CME/MOC

MOC-PSSM CME Article: Zygomatic Fractures

Brogan G. A. Evans Gregory R. D. Evans, M.D.
Orange, Calif.

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the common signs, symptoms, and treatment options for zygomatic fractures. 2. Answer basic questions on therapy for zygomatic fractures. Summary: This maintenance of certification article on zygomatic fractures attempts to review the current approaches to the treatment of these fractures. Although the article does not deal with extended approaches to treatment, it does in a general sense present the preoperative, intraoperative, and postoperative thinking for the plastic surgeon approaching these patients in general practice. A further in-depth review can be obtained through the references at the end of the article. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 121: 1, 2008.)

he cause of facial fractures in the United States is primarily trauma, most frequently motor vehicle accidents. Despite the decrease in prevalence attributable to increased seat belt use along with airbags, facial injury continues to present a significant alteration in the psychosocial aspect of patients.177 Zygomatic fractures are not only associated with motor vehicle accidents but are also seen with sports injuries. Outside the United States, the occurrence of such injuries may be associated with other causes (i.e., bicycles).6,12,53,59 The face is the cornerstone for each patients individualism, and alterations in its form and function secondary to facial injury may lead to detrimental changes in perceptions of how a patient feels, interacts, and present themselves in social environments. It is imperative then that we as plastic surgeons must restore not only the soft-tissue injury but the bony infrastructure to each patients identity. Technology has advanced our ability to treat facial injury. With the advent of computed tomography, three-dimensional reconstructions,
From the Aesthetic and Plastic Surgery Institute, University of California, Irvine. Received for publication June 29, 2006; accepted October 13, 2006. Copyright 2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000294655.16607.ea

plate-and-screw fixation, and bone grafting, the ability to restore structures to their original state has never been more feasible. Furthermore, with the advent of new bone cements, reshaping the contour lost secondary to these injuries has become commonplace. It is the purpose of this maintenance of certification article to evaluate the approach, treatment, and outcomes of facial fractures, specifically, the zygoma.

Disclosures: Neither author has any commercial associations that might pose or create a conflict of interest with information presented in this article. Neither author has any consultancies, stock ownership or other equity interests, patent licensing arrangements, or payments of stipends for conducting or publicizing this article.

The test for the MOC-PSaligned CME article Zygomatic Fractures by Evans and Evans is available at http://www1.plasticsurgery.org/ ebusiness4/OnlineCourse/CourseInfo.aspx? Id12795.

www.PRSJournal.com

Plastic and Reconstructive Surgery January 2008 PREOPERATIVE ASSESSMENT

Although zygomatic fractures can be isolated, they are frequently associated with other facial injuries (Carlin et al. recently demonstrated only an 11 percent isolated zygomatic fracture injury rate without other concomitant injuries).42 The emergency care of facial injuries identifies conditions that require immediate treatment for the prevention of life-threatening complications. These conditions include maintenance of the airway, prevention of hemorrhage, identification and prevention of aspiration, and identification of other injuries.1 Maintenance of the airway is perhaps the most critical. Isolated zygomatic fractures are more commonly associated with localized trauma such as a fist, baseball, or lateral movement of the head during a motor vehicle collision. Although tracheotomy is not frequently required for isolated zygomatic injury, associated other facial injuries may require control of the airway through this mechanism. Major hemorrhage accompanying maxillofacial injuries can occur from open wounds or associated closed fractures. Control of these bleeding wounds is critical in assessing the patient and can be controlled by reduction of the fracture segments. Although not frequently required, anteroposterior nasal packing, soft wraparound facial compression dressings, and external carotid artery ligation are all measures that can be performed to control bleeding. Monitoring of the blood volume is critical in assessing patients, and each should be typed and cross-matched for potential transfusions. Accompanying regional injuries such as cervical spine injuries are frequent and tend to occur at either the upper or lower end of the spine. If the entire cervical spine is not visualized radiographically and the patient is unable to verbally demonstrate symptoms, one must assume that the spine is injured. Computed tomography of the spine may assist in confirming the injury.1,4,9,11,12,2124,27,29,32,33,3539,41,44,47,49,56,57,61,63,64,66,70,71,
74,76,77

the healing of both bone and soft tissues. An accurate clinical examination begins with an evaluation of facial symmetry. Determination of septal hematomas, mobility of the bony segments, stability of the maxilla, alignment of teeth and the bite (although not usually altered in isolated zygomatic fractures), visual acuity, and clear fluid draining from the nose or open wounds must be identified. Evaluation for entrapment of the globe is critical along with diplopia if the patient is alert and able to respond.1,4,9,11,12,2124,27,29,32,33,3539,41,
44,47,49,56,57,61,63,64,66,70,71,74,76,77

