Frontal sinus fractures offer significant challenges to surgeons and the treatment paradigm has been debated for many years. Acute concerns include protection of intracranial structures, identification of associated injuries, and control of cerebrospinal fluid (CSF) leakage. The esthetic forehead contour is an important consideration in repair. Past surgical modalities that removed the anterior bony frontal surface left life-long disfiguring defects and have been largely replaced by techniques that leave a smooth contour without visible scars. Concerns about esthetic deformity, however, must yield to practices that will provide a “safe” sinus resistant to late complications. Long-term issues revolve around surveillance and management of late complications that can present decades after the inciting injury. Traditional treatment paradigms were conceived before the advent of modern endoscopic and advanced imaging techniques and focus on open techniques for fracture reduction and sinus management. Newer modified algorithms incorporate these technologic advancements with improved functional and cosmetic results.