The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
How I Do It
Modified Glabellar Rhytid Incision for Frontal Sinus Trephination Brian A. Fishero, MD; Philip G. Chen, MD; Spencer C. Payne, MD
INTRODUCTION Surgical management of the frontal sinus is more complex compared to the other sinuses. Testament to this fact is that for years the standard for refractory frontal disease has been the destructive procedure of an osteoplastic flap with complete obliteration of the sinus.1 With better understanding of the physiology of the paranasal sinuses, there has been a shift toward surgery directed at functionally improving drainage by widening the natural outflow pathway with purely endoscopic techniques. Whereas expanded frontal approaches such as the endoscopic modified Lothrop procedure (EMLP) can provide quite extensive access,2 they can be nicely augmented with a concomitant mini-trephination. In circumstances such as complicated acute frontal sinusitis, extensive lateral pneumatization of the frontal bone, or neo-osteogenesis of the frontal recess, a trephination continues to be a useful adjunct for both identifying the frontal sinus drainage pathway and delivering medication.3,4 Despite its benefits, the trephination approach still requires an external incision on the face, which, even in the best of hands, may not be aesthetically pleasing. The traditional trephination incision lies within the brow and can be noticeable particularly if there is local alopecia or other brow asymmetry. Given this, we have developed a modified approach to the frontal sinus trephination for chronic disease, utilizing glabellar rhytids when available. This has proven to be a useful adjunct and has resulted in significant benefit with respect to the aesthetic appearance of the face postoperatively.
From the Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System (B.A.F., S.C.P.), Charlottesville, Virginia; and the Department of Otolaryngology–Head and Neck Surgery, University of Texas Health Science Center at San Antonio (P.G.C.), San Antonio, Texas, U.S.A. Editor’s Note: This Manuscript was accepted for publication May 5, 2014. Financial disclosures: S.C.P. consulting, Stryker; consulting and speaker’s bureau, Acclarent; and consulting, Cook Medical. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Spencer Payne, MD, Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA 22908. E-mail: [email protected] DOI: 10.1002/lary.24765
Laryngoscope 124: December 2014
2676
MATERIALS AND METHODS Patients This case series was approved by the University of Virginia’s Institutional Review Board for Health Sciences Research. The medical records of patients presenting for management of chronic rhinosinusitis to the University of Virginia were reviewed. Those patients failing medical therapy or who had pathology requiring surgical approach without prior medical therapy (e.g., neoplasia) and underwent a trephine-assisted endoscopic frontal sinus exploration were included. Patients requiring emergent-isolated trephination for complications of acute frontal sinusitis were excluded from this analysis because their disease process necessitated an inferior and smaller brow-based trephine for drainage as opposed to surgical access.
Surgical Approach We utilize a three-dimensional reconstruction of 0.625-mm thick axial acquired images for our preoperative planning. The picture archiving and communication system allows for an accurate skin representation to be displayed, which also is helpful (Fig. 1). The facial contour is evaluated and the feasibility of placement of an incision in the ipsilateral glabellar rhytid is determined. Crucial to this step is the ability to plan the trajectory of the endoscope, instruments, and necessary size of the trephination. The face is prepared and draped in a sterile fashion, leaving the nose, eyes, and lower forehead exposed. The image guidance system is readied to assist in navigating the complex frontal anatomy. The surgery starts with the endoscopic approach to the frontal sinus, as has been previously described.5,6 If necessary, the trephination is performed after this dissection is complete. The trephination approach starts with identification of a prominent glabellar rhytid for the planned incision (Fig. 2). In cases where it is difficult to readily identify the prominent vertical rhytid, the glabellar skin can be compressed from lateral to medial to accentuate the glabellar rhytid. Local anesthetic agent (1% lidocaine with 1:100,000 parts epinephrine solution) is injected into the overlying skin. The incision is carried through the skin with a 15-blade scalpel. Subcutaneous and muscular dissection is performed with blunt dissection in order to identify and avoid the supratrochlear neurovascular bundle. The more superficial vertical fibers of the procerus and frontalis and the radial fibers of the orbicularis oculi can be distinguished from the more diagonal fibers of the corrugator supercilii that lie beneath. The incision is carried to the periosteum, which is incised vertically.