Radiographic examination provides important evidence to confirm the findings of the physical examination.3,31,46 This occurs through plain radiographs and includes a Waters view, Townes view, posteroanterior (Caldwell) view, lateral skull film, and Panorex examination. Although these plain films are important, computed tomographic examination with or without three-dimensional reconstruction has replaced most of these early radiographs. Advances in ultrasonography and computed tomography allows better visualization of orbital fractures, often associated with zygomatic fractures, for better preoperative evaluation, planning, and intraoperative repair.15,21 The creation of models based on these computed tomographic examinations may assist with preoperative planning. Although isolated zygomatic fractures should not alter dentition, more extensive zygomatic injuries may require the creation of dental impressions and models that can assist with reduction and fixation. These associated injuries may require intermaxillary fixation as the standard immobilization technique for fractures involving the upper and lower jaws.1,4,9,11,12,2124,27,29,32,33,3539,41,44,
47,49,56,57,61,63,64,66,70,71,74,76,77

Intracranial injuries associated with facial fractures require special intracranial monitoring and evaluation. Remote injuries are also common in motor vehiclerelated trauma. Trauma associated with the head, chest, extremity, and pelvis must be managed and considered with regard to the timing of facial bone repair.1,4,9,11,12,2124,27,29,32,33,3539,41,44,47,49,56,57,
61,63,64,66,70,71,74,76,77

A thorough history and physical examination are part and parcel to any operative procedure. A history of smoking, hypertension, coronary artery disease, chronic obstructive pulmonary disease, diabetes, hepatitis, facial asymmetry, or paralysis is critical to determine. All of these factors can alter

Symptoms of zygomatic fractures usually include a combination of periorbital and subconjunctival hematoma and numbness in the distribution of the infraorbital nerve (Fig. 1). The absence of these two symptoms makes the diagnosis questionable. Recent studies on facial trauma indicate the most frequently associated maxillofacial fracture accompanying zygomatic fractures was the mandible (21 percent) and the most common feature was subconjunctival ecchymosis (64 percent).12 Ipsilateral epistaxis is common, as is inferior displacement of the zygoma, which alters the position of the lateral canthus, producing an inferior cant to the palpebral fissure. Numbness of the infraorbital nerve involves the upper lip and side of the nose along with the anterior teeth. Motion of the mandible may be inhibited because of impingement on

Volume 121, Number 1 Zygomatic Fractures

intermaxillary fixation. Severe multiple injuries may require tracheotomy.1,4,9,11,12,2124,27,29,32,33,3539,41, 44,47,49,56,57,61,63,64,66,70,71,74,76,77 The length of intubation is based on the multitude of injuries. Isolated fractures requiring isolated approaches may be performed under local anesthesia and/or intravenous sedation. Ultimately, the age of the patient, the extent of the injury, and patient preference determines anesthetic approaches.7,15,16,25,26,55,73

SURGERY LOCATION
The operation may be performed in a hospital or an accredited freestanding outpatient facility as an inpatient or outpatient. The location will be dictated by the severity of the injury. Regardless of location, ability to admit the patient to a hospital is critical with these potentially severe associated injuries.

Fig. 1. Classic clinical nding demonstrating periorbital ecchymosis associated with fractures of the zygomatico-orbital area.

ANESTHESIA TIMES
Anesthesia and surgery start and stop times along with in and out of room times are documented and recorded.

the coronoid process. Loss of the prominence of the malar eminence may be perceptible if there is not a significant component of cheek swelling. A hematoma in the buccal sulcus may also be present. If there is a significant component of an orbital fracture, impairment of the extraocular muscles may be noted or the position of the globe altered. Enophthalmos can occur secondary to loss of orbital floor support. Globe position can be formally measured or estimated by standing at the head of the bed and comparing eye projection. Enophthalmos may be more evident from this position. Surgical indications for repair of the orbital floor include entrapment, enophthalmos, or orbital floor defects that will increase the likelihood of a larger orbital volume and enophthalmos following trauma (usually 2 cm). Step deformities of the orbital rim may also be palpable. 1,4,9,11,12,2124,27,29,32,33,3539,41,44,47,49,56,57,61,63,64,66,70,71,
74,76,77

SURGICAL TREATMENT
Approaches to the zygoma can be variable and will depend on the extent of injury.7,15,16,25,26,55,73 The zygoma forms the lateral structure of the midfacial skeleton and comprises the lateral and inferior orbital rim and malar eminence. The projections articulate with the sphenoid bone in the lateral orbit and with the frontal bone superiorly, the maxilla medially, and the maxillary alveolus inferiorly. The zygomas prominent position makes it susceptible to traumatic injury and accounts for its frequent injury (Fig. 2). Zygomatic fractures with the exception of arch fractures always include a component of the orbital floor. These injuries may be linear or more severe, such as orbital blowout fractures. General classification of zygomatic fractures include the following: group I, no significant displacement; group II, zygomatic arch fractures; group III, unrotated body fractures; group IV, medially rotated body fractures with outward displacement at the zygomatic prominence or inward at the zygomatic frontal suture; group V, laterally rotated body fracture with upward displacement at the infraorbital margin or outward displacement at the zygomaticofrontal suture; and group VI, complex comminuted injury (Fig. 3).1 Orbitozygomatic fractures can be repaired early (up to 3 to 4 weeks) after injury using primary reduction and fixation techniques. In the younger patient population, this time frame may be shorter. Osteotomies may be required after this acute phase and can be used successfully up to ap-

