The Draf III procedure: A review of indications and techniques

The Draf Ⅲ procedure involves the creation of a common frontal sinus cavity. The most common indication for the Draf Ⅲ procedure is chronic rhinosinusitis of the frontal sinuses despite the failure of more conservative interventions such as bilateral Draf Ⅱa procedures. Primary Draf Ⅲ may be indicated in patients with a high risk of failures such as those with severe polyposis and those with a frontal sinus opening less than 4 mm on computed tomography imaging. Other indications for the Draf Ⅲ include access for tumor removal and repair of traumatic fractures of the frontal sinus. The "inside-out" Draf Ⅲ procedure is the standard approach when the frontal recess anterior-posterior diameter is wide enough for instrument access, usually larger than 4-5 mm. The "outside-in" Draf Ⅲ procedure can be done when the frontal recess is too narrow to safely accommodate instruments. Regular follow-up with debridement should be done to prevent neo-ostium stenosis.