Fishero et al.: Glabellar Rhytid Trephination Incision
Fig. 1. Triplanar reconstruction of a sinus CT scan used for planning. This patient, whose final result is seen in Figure 4, had significant neoosteogenesis between a suprabullar mucocele and the frontal sinus, in addition to significant nasal scarring due to a quiescent ChurgStrauss–like vasculitis. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.] The navigation system pointer is used to confirm the entry point and trajectory into the sinus (Fig. 3). The trephination is completed by drilling with a 4-mm diamond burr into the anterior table of the frontal sinus above the orbital rim. Bone cuts may be further widened either with the drill or Kerrison rongeurs. Using pediatric 2.9-mm endoscopes and pediatric instruments, the sinus disease is addressed.
We have found that, similar to other authors, a trephine with a diameter less than 1 centimeter does not require reconstruction.4 The overlying skin in this area is quite thick, and the defect is well hidden as long as the periosteum is closed as the initial layer. We use 3-0 vicryl for the periosteum, 4-0 vicryl for the muscular and subcutaneous layers, and 6-0 nylon or 6-0 fast-absorbing gut for skin closure.
Fig. 2. Preoperative photograph of one patient demonstrating prominent vertical glabellar rhytids. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 3. Glabellar rhytid incision with mark on bone (dot) denoting where trephination will be performed. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: December 2014
Fishero et al.: Glabellar Rhytid Trephination Incision
2677
TABLE I. Additional Procedures as Described by Draf et al.7 Summary of Patients Treated With Frontal Sinus Trephination. Diagnosis
Sex
Age
Incision
Additional Procedures Performed
CRS, frontal mucocele
M
30
Glabellar
Draf IIa
CRS, frontal osteoma Inverted papilloma
F M
34 37
Glabellar Glabellar
Draf IIb Draf III
Fibrous dysplasia, frontal mucocele
F
41
Horizontal lateral brow
Draf IIa
CRS, frontal mucocele CRS
F F
54 55
Glabellar Glabellar
Draf IIb Drab IIa
CRS, frontal mucocele
F
61
Glabellar
none
CRS
F
62
Glabellar
ipsilateral Draf I, contralateral Draf IIa
Frontal mucocele Inverted papilloma
M M
71 78
Glabellar Glabellar
contralateral Draff IIa Draf IIa
Frontal mucocele
M
89
Glabellar
Draf IIa
Reason for Alternative Incision
Mucocele in lateral supraorbital cell
CRS 5 chronic rhinosinusitis.
The wound is dressed with an ophthalmic preparation of bacitracin.
RESULTS A total of 11 patients have undergone endoscopic frontal sinus exploration, which necessitated a frontal trephination for improved access (Table I). One had pathology, which did not allow for a glabellar rhytid incision due to multiple prior craniofacial reconstructions with a mucocele in an isolated laterally displaced supraorbital cell. In this case, a traditional brow incision was performed, as previously described.8 Of the remaining 10 patients who underwent the glabellar rhytid incision approach, all were very pleased with their cosmetic results, most citing that they could not see the resultant scar (Fig. 4, same patient as seen in Figs. 2 and 3). The most common complaint postoperatively was mild
Fig. 4. Resulting scar 3 months after left frontal sinus trephination. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: December 2014
2678
erythema along the incision that persisted for 2 to 3 months. No patient suffered new-onset forehead pain. No patients complained of forehead paresthesias.