ANESTHESIA
General anesthesia is usually used for reduction of zygomatic fractures. The time after injury and the extent of the trauma and associated medical problems ultimately determine the best method of anesthesia for fixation. Associated injuries such as complex zygomatic fractures involving the orbital and nasal bones may dictate methods of intubation (i.e., oral, nasal, or fiberoptic approaches). Injury to the nose may indicate fractures of the cribriform plate, negating nasal intubation. In contrast, associated maxillary and mandibular injuries may preclude oral intubation because of the necessity for

Plastic and Reconstructive Surgery January 2008

alveolus at the zygomaticomaxillary buttresses usually fracture first, with the more incomplete fracture generally occurring through the zygomaticofrontal junction. The presence of this incomplete fracture is the basis for the success of closed reduction techniques by manipulation. Other displaced fractures require open reduction. Inward displacement of zygomatic fractures may cause impingement on the coronoid process and limit oral excursion. Reduction is required to allow resumed mandibular mobility. Complex Zygomatic Injury Classic treatment of zygoma fractures has involved reduction and interfragment wiring at the zygomaticofrontal suture and infraorbital rim. Small drill holes were placed adjacent to the fracture site and wire was used to link the fragments together. Today, plate-and-screw fixation at the zygomaticomaxillary buttresses, zygomaticofrontal suture, and zygomatic arch are used.8,10,14,18,19,28,34,54,60 A coronal approach to the fractures may be indicated with lateral displacement of the arch (Fig. 4).7,15,16,25,26,55,73 Care is taken to ensure that the frontal branch of the facial nerve is not injured during elevation of this flap. The initial incision is placed through a curving S incision to avoid potential linear scarring postoperatively. The dissection continues along the deep temporal fascia until the superficial layer of the deep temporal fascia is incised. This keeps the frontal branch of the facial nerve superficial to the dissection. Care is taken not to interfere with the temporal fat pad. Despite these best efforts, atrophy of the temporal fat pad can occur following surgery. This can create permanent indentation in the temporal area that is noticeable postoperatively. With the incision under the superficial layer of the deep temporal fascia, dissection continues without fear of injury to the frontal branch of the facial nerve as dissection continues onto the zygomatic arch. Removing the supraorbital nerve from its bony notch may allow easier access to the fragment segment (Fig. 5). Plating then occurs under wide exposure. This allows accurate placement of the arch and fixation with a large plate, reestablishing the shape of the lateral face. Fixation of the arch to the temporal bone also allows accurate reduction through this approach. Alternatively, rigid internal fixation may be performed throughout the zygomatic arch. Alopecia is not uncommon with a coronal incision, and the patient should be aware of this potential complication.

Fig. 2. Position of the zygoma and its relationship to the other facial bones.

Fig. 3. Complex comminuted zygomatic injury.

proximately 4 months after injury. After 4 months, successful repair may require onlay bone grafting.64 The strongest articulation of the zygoma is that at the zygomaticofrontal suture. The articulations with the maxilla, the inferior orbital rim, and the maxillary

Volume 121, Number 1 Zygomatic Fractures

Fig. 4. Complex zygomatic arch fracture demonstrated by computed tomographic scanning. A coronal approach is required for accurate reduction.

Fig. 5. Freeing of the supraorbital nerve from the orbital notch.

At times, displacement of the zygomatic fracture does not extensively involve the arch (Fig. 6). A lesser approach using multiple facial and oral incisions allows good exposure for those patients

who do not have extensive facial traumatic injury. A patients fear of scarring may also preclude the use of a coronal incision. Alternative approaches to the zygomatic complex include a subciliary or

Plastic and Reconstructive Surgery January 2008

Fig. 6. Minimal fracture of the zygomatic arch as seen on this computed tomographic scan.

