall Micro Sagittal Saw Tray (Pneumatic)
      2. Special
        1. Bien Otologic Electric Drill Tray
        2. Varidyne vacuum suction controller
        3. Raney scalp hemostatic clips
        4. Syringe, Luer Lock, 30 cc, with 18-gauge blunt needle, for irrigation while drilling
    3. Medications (specific to nursing)
      1. 1% lidocaine with 1:100,0000 epinephrine injection
      2. Ocular lubricant ointment
      3. Antibiotic ointment
    4. Prep and Drape
      1. Standard prep, 10% providone iodine
      2. Drape
        1. Head drape
        2. Square off with towels around face and neck, leaving eyes exposed. If fat grafts are needed, then prep and square off with towels the specified area of the abdomen or thigh (along with extra sterile sheet over the abdomen).
        3. Split sheet
        4. An irrigation pouch with suction attachments is positioned around the head to appropriately deal with blood and fluid drainage.
    5. Drains and Dressings
      1. Antibiotic ointment to suture line
      2. Adaptic, large, 3 x 8 in
      3. Fluffs x 3
      4. Kling wrap, 4 in x 2
      5. Varidyne vacuum suction (7 or 10 mm) or Penrose 0.25 in
    6. Special Considerations
      1. The face and entire scalp should be prepped and draped.
      2. The hair is washed with Betadine solution.
      3. A green towel is stapled to the scalp behind the anticipated location of the incision. This should be stapled along the lateral head down to the region of the mastoids behind helical root.
      4. In most cases, tarsorrhaphy sutures are placed to protect the eyes.
      5. Rubber bands, 1/4 in or 18 in, may be used to secure hair.
  4. ANESTHESIA CONSIDERATIONS
    1. General
      1. Depending on the indication for surgery, the patient will either have an oral endotracheal intubation or tracheostomy.
    2. Specific
      1. Patient will be supine on a Mayfield headrest.
      2. The head will be turned 180° from the anesthesiologist.
      3. Other than brief paralysis used during induction, no paralyzing anesthetic agents are used.
  5. OPERATIVE PROCEDURE
    1. The standard coronal incision runs from helical crus to helical crus approximately 2 to 3 cm posterior to the hairline. Rubber band pigtails are used to gather up the hair on either side of the intended incision line.
    2. The incision line should follow a geometric broken line type of pattern. This will minimize visibility of the incision, particularly when the hair is wet.
    3. The initial incision is carried down to the level of the periosteum. Raney clips are not used.
    4. If the incision is being used as an approach to the frontal sinus, the dissection plane changes to the subperiosteal plane above the sinus. If the access is for upper central facial surgery the dissection changes to the subperiosteal plane approximately 2 cm above the supraorbital rim.
    5. Laterally over the temporalis muscle, the plane of dissection should be deep to the temporoparietal fascia, just above the deep temporal fascia. This plane will allow elevation of the frontal branch of the facial nerve with the coronal flap.
    6. If access to the zygoma is required, the superficial layer of the deep temporal fascia is opened just above the arch. If this plane (temporal fat pad) is entered more superiorly, bleeding from the middle temporal artery will be encountered, and atrophy of the fat in this pad will be more pronounced after surgery.
    7. Extended access to the upper orbits and nasoethmoid areas requires release of the supraorbital neurovascular bundle that is then reflected anteriorly with the coronal flap. The inferior aspect of the short bony foramen through which this neurovascular bundle occasionally passes is simply removed with a downward tap of the osteotome.
    8. Closure of the incision is in two layers. The galea and subcutaneous tissue are closed with 2-0 vicryl. The skin is closed with a running lock stitch of 3-0 nylon or with staples. The flap is closed over 10 mm fully perforated suction drains. For coronal incisions, two drains are placed.
    9. The incision is covered with antibiotic ointment.
  6. POSTOPERATIVE CARE
    1. The drains may be removed when drainage is less than 30 cc per 24 hours.
    2. Patients with long hair may wash the hair carefully on postoperative day 3 or 4, followed by reapplication of antibiotic ointment.
  7. SUGGESTED READING
    1. Frodel JL, Marentette LJ. The coronal approach anatomic and technical considerations and morbidity. Arch Otolaryngol Head Neck Surg. 1993;119:201-207.
    2. Munro IR, Chir B, Fearson JA. The coronal incision revisited. Plast Reconstr Surg. 1994;93:185-187.
    3. Obwegeser HL. Temporal approach to the TMJ, the orbit, and the retromaxillary-infracranial region. Head Neck Surg. 1985;7:185-199.
    4. Stanley RB. The temporal approach to impacted lateral orbital wall fractures. Arch Otolaryngol Head Neck Surg. 1988;114:550-553.
    5. Stuzin JM, Wangstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:265-271.