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F
ractures involving the zygoma are among the The diagnosis and management of orbitozy-
most common facial fractures seen in trauma gomatic injuries remains a controversial issue
centers. Isolated fractures of the zygoma among surgeons dealing with facial trauma. The
have been variously termed zygomatic, tripod, or debate continues unabated as to which of these
orbitozygomatic fractures. We recommend the common fractures can be treated with less invasive
term orbitozygomatic fracture because this term methods and which ones need more extensive
refers to the two most important considerations in open reduction and internal fixation to accom-
treatment, which are accurate anatomical reduc- plish the desired repair. The essential elements of
tion of the zygoma and restoration of appropriate the debate are centered on the degree of displace-
orbital anatomy. Accurate anatomical reduction ment and comminution that leads to secondary
in the primary setting, usually within 2 weeks of deformities if left untreated or treated with less
injury, is imperative because this is the best op- comprehensive techniques. Other issues lacking
portunity to restore the patient to their preinjury consensus are the most reliable sites of assessment
state. Secondary correction of deformities related to of anatomical deformity and displacement, the
the untreated or mistreated, malpositioned zygoma appropriate sites of surgical exposure and stabili-
is challenging and often less successful because of zation, and the best methods of internal fixation.
bony malunion and soft-tissue contracture.17 It is generally agreed, however, that the standard
for comparison of other techniques of repair of
From the Department of Craniofacial, Plastic, and Recon- the orbitozygomatic structure is anatomical reduc-
structive Surgery, Dell Childrens Medical Center of Central tion after full anatomical exposure (assessment of
Texas; Division of Plastic Surgery, Department of Surgery,
University of Washington; and Division of Craniofacial,
Plastic, and Reconstructive Surgery, Childrens Hospital
and Regional Medical Center. Disclosure: None of the authors has any commer-
Received for publication May 4, 2006; accepted December 6, cial associations or financial disclosures that might
2006. create a conflict of interest with information pre-
Copyright 2007 by the American Society of Plastic Surgeons sented in this article.
DOI: 10.1097/01.prs.0000260720.73370.d7
www.PRSJournal.com 5S
Plastic and Reconstructive Surgery December Supplement 2, 2007
all articulations of the zygoma) and rigid fixation lateral orbital wall in concert make up the five
of all possible points of fixations (buttresses). most accurate points of assessment for the degree
Anything less than this is inherently a compromise of displacement, and only by assessing at least
that may or may not be justified based on a logical three (more commonly all five) can accurate re-
assessment of the degree of displacement, fracture duction be ensured (Fig. 1).
patterns, and comminution present. The anterior portion of the lateral orbital wall
is formed by the zygoma. The frontal bone and
ANATOMY greater wing of the sphenoid articulate with the
The zygomatic complex has been incorrectly zygoma through a suture within the lateral orbital
labeled in the past as a tripod and, in fact, should wall, which starts as the zygomaticofrontal suture
be considered a quadripod. The lateral orbital wall on the upper portion of the lateral orbital rim and
should be considered the base of the quadripod,
with the four legs being the lateral orbital rim,
the inferior orbital rim, the zygomaticomaxillary
buttress, and the zygomatic arch. Fractures of the
zygomatic complex involve all four legs in addition
to the fracture that extends through the lateral
orbital wall. These four legs and the lateral orbital
wall make up five potential points of assessment
for the degree of displacement. The legs of the
quadripod provide two attachments to the cra-
nium and two to the maxilla and create a large
portion of the orbital floors and lateral orbital
walls. The zygomaticomaxillary complexes are
therefore surgically important in establishing or-
bital volume and serving as a reference for reduc-
tion of maxillary fractures to the cranium.
Fractures often, but not always, occur across
the three buttress-related sutures. The term tripod
fracture was derived out of reference to the three
related sutures, but reference to the associated
sutures is inconsequential because they do not
provide consistent and reliable information with
regard to anatomical alignment, nor do they have
any significance with regard to durable points of
fixation. In addition, the term tripod fails to rec-
ognize the posterior relationship of the zygoma
with the sphenoid bone of the skull base and its
extension inferiorly down the lateral wall of the
maxillary sinus.