transconjunctival incision, a lateral brow or upper blepharoplasty incision, and a gingival buccal incision. Naturally, any external lacerations can assist with exposure to the facial skeleton. Fixation at the zygomaticofrontal suture can occur through this coronal approach or through a lateral eyebrow or upper lid incision. The tendency toward an upper lid incision has been a recent preference. Fixation of the infraorbital rim can occur through a subciliary or transconjunctival incision.7,15,16,25,26,55,73 This allows accurate placement of the bony fragments, with the potential of adding prosthetic material for the orbital floors.40,51,58,65,69,72 Recent data support the use of transconjunctival incisions and lateral cantholysis to avoid visible scarring and potential complications.25,26 The zygomaticofrontal suture can also be addressed through this incision; however, taking down the lateral canthus may be required. When repositioned, the lateral canthus should be reanchored through a drill hole into the lateral orbital wall at a slightly higher position or on the inner aspects of the orbital rim to the periosteum. The zygomaticomaxillary buttresses are approached through a gingivobuccal sulcus (Caldwell-Luc) incision (Fig. 7).55 Bone grafts can be used for additional support. Alteration in occlusion may require intermaxillary fixation. This usually proceeds before zygo-

matic fracture reduction. Critical issues to resolve involve evaluation of the class of occlusion before surgery. If mandibular fractures are associated with zygomatic fractures and intermaxillary occlu-

Fig. 7. Approach to the lateral and medial buttresses through a gingivobuccal incision.

Volume 121, Number 1 Zygomatic Fractures

sion is not accurate, creation of palatal splints and orthognathics may be necessary before fracture reduction. Variable sizes of plates for fixation are available (1.0 to 2.0 mm). Smaller plates at the zygomaticofrontal and infraorbital rim are critical to avoid patient complaints of feeling the plates postoperatively.8,10,14,18,19,28,34,54,60 Although not common, lag screw fixation provides quick, stable, effective reduction of obliquely oriented zygomatic fractures.8 Recent studies by Wittwer et al. have demonstrated that there is no difference in complications between biodegradable osteosynthesis materials or between biodegradable materials and titanium fixation with respect to fracture healing.2 During open reduction of zygomatic fractures, reducing the sphenozygomatic suture first combined with other fracture lines will reconstruct the zygomatic complex precisely for better aesthetic outcomes.7,15,16,25,26,55,73 Three-point fixation is indicated only in exceptional cases.4 Despite these complicated cases, there still is disagreement as to fixation points for zygomatic fractures. Lastly, as more noninvasive procedures are expanding, fractures that are not large enough to cause functional or severe aesthetic deformities may not require any treatment. Recent studies indicate that for low-impact fractures, patients who did not undergo fixation of the inferior orbital rim were free of deformity, diplopia, and postreduction rotation.16 Perfect alignment of bony segments may not be required and soft-tissue changes may not be significant enough to require operative treatment. Associated Orbital Floor Injuries As indicated previously, repair of the orbital floor is indicated if the defect is greater than 2 cm, if enophthalmos is present, if there is entrapment, or if the increase in orbital volume will lead to further complications. The combination of computed tomography as a baseline measurement and optical three-dimensional imaging for the follow-up examinations reveals more realistic data in cases of zygomatic fractures than Hertel measurements.31 In addition to reduction of the infraorbital segments, placement of material in the orbital floor to restore volume may be indicated.40,51,58,65,69,72 This may include placement of an orbital floor plate with or without bone grafts. Further placement of other material such as Medpor (Porex Surgical, Inc., Newnan, Ga.) or some other type of synthetic polymers may be indicated. It is critical to test for forced duction following this placement of orbital floor material to ensure that the placement of the orbital floor correction does not impinge on eye motion. Recent studies indicate that endoscopic repair has been successful in reconstruction of the orbital floor.48 Placement of an endoscope through the maxillary sinus allows adequate visualization of the orbital floor and reduction of the bony fragments if pushed into the maxillary sinus. Furthermore, the placement of material in the orbital floor through the same approach allows stabilization of the orbital contents and a decrease in volume. In many cases of associated blowout fractures, surgery is not indicated. Isolated Zygomatic Fractures If the arch is displaced medially, reduction can occur through the Gillies approach, allowing lateral displacement for the reduction (Fig. 8). An incision is carried through the temporal hair-bearing scalp and an elevator slipped between the deep fascia and the temporalis muscle. In addition, this reduction could occur through a gingivobuccal sulcus approach. This approach is only successful if comminution does not exist in the arch and if

Fig. 8. The Gillies approach for minimally displaced fractures of the zygomatic arch.

