Introduction
The modified endoscopic Lothrop (Draf III) procedure is a well-established technique for managing refractory frontal sinus disease, providing wide access and drainage via creation of a common frontal neo-ostium.Reference Shih, Patel, Choby, Nakayama and Hwang1 Achieving reliable mucosal coverage of the exposed bone within this cavity is critical to optimise healing, promote mucosalisation and minimise the risk of restenosis.Reference Ye, Zhou, Li, Zhang, Shao and Huang2 Free mucosal grafts are often employed for this purpose, offering effective epithelialisation, protection of underlying bone and reduction in post-operative scarring.Reference Lein, Liu, Knerer, Mueller, Rotter and Vyskocil3 However, their fixation within the frontal neo-ostium can be technically challenging given the limited access, irregular surfaces and the absence of stable anchorage points, which may lead to graft displacement and impaired integration.Reference Wang, Shen, Hsieh and Wormald4 We describe the utility of bioabsorbable steroid–eluting implants as a novel application to provide mechanical support, facilitating secure fixation and enhanced integration of free mucosal grafts within the frontal neo–ostium. This report outlines the technical steps and our experience with this approach as a practical description, rather than a formal comparative outcomes study with quantitative data.
Technical description
Following creation of a wide frontal neo-ostium via a Draf III frontal sinusotomy, haemostasis is achieved within the exposed bony cavity. The recipient site is inspected, and any residual debris is gently cleared. Donor mucosa is harvested from the nasal septal window or inferior turbinate and trimmed to fit the dimensions of the denuded bone within the frontal neo-ostium (Figure 1). The free mucosal graft is carefully positioned over the exposed bone, ensuring full contact between its undersurface and the recipient bed and extending to the margins of the neo-ostium. To stabilise the graft and prevent displacement, a bioabsorbable steroid-eluting implant (PROPEL™, Medtronic Limited, Watford, UK) is deployed over the graft within the neo-ostium. The implant is positioned to achieve even, low-pressure apposition, securing the graft without excessive compression or folding (Figure 2A).
Intraoperative measurement of the dimensions of the denuded frontal neo-ostium following completion of the modified endoscopic Lothrop procedure.
Figure 1 Long description
Two circular endoscopic views are stacked vertically on a plain background. Upper view: A ruler with tick marks is held across internal tissue. A metal instrument supports the ruler from the right side. Tissue fills the lower part of the circular view. Lower view: A ruler with tick marks is positioned along internal tissue. A pair of forceps enters from the right and grips a small piece of tissue near the ruler. Tissue and fluid occupy the lower part of the circular view.
(A) Deployment of a PROPEL™ Contour implant over a free mucosal graft providing even apposition within the frontal neo-ostium. (B) Long-term results at 2 years showing a patent, fully mucosalised neo-ostium with stable integration of the graft and mild polypoid changes.
Figure 2 Long description
The image A shows an endoscopic surgical view of internal anatomical structures with blood. The image B shows another endoscopic surgical view of internal anatomical structures.
Patients receive standard post-operative care, including saline nasal irrigations and intra-nasal corticosteroid drops. Systemic antibiotics are prescribed only when clinically indicated. No additional packing or non-bioabsorbable stenting material is used in the frontal neo-ostium. Patients are typically reviewed at three weeks, three months and six months post-operatively, with endoscopic evaluation to monitor healing, graft integration and mucosalisation. Further follow-up is scheduled according to clinical need (Figure 2B).
The described technique eliminates the need for complex packing or suturing, which can be impractical in the confined and irregular geometry of the frontal neo-ostium. The PROPEL™ implant gradually releases mometasone furoate (370 μg), providing sustained corticosteroid delivery to the surgical site for a period of approximately 30 days and fully degrading within 30–45 days. Beyond drug delivery, the implant functions as a temporary scaffold that stabilises the mucosal graft during the critical early healing phase. Its lightweight, self-expanding structure incorporates a flexible spring-like mechanism that allows gentle outwards pressure to maintain consistent apposition of the graft against the recipient bed. It supports graft immobilisation, reduces post-operative inflammation and fibrosis and facilitates progressive re-epithelialisation as the material resorbs.
An alternative method of graft immobilisation may be the use of fibrin sealants such as TISSEEL™ (Baxter Healthcare Ltd, Newbury, UK), which can enhance graft adhesion, although direct application in the frontal recess may pose technical challenges due to difficulty in access. Meanwhile, a PROPEL™ implant, with its purpose-designed delivery system, allows controlled deployment under direct endoscopic visualisation and may be preferred when controlled, self-expanding scaffolding with concomitant anti-inflammatory effects are desired.
The current technique appears to reduce restenosis and support durable neo-ostium patency, in keeping with contemporary reconstructive principles that emphasise mucosal preservation and minimally traumatic healing following Draf III surgery, while also complementing previously published work describing the use of pedicled flap-based reconstruction approaches.Reference Zheng, Huang, Wang, Liu, Chen and Ye5 In the United Kingdom, the typical NHS unit cost of a PROPEL™ implant is approximately £580 per device, subject to local procurement arrangements, and this represents an important consideration when selecting patients and planning resources for complex frontal sinus surgery.
What is already known:
• The modified endoscopic Lothrop (Draf III) procedure is an established technique for refractory frontal sinus disease and creates a common neo-ostium for improved drainage
• Reliable mucosal coverage of the exposed bone within the neo-ostium is crucial for healing, mucosalisation and minimising restenosis risk
• Free mucosal grafts are commonly used but can be difficult to fixate due to lack of stable and reliable anchoring points, leading to potential graft displacement and poor integration
• Previous methods for graft fixation include complex packing, suturing and use of pedicled flaps, which may be impractical or technically demanding
What this paper adds:
• Introduces a novel, pragmatic technique using bioabsorbable steroid-eluting implants for secure fixation of free mucosal grafts within the frontal neo-ostium
• Highlights the potential added benefit of sustained localised anti-inflammatory effects from the steroid component, which may enhance graft mucosalisation and reduce restenosis
• Avoids the need for additional packing or suturing, simplifying the procedure and making it suitable for select endoscopic frontal sinus surgery cases
• Suggests that this technique can promote reliable graft integration and durable neo-ostium patency, potentially optimising long-term outcomes for patients
Conclusion
Bioabsorbable steroid-eluting implants represent a practical solution for stabilising free mucosal grafts in Draf III frontal sinus surgery, addressing the technical challenges of graft fixation within the neo-ostium. The technique provides both mechanical support and targeted anti-inflammatory effects, promoting reliable mucosalisation and potentially reducing restenosis risk without the complexity of packing or suturing. This simple, reproducible approach complements existing reconstructive strategies and may help optimise long-term outcomes for selected patients undergoing endoscopic modified Lothrop procedures.
Funding
Not applicable.
Competing interests
H.S. has delivered lectures sponsored by Intersect ENT and Medtronic. The present manuscript is an independent analysis, with no commercial involvement in the design, data collection, analysis, interpretation or preparation. All other authors declare no competing interests.
Ethical approval and informed consent
This work did not require ethical review and approval in accordance with local institutional requirements. Individual patient consent was waived due to the analysis of anonymised clinical data.