DISCUSSION Management of the frontal sinus has evolved throughout the last 30 years as the advent of endoscopic techniques and specialized instruments has improved visualization and access using more minimally invasive approaches. Although the osteoplastic flap approach offers superior direct visualization, it is not without its risks. The EMLP has mostly supplanted this approach because it allows for superb visualization and access while helping to ensure continued function and improved postoperative surveillance. Both of these techniques, however, are time consuming and technically demanding. Even in the best of circumstances, they may not afford access to significant lateral portions of the sinuses. Several authors have thus described frontal sinus trephination as a less invasive adjunctive approach for certain pathologies.4,9,10 The downside of this procedure, although not noted by these authors, is the placement of the incision in, above, or below the brow line, with significant opportunity for poor cosmetic result. Given the curved facial contour in this area, and a need to appropriately align the bevel with respect to the hair follicles, a properly planned cutting angle can be difficult. The glabellar region is one of the first areas of the face to reveal early aging in the form of rhytids.11 Vertically oriented rhytids in this area result from repeated contracture of the paired corrugator supercilii and can present as early as the third and fourth decades of life, which often correlates with the emergence of sinonasal disease.12 As has been exemplified by surgical approaches to other areas in head and neck surgery, the incorporation of naturally occurring skin wrinkles or relaxed skin tension lines (RSTL) into planned incisions can minimize the appearance of the postoperative scar. Thus, the extension of this precept to the performance of Fishero et al.: Glabellar Rhytid Trephination Incision
adjunctive frontal trephination is a natural one that the authors have found to facilitate the approach and provide a pleasing aesthetic outcome. Proponents of “above and below” approaches have noted that a benefit of the trephine is the ability to access lateral lesions that may be difficult to reach with even more extensive procedures.8,9 Although providing a more minimally invasive, less technically demanding approach for superior frontal sinus lesions, a limitation of the glabellar rhytid approach is its naturally medial position and restriction to the location of the rhytid or RSTL. Thus, laterally based lesions may remain out of reach without vertical extension of the incision to allow for greater lateral dissection. The authors have found that, in certain circumstances, this can be accomplished by extending a j-arm below the head of the medial brow, taking care to avoid the hair-bearing skin. Nonetheless, we were unable to capitalize from this approach in the one patient with significantly altered cranial anatomy and a very laterally based, isolated supraorbital cell.
CONCLUSION The above and below approach to management of the frontal sinus has been a well described adjunct to endoscopic techniques. Incorporation of preexisting or developing facial rhytids into the operative plan allows for an aesthetically pleasing result with minimal risk of additional complication or negative outcome.
Laryngoscope 124: December 2014
Acknowledgment This work took place at the University of Virginia and involved patients who presented there.
BIBLIOGRAPHY 1. Lynch RC. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope 1921;31:1–5. 2. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg 1995;113:427–434. 3. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy 2009;23:342–347. 4. Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: a minimally invasive approach for hard-to-reach frontal sinus disease. Otolaryngol Head Neck Surg 2006;135:518–522. 5. Kuhn FA, Javer AR. Primary endoscopic management of the frontal sinus. Otolaryngol Clin North Am 2001;34:59–75. 6. Kuhn FA. An integrated approach to frontal sinus surgery. Otolaryngol Clin North Am 2006;39:437–61, viii. 7. Draf W, Minovi A. The “Frontal T” in the refinement of endonasal frontal sinus type III drainage. Operative Techniques in Otolaryngology–Head and Neck Surgery 2006;17:121–125. 8. Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinol 1999;13:289–293. 9. Hwang PH, Han JK, Bilstrom EJ, Kingdom TT, Fong KJ. Surgical revision of the failed obliterated frontal sinus. Am J Rhinol 2005;19:425–429. 10. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology. Am J Rhinol 2005;19:435–441. 11. Bassichis BA, Thomas JR. The use of Botox to treat glabellar rhytids. Facial Plast Surg Clin North Am 2003;11:453–456. 12. Mattos JL, Woodard CR, Payne SC. Trends in common rhinologic illnesses: analysis of U.S. healthcare surveys 1995–2007. Int Forum Allergy Rhinol 2011;1:3–12.
Fishero et al.: Glabellar Rhytid Trephination Incision
2679
Rhinological and Otological Society, Inc.