Plastic and Reconstructive Surgery January 2008

there is intact periosteum allowing interconnections of bony segments. If these conditions are not present, it is possible then to have isolated segments with lateral displacement and misalignment to the arch. A Carol-Girad screw can also be placed in the zygoma, allowing ease of reduction by manipulation of the fractured bones through a subciliary or transconjunctival incision. Lastly, a towel clamp can be placed around the zygoma to pull and reduce the segment.54 Ankylosis of the zygoma to the coronoid process is occasionally seen with severe injuries and may be managed by intraoral resection of the coronoid process. Newer approaches to reduction and fixation of the zygoma include endoscopic techniques. Endoscope-assisted realignment of the arch and fixation allow anatomical repair without sustaining the drawbacks of extensive access incisions.5,20,48 This can be done through a Gillies approach or through dissection of the midface. Correct anatomical reduction is necessary. Finally, bone grafts may be indicated for the zygomatic arch or maxillary segments. Extensive soft-tissue loss may require error on the side of delayed bone grafting. In the pediatric population, a requirement for more resorbable plates for fixation may be necessary.44 In addition to management of the bony segments, soft-tissue management is critical. Resuspension of the midface and prevention of ectropion are vital to an acceptable outcome. Elevation of the midface can occur with stripping of the periosteum off of the maxilla. This may already have been performed to access the lateral or medical buttresses for fracture stabilization. Fixation can occur by a suture ligature around the periosteum or around a plate screw to prevent pulling and potential ectropion. Prevention of scarring should be performed by gentle handling of tissue and diminution of tension. Resuspension and fixation of the lateral canthus is important for restoration of appropriate symmetry. It is becoming clearer that our aggressive approach to these fractures may not be necessary. Nondisplaced or minimally displaced fractures may not require operative repair. One has to discuss the options with the patient and determine by clinical examination what the appropriate course of action should be. Occasionally, some patients may be willing to exchange a bit of asymmetry for avoidance of surgery. One must be careful to treat the clinical issues and signs more than the radiographic ones. Evaluation of a patients bony reduction is always appropriate. This can be performed by magnetic resonance imaging, computed tomography, facial films, clinical examination, or a combination of these methods. Alterations in the bony fixation may or may not require further revisions of the reduction. The ultimate goal is to work with the patient and determine whether the results are acceptable.

OUTCOME
Immediate complications include uneven healing, infection, hematoma, seroma, and visual changes. It is critical to have an accurate assessment of visual acuity before surgery. Changes in light perception or visual loss may indicate optic nerve compression, which demands emergent correction and consultation. Treatment may include the release of sutures to allow expansion of the orbital contents, lateral canthotomy, or the use of high-dose steroids. Placement of any orbital floor plates or material would demand immediate removal to reduce compression on the nerve. Decompression, if performed and indicated, is urgent. This frequently can be performed through an endoscope placed and manipulated through the ethmoid sinus. Soft-tissue loss resulting from the initial injury may occur. Because of the vibrant blood supply of the face, preservation of as much soft tissue as possible is critical during the initial operation. However, all devitalized tissue during the initial operation should be debrided. Extensive hematoma or seroma formation may require reoperation. Patients who have extensive injury and require intubation nasally or through a tracheotomy may require prolonged assistance with breathing. Extensive operative intervention may also require prolonged intubation. If maxillomandibular fixation is performed, wire cutters should be placed by the bedside for those patients in case vomiting or other airway compromise occurs.2,43,45,62,67,68,75 Early complications may include plate exposure, facial asymmetry, malocclusion resulting from inadequate reduction or a lack of intermaxillary fixation, malposition of the fracture segments, soft-tissue deformities at the surgical sites, ectropion, blindness, and infection. In the acute stage of infection, supportive care and antibiotics are important treatment options. Tissue and scar massage and waiting for edema to decrease are appropriate in the early stage after surgery. Undercorrection or overcorrection of orbital floor fractures may occur and require repositioning of the plate and screws and re-reduction of the bony segment. This may be seen by continued enophthalmos or orbital proptosis. Placement of additional material in the orbital floor may be required. Alternatively, overcorrection may require

Volume 121, Number 1 Zygomatic Fractures

CPT Codes Commonly Used in Zygomatic Fracture Treatment
Code 21355 21356 21360 21365 21366 21385 21386 21387 21390 21395 Descriptor Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod, with manipulation Open treatment of depressed zygomatic arch fracture (eg, Gillies approach) Open treatment of depressed malar fracture, including zygomatic arch and malar tripod Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation and multiple surgical approaches Open treatment of complicated (eg, comminuted or involving cranial nerve foramina) fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting (includes obtaining graft) Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc type operation) Open treatment of orbital floor blowout fracture; periorbital appoach Open treatment of orbital floor blowout fracture; combined approach Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or other implant Open treatment of orbital floor blowout fracture; periorbital approach with bone graft (included obtaining graft)

removal of the material. Resorption of bone in the orbital floor may lead to undercorrection, requiring further surgery. The best time to correct posttraumatic orbital deformities is during the acute phase.45 Late complications can include the above; however, enophthalmos may be more obvious as the edema decreases and bone resorption occurs. Late infections are uncommon but may indicate a loose screw or infection of the material placed in the orbital floor or infection of the maxillary sinus. Maxillary sinusitis, although not common, can occur following zygomatic and midfacial fractures.24 Nonunion of fractures is uncommon in the facial area; however, small bone segments or grafts that lack adequate vascular supply may not heal and/or resorb. Palpation of the plates at the infraorbital and frontal locations may occur and patients may request removal. Correction of enophthalmos may require further placement of bone in the orbital floor or recorrection of the orbital volume. Assessment of ectropion may require additional soft-tissue placement or elevation of the midface. Frequently, injury leads to scarring in the anterior lamellae, requiring placement of mucosal, cartilage, or buccal grafts to free the tissues and reduce continued scar contractures. Loose screws or plates demand removal to control infections and draining sinuses. Injury to the inferior oblique muscle or lacrimal system obstruction may also occur. Epiphora or tearing may be caused by nasolacrimal obstruction, ectropion, damage to the orbicularis oculi muscle, or medial canthal malposition and may necessitate repair. Pain related to infraorbital nerve injury may dictate local injections or desensitization. Thermal sensitivity may be a predictive measurement

