Revolutionizing Frontal Bone Fracture Stability: Extracorporeal Fixation with Fibrin Sealant as a Benchmark in Management

Surgical Technique

The patient underwent surgery under general anaesthesia. A bicoronal incision was made, beginning approximately 2 cm behind the hairline and extending laterally to the temporal region. This incision allowed for comprehensive access to the frontal area, including the forehead, nasal bridge, and upper orbital regions. Careful dissection was performed through the skin and subcutaneous tissue, exposing the underlying temporalis fascia and muscle [Figure 4].

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Figure 4:

Bicoronal incision provides access to the frontal and upper orbital regions, exposing the temporalis fascia.

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Muscle and Vascular Considerations

The incision was designed to avoid damaging the frontalis muscle, which plays a crucial role in forehead movement and aesthetics. As the dissection progressed, attention was given to the vascular supply, particularly the branches of the superficial temporal artery and the frontal branch of the facial nerve. Maintaining the integrity of these structures was essential for minimising postoperative complications, such as haematoma formation and motor deficits.

Once the periosteum was exposed, a pericranial flap was raised. The pericranial flap was carefully elevated, preserving its vascular supply from the underlying periosteal vessels. This flap is critical for reconstructive purposes, as it not only aids in wound healing but also serves as a biological barrier against infections and contributes to the repair of dural defects [Figure 5].

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Figure 5:

Pericranial flap elevated with preserved vascularity for wound healing and dural repair.

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Upon achieving adequate exposure to the fracture site, a dural tear was identified, confirming the presence of CSF leakage. This was meticulously assessed to ensure a comprehensive understanding of the injury’s extent. The dura mater was gently manipulated to visualise the CSF leak, facilitating a thorough repair [Figure 6].

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Figure 6:

A dural tear with a cerebrospinal fluid (CSF) leak was identified at the fracture site.

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Extracorporeal Fixation Technique

An extracorporeal fixation approach was employed to stabilise the fractured bone fragments. This technique involved osteotomizing the fractured segments, allowing for precise realignment. X-shaped titanium plates and 1.5 mm screws were used for stabilisation [Figure 7]. The use of titanium is preferred due to its strength, lightweight properties, and biocompatibility. The plates were secured externally, enabling the fractured fragments to be repositioned accurately during reconstruction [Figure 8].

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Figure 7:

Extracorporeal fixation of fractured bone using (a) X-shaped titanium plates and (b)1.5 mm screws.

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Figure 8:

Titanium plates and screws secure bone fragments in anatomical alignment.

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Following stabilisation, fibrin glue was meticulously applied to seal the nasofrontal duct [Figure 9]. This application is critical to preventing potential sinus complications that may arise from CSF leakage, such as meningitis or rhinosinusitis. The fibrin glue acts as a biological adhesive, promoting tissue healing while providing a watertight seal.

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Figure 9:

Fibrin glue is applied to seal the nasofrontal duct and prevent cerebrospinal fluid (CSF) leak complications.

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Intradural Repair

The anterior cranial fossa base was subsequently repaired using the pericranial flap and a muscle graft harvested from the temporalis muscle [Figure 10]. The temporalis muscle graft was selected for its robust vascularity and compatibility with cranial repair needs. The muscle graft was meticulously placed over the dural tear, with the pericranial flap overlaying it to reinforce the CSF seal. This layered approach enhances the durability of the repair, as supported by studies from Kaufman et al. (2009) and Pradhan et al. (2019)^[4,5], which highlight the efficacy of fibrin glue as a biocompatible and non-inflammatory adhesive [Figure 11].

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Figure 10:

Intradural repair using pericranial flap and temporalis muscle graft for cerebrospinal fluid (CSF) leak closure.

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Figure 11:

Layered repair reinforced with pericranial flap and fibrin glue for durability.

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The meticulous closure of the surgical site involved reapproximating the periosteum and overlying soft tissues, ensuring proper alignment and minimising tension on the incision. This approach aids in optimal healing and aesthetic outcomes.

Finally, the skin was closed in layers, ensuring careful suturing of the subcutaneous tissue and skin to promote healing and minimise scarring [Figure 12]. A sterile dressing was applied, and the patient was closely monitored postoperatively for any signs of complications.

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Figure 12:

Layered closure of the surgical site.

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Complications and Comparative Techniques

Postoperative outcomes in frontal bone fracture repair focus on reducing sinus-related complications. Kumar et al. (2020)^[12] reported lower rates of sinusitis and mucoceles when fibrin glue was used for ductal sealing. Studies by Ogawa and Imai (2016)^[13] compared titanium-based extracorporeal fixation to bioresorbable alternatives, finding titanium to provide better stability and longevity, particularly in cases requiring extended structural support. Although challenges in aligning fragments precisely in cases of severe comminution may necessitate additional grafts or customised plates, Wu and Park (2019)^[14] reported fewer late sinus complications and CSF leaks with combined fibrin glue and extracorporeal fixation, indicating the benefits outweigh limitations in appropriate cases.