How I Do It
Modified Glabellar Rhytid Incision for Frontal Sinus Trephination Brian A. Fishero, MD; Philip G. Chen, MD; Spencer C. Payne, MD
INTRODUCTION Surgical management of the frontal sinus is more complex compared to the other sinuses. Testament to this fact is that for years the standard for refractory frontal disease has been the destructive procedure of an osteoplastic flap with complete obliteration of the sinus.1 With better understanding of the physiology of the paranasal sinuses, there has been a shift toward surgery directed at functionally improving drainage by widening the natural outflow pathway with purely endoscopic techniques. Whereas expanded frontal approaches such as the endoscopic modified Lothrop procedure (EMLP) can provide quite extensive access,2 they can be nicely augmented with a concomitant mini-trephination. In circumstances such as complicated acute frontal sinusitis, extensive lateral pneumatization of the frontal bone, or neo-osteogenesis of the frontal recess, a trephination continues to be a useful adjunct for both identifying the frontal sinus drainage pathway and delivering medication.3,4 Despite its benefits, the trephination approach still requires an external incision on the face, which, even in the best of hands, may not be aesthetically pleasing. The traditional trephination incision lies within the brow and can be noticeable particularly if there is local alopecia or other brow asymmetry. Given this, we have developed a modified approach to the frontal sinus trephination for chronic disease, utilizing glabellar rhytids when available. This has proven to be a useful adjunct and has resulted in significant benefit with respect to the aesthetic appearance of the face postoperatively.
From the Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System (B.A.F., S.C.P.), Charlottesville, Virginia; and the Department of Otolaryngology–Head and Neck Surgery, University of Texas Health Science Center at San Antonio (P.G.C.), San Antonio, Texas, U.S.A. Editor’s Note: This Manuscript was accepted for publication May 5, 2014. Financial disclosures: S.C.P. consulting, Stryker; consulting and speaker’s bureau, Acclarent; and consulting, Cook Medical. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Spencer Payne, MD, Department of Otolaryngology–Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA 22908. E-mail: [email protected] DOI: 10.1002/lary.24765
Laryngoscope 124: December 2014
2676
MATERIALS AND METHODS Patients This case series was approved by the University of Virginia’s Institutional Review Board for Health Sciences Research. The medical records of patients presenting for management of chronic rhinosinusitis to the University of Virginia were reviewed. Those patients failing medical therapy or who had pathology requiring surgical approach without prior medical therapy (e.g., neoplasia) and underwent a trephine-assisted endoscopic frontal sinus exploration were included. Patients requiring emergent-isolated trephination for complications of acute frontal sinusitis were excluded from this analysis because their disease process necessitated an inferior and smaller brow-based trephine for drainage as opposed to surgical access.
Surgical Approach We utilize a three-dimensional reconstruction of 0.625-mm thick axial acquired images for our preoperative planning. The picture archiving and communication system allows for an accurate skin representation to be displayed, which also is helpful (Fig. 1). The facial contour is evaluated and the feasibility of placement of an incision in the ipsilateral glabellar rhytid is determined. Crucial to this step is the ability to plan the trajectory of the endoscope, instruments, and necessary size of the trephination. The face is prepared and draped in a sterile fashion, leaving the nose, eyes, and lower forehead exposed. The image guidance system is readied to assist in navigating the complex frontal anatomy. The surgery starts with the endoscopic approach to the frontal sinus, as has been previously described.5,6 If necessary, the trephination is performed after this dissection is complete. The trephination approach starts with identification of a prominent glabellar rhytid for the planned incision (Fig. 2). In cases where it is difficult to readily identify the prominent vertical rhytid, the glabellar skin can be compressed from lateral to medial to accentuate the glabellar rhytid. Local anesthetic agent (1% lidocaine with 1:100,000 parts epinephrine solution) is injected into the overlying skin. The incision is carried through the skin with a 15-blade scalpel. Subcutaneous and muscular dissection is performed with blunt dissection in order to identify and avoid the supratrochlear neurovascular bundle. The more superficial vertical fibers of the procerus and frontalis and the radial fibers of the orbicularis oculi can be distinguished from the more diagonal fibers of the corrugator supercilii that lie beneath. The incision is carried to the periosteum, which is incised vertically.