to determine postoperative infraorbital nerve recovery.13 Plate fixation allows for significantly better restoration of infraorbital nerve function.17 Reoperation is indicated for exposed plates, loose screws, palpable plates, malalignment of the bony segments, and tissue loss. Loss of fixation may require a change from wires to plates and screws or vice versa. Correction of any malocclusion by refracturing the segments or orthognathic surgery may be required. Ultimately, the patients satisfaction is critical in the long-term result. The moderate or dissatisfied patient will require consultation to determine whether their dissatisfaction is surgically correctable. Measured with patient satisfaction is surgeon satisfaction. Again, discussion with the patient is critical in determining whether further surgery is indicated. Asymmetry, malocclusion, chronic pain, or plate palpation may be issues for the patient, surgeon, or both. Although postoperative radiographic imagining may assist with determining appropriate bony alignment, studies indicate that routine postoperative radiography in the management of factures of the zygomatic complex is not supported clinically.3 Finally, self-evaluation for improvement is critical to any of our operations. Evaluation of the clinical and radiographic results may lead to changes in our approach and postoperative management. Both closed and open reductions are good treatment modalities and have been frequently used. Balancing postoperative facial deformity with closed reduction versus more complications related to incisions in open reduction continues to be our challenge. Fractures with more unstable and/or markedly displaced

Plastic and Reconstructive Surgery January 2008

or comminuted fragments require open reduction.36 Thus, multiple approaches allow us to achieve the best results individualized for each of our patients.
Gregory R. D. Evans, M.D Aesthetic and Plastic Surgery Institute 200 South Manchester, Suite 650 Orange, Calif. 92868 gevans@uci.edu
17. Benoliel, R., Birenboim, R., Regev, E., and Eliav, E. Neurosensory changes in the infraorbital nerve following zygomatic fractures. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 99: 657, 2005. 18. Enislidis, G., Yerit, K., Wittwer, G., Kohnke, R., Schragl, S., and Ewers, R. Self-reinforced biodegradable plates and screws for fixation of zygomatic fractures. J. Craniomaxillofac. Surg. 33: 95, 2005. 19. Hanemann, M., Simmons, O., Jain, S., Baratta, R., Guerra, A. B., and Metzinger, S. E. A comparison of combinations of titanium and resorbable plating systems for repair of isolated zygomatic fractures in the adult: A quantitative biomechanical study. Ann. Plast. Surg. 54: 402, 2005. 20. Czerwinski, M., and Lee, C. Traumatic arch injury: Indications and an endoscopic method of repair. Facial Plast. Surg. 20: 231, 2004. 21. Chang, E. L., and Bernardino, C. R. Update on orbital trauma. Curr. Opin. Ophthalmol. 15: 411, 2004. 22. Honig, J. F., and Merten, H. A. Classification system and treatment of zygomatic arch fractures in the clinical setting. J. Craniofac. Surg. 15: 986, 2004. 23. Ferreira, P., Marques, M., Pinho, C., Rodrigues, J., Reis, J., and Amarante, J. Midfacial fractures in children and adolescents: A review of 492 cases. Br. J. Oral Maxillofac. Surg. 42: 501, 2004. 24. Top, H., Aygit, C., Sarikaya, A., Karaman, D., and Firat, M. F. Evaluation of maxillary sinus after treatment of midfacial fractures. J. Oral Maxillofac. Surg. 62: 1229, 2004. 25. Holzle, F., Swaid, S., Schiwy, T., Wolfelschneider, P., Nolte, D., and Wolff, K. D. Management of zygomatic fractures via a transconjunctival approach with lateral canthotomy while preserving the lateral ligament. Mund. Kiefer. Gesichtschir. 8: 296, 2004. 26. Zhong, L. P., and Chen, G. F. Subciliary incision and lateral cantholysis in rigid internal fixation of zygomatic complex fractures. Chin. J. Traumatol. 7: 170, 2004. 27. Cheema, S. A. Zygomatic bone fracture. J. Coll. Physicians Surg. Pak. 14: 337, 2004. 28. Deveci, M., Eski, M., Gurses, S., Yucesoy, C. A., Selmanpakoglu, N., and Akkas, N. Biomechanical analysis of the rigid fixation of zygoma fractures: An experimental study. J. Craniofac. Surg. 15: 595, 2004. 29. He, D. M., Zhang, Y., and Zhang, Z. K. A study on the classification and treatment of zygomatic complex fractures. Zhonghau Kou Qiang Yi Xue Za Zhi 39: 211, 2004. 30. Fogaca, W. C., Fereirra, M. C., and Dellon, A. L. Infraorbital nerve injury associated with zygomatic fractures: Documentation with neurosensory testing. Plast. Reconstr. Surg. 113: 834, 2004. 31. Nkenke, E., Maier, T., Benz, M., et al. Hertel exophthalmometry versus computed tomography and optical 3D imaging for the determination of the globe position in zygomatic fractures. Int. J. Oral Maxillofac. Surg. 33: 125, 2004. 32. Folkestad, L., and Granstrom, G. A prospective study of orbital fracture sequelae after change of surgical routines. J. Oral Maxillofac. Surg. 61: 1038, 2003. 33. Hollier, L. H., Thornton, J., Pazmino, P., and Stal, S. The management of orbitozygomatic fractures. Plast. Reconstr. Surg. 111: 2386, 2003. 34. Rohrich, R. J., Janis, J. E., and Adams, W. P. Subciliary versus subtarsal approaches to orbitozygomatic fractures. Plast. Reconstr. Surg. 111: 1708, 2003. 35. Yokoo, S., Tahara, S., Sakurai, A., et al. Replantation of an avulsed zygomatic bone as a freeze-preserved autologous graft: A case report. J. Craniomaxillofac. Surg. 31: 115, 2003. 36. Tadj, A., and Kimble, F. W. Fractured zygomas. Aust. N. Z. J. Surg. 73: 49, 2003.

