Correction of Severe Frontal Bossing with Coronal Brow Lift and Osteoplastic Frontal Sinus Setback Aided by Virtual Surgical Planning: A Case Report

Abstract

Objective: An 18 year old male with a hypoplastic midface, low anterior hairline, heavy brows and marked frontal bossing presented for evaluation. Laboratory evaluation for acromegaly was negative. He did have impairment of his bilateral visual fields as confirmed by visual field testing by ophthalmology. His nasal radix was also of particular concern to him as it formed a significantly depressed crease between his nasal bridge and his brow. He requested surgical correction of these deformities from both a functional and aesthetic standpoint. Methods: We performed thin-cut CT maxillofacial scanning with 3D reformats and submitted this for virtual surgical planning (VSP). We were able to create a template with which to remove the anterior table of the frontal sinus safely, confidently, and without the aid of a craniotomy. The operation was performed through a preexisting bicoronal incision. The anterior table of the frontal sinus was removed in one piece. His forehead and superior orbits were contoured with a burr. After contouring, the anterior table was fixated in a more recessed position. Nasal radix augmentation was also performed using bone grafting. A coronal brow lift was then performed. Results: The patient’s post-operative course was uneventful. He noted marked improvement in his superior visual fields. He had complete resolution of his nasal radix deformity and his frontal bossing. This was confirmed by thin-cut CT maxillofacial scanning postoperatively. His frontal branches were functionally intact and his hairline was raised to a more appropriate position. Conclusions: Virtual surgical planning allowed us to perform an osteoplastic forehead reduction safely and without older methods such as Caldwell x-rays with coin reference, transillumination, or the bayonet forcep technique. It also allowed us to avoid the use of surgical navigation which can be time consuming and cumbersome. This VSP-based access to the frontal sinus has applications in many aspects of reconstructive cranial surgery as well as aesthetic forehead reductions for patients that do not require a craniotomy.