Fishero et al.: Glabellar Rhytid Trephination Incision
Fig. 1. Triplanar reconstruction of a sinus CT scan used for planning. This patient, whose final result is seen in Figure 4, had significant neoosteogenesis between a suprabullar mucocele and the frontal sinus, in addition to significant nasal scarring due to a quiescent ChurgStrauss–like vasculitis. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.] The navigation system pointer is used to confirm the entry point and trajectory into the sinus (Fig. 3). The trephination is completed by drilling with a 4-mm diamond burr into the anterior table of the frontal sinus above the orbital rim. Bone cuts may be further widened either with the drill or Kerrison rongeurs. Using pediatric 2.9-mm endoscopes and pediatric instruments, the sinus disease is addressed.
We have found that, similar to other authors, a trephine with a diameter less than 1 centimeter does not require reconstruction.4 The overlying skin in this area is quite thick, and the defect is well hidden as long as the periosteum is closed as the initial layer. We use 3-0 vicryl for the periosteum, 4-0 vicryl for the muscular and subcutaneous layers, and 6-0 nylon or 6-0 fast-absorbing gut for skin closure.
Fig. 2. Preoperative photograph of one patient demonstrating prominent vertical glabellar rhytids. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Fig. 3. Glabellar rhytid incision with mark on bone (dot) denoting where trephination will be performed. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: December 2014
Fishero et al.: Glabellar Rhytid Trephination Incision
2677
TABLE I. Additional Procedures as Described by Draf et al.7 Summary of Patients Treated With Frontal Sinus Trephination. Diagnosis
Sex
Age
Incision
Additional Procedures Performed
CRS, frontal mucocele
M
30
Glabellar
Draf IIa
CRS, frontal osteoma Inverted papilloma
F M
34 37
Glabellar Glabellar
Draf IIb Draf III
Fibrous dysplasia, frontal mucocele
F
41
Horizontal lateral brow
Draf IIa
CRS, frontal mucocele CRS
F F
54 55
Glabellar Glabellar
Draf IIb Drab IIa
CRS, frontal mucocele
F
61
Glabellar
none
CRS
F
62
Glabellar
ipsilateral Draf I, contralateral Draf IIa
Frontal mucocele Inverted papilloma
M M
71 78
Glabellar Glabellar
contralateral Draff IIa Draf IIa
Frontal mucocele
M
89
Glabellar
Draf IIa
Reason for Alternative Incision
Mucocele in lateral supraorbital cell
CRS 5 chronic rhinosinusitis.
The wound is dressed with an ophthalmic preparation of bacitracin.
RESULTS A total of 11 patients have undergone endoscopic frontal sinus exploration, which necessitated a frontal trephination for improved access (Table I). One had pathology, which did not allow for a glabellar rhytid incision due to multiple prior craniofacial reconstructions with a mucocele in an isolated laterally displaced supraorbital cell. In this case, a traditional brow incision was performed, as previously described.8 Of the remaining 10 patients who underwent the glabellar rhytid incision approach, all were very pleased with their cosmetic results, most citing that they could not see the resultant scar (Fig. 4, same patient as seen in Figs. 2 and 3). The most common complaint postoperatively was mild
Fig. 4. Resulting scar 3 months after left frontal sinus trephination. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]
Laryngoscope 124: December 2014
2678
erythema along the incision that persisted for 2 to 3 months. No patient suffered new-onset forehead pain. No patients complained of forehead paresthesias.