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1. Manson, P. Facial fractures. In J. Smith and S. Aston (Eds.), Plastic Surgery. Boston: Little, Brown, 1991. Pp. 347396. 2. Wittwer, G., Adeyemo, W. L., Yerit, K., et al. Complications after zygoma fracture fixation: Is there a difference between biodegradable materials and how do they compare with titanium osteosynthesis? Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 101: 419, 2006. 3. Crighton, L. A., and Koppel, D. A. The value of postoperative radiographs in the management of zygomatic fractures: Prospective study. Br. J. Oral Maxillofac. Surg. 45: 51, 2006. 4. Nitsch, A., Bruns, A., Gruber, R. M., Wiese, K. G., and Merten, H. A. Evaluation of the postoperative clinical results of repositioning isolated zygomatic fractures. Schweiz. Monatsschr. Zahnmed. 116: 43, 2006. 5. Czerwinski, M., and Lee, C. The rationale and technique of endoscopic approach to the zygomatic arch in facial trauma. Facial Plast. Surg. Clin. North Am. 14: 37, 2006. 6. Gomes, P. P., Passeri, L. A., and Barbosa, J. R. A 5 year retrospective study of zygomatico-orbital complex and zygomatic arch fractures in Sao Paulo State, Brazil. J. Oral Maxillofac. Surg. 64: 63, 2006. 7. Langsdon, P. R., Knipe, T. A., Whatley, W. S., and Costello, T. H. Transconjunctival approach to the zygomatico-frontal limb of orbitozygomatic complex fractures. Facial Plast. Surg. 21: 171, 2005. 8. Pribitkin, E. A., Cognetti, D. M., Marshall, S. N., and Bilyk, J. Lag screw fixation in midface fractures. Facial Plast. Surg. 21: 165, 2005. 9. Dziadek, H., and Cieslik, T. Treatment of zygomatico-orbital and zygomatico-maxillo-orbital fractures by open reduction and rigid internal fixation (in Polish). Wiad. Lek. 58: 270, 2005. 10. Mavili, M. E., and Tuncbilek, G. Treatment of noncomminuted zygoma fractures with percutaneous reduction and rigid external devices. J. Craniofac. Surg. 16: 829, 2005. 11. Dziadek, H., and Cieslik, T. Causes and effects of zygomaticoorbital and zygomatico-maxillo-orbital fractures managed by open reduction and rigid internal fixation. Ann. Univ. Mariae Curie Sklodowska 59: 44, 2004. 12. Obuekwe, O., Owotade, F., and Osaiyuwu, O. Etiology and pattern of zygomatic complex fractures: A retrospective study. J. Natl. Med. Assoc. 97: 992, 2005. 13. Pedemonte, C., and Basili, A. Predictive factors in infraorbital sensitivity disturbances following zygomaticomaxillary factures. Int. J. Oral Maxillofac. Surg. 34: 503, 2005. 14. Czerwinski, M., Martin, M., and Lee, C. Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures. Plast. Reconstr. Surg. 115: 1848, 2005. 15. Chang, E. L., Hatton, M. P., Bernardion, C. R., and Rubin, P. A. Simplified repair of zygomatic fractures through a transconjunctival approach. Ophthalmology 112: 1302, 2005. 16. Yonehara, Y., Hirabayashi, S., Tachi, M., and Ishii, H. Treatment of zygomatic fractures without inferior orbital rim fixation. J. Craniofac. Surg. 16: 481, 2005.

