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Evolution of the Draf III Procedure: Mucosal Grafting Technique

Objective: The Draf III procedure is an advanced surgical option for frontal sinus disease refractory to endoscopic frontal sinustomy and also delineates the anterior limit of skull base tumors during endoscopic resection. Our objective was to evaluate outcomes of a novel strategy utilizing mucosal grafts to decrease postoperative closure. Method: Patients with frontal sinus pathology requiring a Draf III procedure were prospectively enrolled in the study. Demographics, reason for the procedure, percent graft viability, and complications were recorded. The primary outcome measure was anterior-posterior (AP) diameter at 3 months. Results: Mucosal grafting technique was performed during 19 Draf III procedures from August 2008 to November 2010. Seventeen patients (average age 54 years) were available for endoscopic measurement at 3 months with an average postoperative follow-up of 13.5 months (4-24). Reasons for the procedure included tumor (n = 9), frontal ostium stenosis (n = 7), and trauma (n = 1). Fourteen patients (83%) had complete mucosal graft viability. Average intraoperative AP diameter was 12.3 mm. All patients maintained a patent combined frontal sinus ostium for the duration of follow-up with an average diameter of 10.9 mm at 3 months and no closure >25% of intraoperative size. Conclusion: Cicatricial stenosis and osteoneogenesis are common following the Draf III procedure in up to 50% of individuals. The present study demonstrated that the mucosal grafting technique decreases Draf III stenosis when compared with historical series and should be considered a routine strategy for preventing postoperative closure.