Pericranial flap: for a destroyed septum

The flap travels down from the skull into the nose through a bony window in the forehead.

First described by : Paloma, Samper and Cervera-Paz, Head Neck 2000, for septal reconstruction with a pericranial flap; Alobid, Langdon and Santamaría for the “money box approach” (JAMA Facial Plast Surg 2018, Laryngoscope 2018).

When there is no septum left to repair (total or subtotal perforation, destruction after cocaine or vasculitis, several failures), no nasal tissue can suffice. The pericranium, the vascularised membrane covering the skull, is harvested on the supratrochlear and supraorbital arteries. An extended frontal sinusotomy (Draf III), nicknamed the “money box” by its authors, opens a passage from the forehead into the nose; the flap is brought down through it to line the defect. The tissue brought in is not mucosa: it slowly covers itself with an epithelium lacking functional cilia.

1. 1Work-up: CT, endoscopy, search for active systemic disease (vasculitis, cocaine use); surgery is only offered on controlled disease.
2. 2Coronal incision behind the hairline, harvest of the pericranial flap on its supraorbital pedicle.
3. 3Endoscopic Draf III frontal sinusotomy: it creates the window through which the flap descends from forehead to nasal cavity.
4. 4Inset of the flap, which lines the septal defect; fixation, dressings, then slow healing.
5. 5Prolonged endoscopic follow-up: cleaning of the permanently opened frontal sinus, rinses, monitoring of flap take.

Named variants

• Total or subtotal perforations where no local technique is feasible.
• Repeated failure of several local techniques, with septal mucosa exhausted.
• Destruction after cocaine or granulomatosis with polyangiitis, provided the disease is controlled and documented.
• Patients informed of heavy morbidity and accepting lifelong endoscopic follow-up.
• Centres that regularly perform advanced endoscopic sinus surgery.

• First-line use: this family is salvage, never a starting point.
• Active, uncontrolled inflammatory disease or addiction.
• Patients who could not keep up follow-up of an opened frontal sinus.
• Plans for simple turbinate reconstruction later: the Draf III and the flap complicate it.
• A medium perforation for which a local technique is still possible.

Published results

• Coronal scar, patches of alopecia, scalp numbness.
• A frontal sinus opened for life by the Draf III: crusting, repeated endoscopic cleaning, risk of stenosis.
• Epithelium without functional cilia: mucus stagnates, crusting persists despite closure.
• Major morbidity of the last resorts: forehead scar of the paramedian flap, microsurgery for the free flap.
• Small series and radio-anatomical studies: limited evidence for major surgery.

1. 1Have all local techniques really been ruled out in my case, and why?
2. 2What does a Draf III mean for the rest of my life, in practice?
3. 3How many pericranial flaps have you brought down into the nose?
4. 4What will my breathing and smell be like if closure succeeds?
5. 5What happens if this flap fails: is there any option left?

Write the answers down: they are what lets you compare two opinions.

Where it is done

Related techniques