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Volume 121, Number 1 Zygomatic Fractures

37. Motamedi, M. H. An assessment of maxillofacial fractures: A 5 year study of 237 patients. J. Oral Maxillofac. Surg. 61: 61, 2003. 38. Manolidis, S., Weeks, B. H., Kirby, M., Scarlett, M., and Hollier, L. Classification and surgical management of orbital fractures: Experience with 111 orbital reconstructions. J. Craniofac. Surg. 13: 726, 2002. 39. Rohner, D., Tay, A., Meng, C. S., Hutmacher, D. W., and Hammer, B. The sphenozygomatic suture as a key site for osteosynthesis of the orbitozygomatic complex in panfacial fractures: A biomechanical study in human cadavers based on clinical practice. Plast. Reconstr. Surg. 110: 1463, 2002. 40. Baumann, A., Burggasser, G., Gauss, N., and Ewers, R. Orbital floor reconstruction with an alloplastic resorbable polydioxanone sheet. Int. J. Oral Maxillofac. Surg. 31: 367, 2002. 41. Becelli, R., Carboni, A., Cerulli, G., Perugini, M., and Iannetti, G. 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Surg. 16: 169, 2000. 47. McRae, M., and Frodel, J. Midface fractures. Facial Plast. Surg. 16: 107, 2000. 48. Chen, C. T., and Chen, Y. R. Endoscopically assisted repair of orbital floor fractures. Plast. Reconstr. Surg. 108: 2011, 2001. 49. Kovacs, A. F., and Ghahremani, M. Minimization of zygomatic complex fracture treatment. Int. J. Oral Maxillofac. Surg. 30: 380, 2001. 50. Becelli, R., Renzi, G., Perugini, M., and Iannetti, G. Craniofacial traumas: Immediate and delayed treatment. J. Craniofac. Surg. 11: 265, 2000. 51. Iatrou, I., Theologie-Lygidakis, N., and Angelopoulos, A. Use of membrane and bone grafts in the reconstruction of orbital fractures. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 91: 281, 2001. 52. McGimpsey, J. G., Vaidya, A., Biagioni, P. A., and Lamey, P. J. Role of thermography in the assessment of infraorbital nerve injury after malar fractures. Br. J. Oral Maxillofac. Surg. 38: 581, 2000. 53. Roccia, F., Servadio, F., and Gerbino, G. Maxillofacial fractures following airbag deployment. J. Craniomaxillofac. Surg. 27: 335, 1999. 54. Hwang, K., and Lee, S. I. Reduction of zygomatic arch fractures using a towel clip. J. Craniofac. Surg. 10: 439, 1999. 55. Courtney, D. J. Upper buccal sulcus approach to management of fractures of the zygomatic complex: A retrospective study of 50 cases. Br. J. Oral Maxillofac. Surg. 37: 464, 1999. 56. Strong, E. B., and Sykes, J. M. Zygoma complex fractures. Facial Plast. Surg. 14: 105, 1998. 57. Patel, B. C., and Hoffman, J. Management of complex orbital fractures. Facial Plast. Surg. 14: 83, 1998. 58. Shumrick, K. A., and Campbell, A. C. Management of the orbital rim and floor in zygoma and midface fractures: Criteria for selective exploration. Facial Plast. Surg. 14: 77, 1998. 59. Gassner, R., Hackl, W., Tuli, T., and Emshoff, R. Facial injuries in skiing: A retrospective study of 549 cases. Sports Med. 27: 127, 1999. 60. Martin, R. J., Greenman, D. N., and Jackman, D. S. A custom splint for zygomatic fractures. Plast. Reconstr. Surg. 103: 1254, 1999. 61. Zachariades, N., Mezitis, M., and Anagnostopoulos, D. Changing trends in the treatment of zygomaticomaxillary complex fractures: A 12 year evaluation of methods used. J. Oral Maxillofac. Surg. 56: 1152, 1998. 62. Longaker, M. T., and Kawamoto, H. K. Evolving thoughts on correcting posttraumatic enophthalmos. Plast. Reconstr. Surg. 101: 899, 1998. 63. Burns, J. A., and Park, S. S. The zygomatic-sphenoid fracture line in malar reduction: A cadaver study. Arch. Otolaryngol. Head Neck Surg. 123: 1308, 1997. 64. Carr, R. M., and Mathog, R. H. Early and delayed repair of orbitozygomatic complex fractures. J. Oral Maxillofac. Surg. 55: 253, 1997. 65. Celikoz, B., Duman, H., and Selmanpakoglu, N. Reconstruction of the orbital floor with lyophilized tensor fascia lata. J. Oral Maxillofac. Surg. 55: 240, 1997. 66. Ellis, E., and Kittidumkerng, W. 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