DISCUSSION Management of the frontal sinus has evolved throughout the last 30 years as the advent of endoscopic techniques and specialized instruments has improved visualization and access using more minimally invasive approaches. Although the osteoplastic flap approach offers superior direct visualization, it is not without its risks. The EMLP has mostly supplanted this approach because it allows for superb visualization and access while helping to ensure continued function and improved postoperative surveillance. Both of these techniques, however, are time consuming and technically demanding. Even in the best of circumstances, they may not afford access to significant lateral portions of the sinuses. Several authors have thus described frontal sinus trephination as a less invasive adjunctive approach for certain pathologies.4,9,10 The downside of this procedure, although not noted by these authors, is the placement of the incision in, above, or below the brow line, with significant opportunity for poor cosmetic result. Given the curved facial contour in this area, and a need to appropriately align the bevel with respect to the hair follicles, a properly planned cutting angle can be difficult. The glabellar region is one of the first areas of the face to reveal early aging in the form of rhytids.11 Vertically oriented rhytids in this area result from repeated contracture of the paired corrugator supercilii and can present as early as the third and fourth decades of life, which often correlates with the emergence of sinonasal disease.12 As has been exemplified by surgical approaches to other areas in head and neck surgery, the incorporation of naturally occurring skin wrinkles or relaxed skin tension lines (RSTL) into planned incisions can minimize the appearance of the postoperative scar. Thus, the extension of this precept to the performance of Fishero et al.: Glabellar Rhytid Trephination Incision
adjunctive frontal trephination is a natural one that the authors have found to facilitate the approach and provide a pleasing aesthetic outcome. Proponents of “above and below” approaches have noted that a benefit of the trephine is the ability to access lateral lesions that may be difficult to reach with even more extensive procedures.8,9 Although providing a more minimally invasive, less technically demanding approach for superior frontal sinus lesions, a limitation of the glabellar rhytid approach is its naturally medial position and restriction to the location of the rhytid or RSTL. Thus, laterally based lesions may remain out of reach without vertical extension of the incision to allow for greater lateral dissection. The authors have found that, in certain circumstances, this can be accomplished by extending a j-arm below the head of the medial brow, taking care to avoid the hair-bearing skin. Nonetheless, we were unable to capitalize from this approach in the one patient with significantly altered cranial anatomy and a very laterally based, isolated supraorbital cell.
CONCLUSION The above and below approach to management of the frontal sinus has been a well described adjunct to endoscopic techniques. Incorporation of preexisting or developing facial rhytids into the operative plan allows for an aesthetically pleasing result with minimal risk of additional complication or negative outcome.
Laryngoscope 124: December 2014
Acknowledgment This work took place at the University of Virginia and involved patients who presented there.
BIBLIOGRAPHY 1. Lynch RC. The technique of a radical frontal sinus operation which has given me the best results. Laryngoscope 1921;31:1–5. 2. Gross WE, Gross CW, Becker D, Moore D, Phillips D. Modified transnasal endoscopic Lothrop procedure as an alternative to frontal sinus obliteration. Otolaryngol Head Neck Surg 1995;113:427–434. 3. Hahn S, Palmer JN, Purkey MT, Kennedy DW, Chiu AG. Indications for external frontal sinus procedures for inflammatory sinus disease. Am J Rhinol Allergy 2009;23:342–347. 4. Zacharek MA, Fong KJ, Hwang PH. Image-guided frontal trephination: a minimally invasive approach for hard-to-reach frontal sinus disease. Otolaryngol Head Neck Surg 2006;135:518–522. 5. Kuhn FA, Javer AR. Primary endoscopic management of the frontal sinus. Otolaryngol Clin North Am 2001;34:59–75. 6. Kuhn FA. An integrated approach to frontal sinus surgery. Otolaryngol Clin North Am 2006;39:437–61, viii. 7. Draf W, Minovi A. The “Frontal T” in the refinement of endonasal frontal sinus type III drainage. Operative Techniques in Otolaryngology–Head and Neck Surgery 2006;17:121–125. 8. Gallagher RM, Gross CW. The role of mini-trephination in the management of frontal sinusitis. Am J Rhinol 1999;13:289–293. 9. Hwang PH, Han JK, Bilstrom EJ, Kingdom TT, Fong KJ. Surgical revision of the failed obliterated frontal sinus. Am J Rhinol 2005;19:425–429. 10. Batra PS, Citardi MJ, Lanza DC. Combined endoscopic trephination and endoscopic frontal sinusotomy for management of complex frontal sinus pathology. Am J Rhinol 2005;19:435–441. 11. Bassichis BA, Thomas JR. The use of Botox to treat glabellar rhytids. Facial Plast Surg Clin North Am 2003;11:453–456. 12. Mattos JL, Woodard CR, Payne SC. Trends in common rhinologic illnesses: analysis of U.S. healthcare surveys 1995–2007. Int Forum Allergy Rhinol 2011;1:3–12.
Fishero et al.: Glabellar Rhytid Trephination Incision
2679
