# Draf III Procedure Using Multiple Pedicled Mucosal Flaps for Refractory Frontal Sinusitis: A Case Report

## TL;DR

A Draf III procedure using multiple mucosal flaps successfully treated a patient with severe, recurring frontal sinusitis and bony overgrowth.

## Contribution

A novel flap combination is proposed for refractory frontal sinusitis with extensive neo-osteogenesis and anatomical challenges.

## Key findings

- Multiple mucosal flaps maintained frontal sinus patency in a high-risk revision case.
- The patient experienced complete resolution of frontal headache without analgesics at six months.
- Combined flap reconstruction may be essential in cases with marked bony overgrowth and lost anatomical landmarks.

## Abstract

The Draf III procedure may serve as a surgical option for patients with frontal sinusitis that is refractory to standard treatment or prone to recurrence. However, postoperative restenosis caused by neo-osteogenesis and granulation tissue formation remains a major clinical problem. Coverage of exposed bone using mucosal grafts or pedicled flaps has been advocated to prevent restenosis, but adequate flap reconstruction may be difficult in revision cases with marked bony overgrowth. We report a case of a 62-year-old woman with refractory frontal sinusitis associated with IgG4-related disease and extensive neo-osteogenesis. The patient had undergone multiple prior endoscopic sinus surgeries, resulting in the loss of normal anatomical landmarks and progressive frontal sinus obstruction despite medical therapy, including biological therapy. A Draf III procedure was then performed. Given the extensive bone exposure and anatomical limitations, reconstruction was achieved using a combination of multiple mucosal flaps, including a superior lateral anterior pedicle flap, a septoturbinal flap, a Hadad-Bassagasteguy flap, and free mucosal grafts. Postoperatively, frontal sinus patency was maintained, and the patient’s frontal headache resolved without the need for analgesics at the six-month follow-up. In refractory frontal sinusitis with marked bony overgrowth and a high risk of restenosis, particularly in revision cases, reconstruction using a combination of multiple mucosal flaps tailored to the remaining anatomy may be crucial for maintaining frontal sinus patency.