The four legs represent two major buttresses
of the face which are the upper transverse max-
illary (across the zygomaticomaxillary and zygo- Fig. 1. (Above) Orbitozygomatic fractures can be described as
maticotemporal sutures) and the lateral vertical quadripods, with the legs being the inferior orbital rim, the zy-
maxillary (across the zygomaticomaxillary and the gomaticomaxillary buttress, the lateral orbital rim, and the zygo-
frontozygomatic sutures). If the two buttresses of matic arch. The base of the quadripod is the lateral orbital wall.
the zygoma are reduced and fixated, it is still pos- The most accurate means of determining anatomical reduction is
sible to have a rotational deformity of the zygoma through assessment of all five of these points in concert. (Below)
about the zygomaticosphenoid suture. The four The facial buttresses represent thickened regions of bone that
legs are composed of narrow, dense bone, which provide structure to the face and stabilize the position of the face
is excellent for alignment and fixation. However, with the cranium; as such, they represent ideal points of fixation.
because they are narrow structures, it is difficult to The illuminated skull illustrates that there is thickened bone at
determine the degree of rotation of the zygoma the lateral orbital wall, the zygomatic arch, the inferior orbital rim,
from assessment of only one or two of these points and the lateral wall of the maxillary sinus, known as the zygomat-
alone. The four legs of the quadripod and the icomaxillary buttress.
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Volume 120, Number 7 Suppl. 2 Zygomatic Fractures
Fig. 2. (Left) The zygomatic complex articulates with the frontal bone and sphenoid through a suture within the lateral orbital wall.
Orbitozygomatic fractures often but not always extend directly through this suture line (arrows). The thickness of the lateral orbital
wall in relation to the other orbital walls often prevents comminution at this fracture site. The lack of comminution in addition to the
natural three-dimensional character of this concave wall makes it the single most reliable indicator of anatomical reduction. (Right)
One exception to this rule is the presence of an orbitozygomatic injury ipsilateral to an impacted sphenoid fracture, unless it is a large
fragment that can be anatomically reduced before reduction of the orbitozygomatic injury.
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Plastic and Reconstructive Surgery December Supplement 2, 2007
Fig. 4. Most orbitozygomatic injuries present with ipsilateral proptosis secondary to orbital swelling even in cases of orbital blow-out
(orbital expansion). When a patient presents with acute enophthalmos, it is indicative of severe orbital expansion, as indicated in the
associated floor fracture of this patient with an otherwise simple orbitozygomatic fracture.
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Volume 120, Number 7 Suppl. 2 Zygomatic Fractures
Facial swelling is usually substantial by the time equate suspension after extensive surgical expo-
the patient presents to the plastic surgeon, and it sure. Cheek ptosis, inferior displacement of the
tends to minimize the degree of deformity by lateral canthus, temporal hollowing, and lower lid
masking globe and cheek malposition. The swell- ectropion are among the most common findings.
ing has usually resolved sufficiently by approxi-
mately 2 weeks after injury that the underlying IMAGING
deformity can be appreciated. It is important for Advancement of computed tomographic
the patient to understand this dynamic because scanning technology has resulted in vast im-
treatment should be carried out within the first 2 provements in the quality of images, the ability
weeks after injury, still within the timeframe where to develop three-dimensional models (digital
it is difficult for the patient to appreciate the true and stereolithographic), increased speed of scan-
deformity. ning, and reduced radiation exposure. This has
The position of the globe is affected by the established computed tomography as the modality
integrity of the periorbital fascial support, the di- of choice for the evaluation of facial fractures.
rection and degree of displacement of the zygoma, Patients with suspected facial trauma on initial
and the degree of concomitant swelling. Fractures evaluation are evaluated with a complete cranio-
that cause an increase in orbital volume (blow-out facial computed tomographic scan. Our protocol
fracture) will predispose to enophthalmos, but includes a full facial analysis from the top of the head
during the acute period, swelling within the orbit through the mandible with 1.5-mm axial cuts. Coro-
may cause some degree of proptosis despite the nal reformatting can then be constructed from
expansion of the orbit. As swelling resolves, the this data set without additional scanning. Al-
globe progressively sinks back, revealing the un- though sagittal reformat and three-dimensional
derlying orbital expansion. Zygomatic fractures representation of the data are not part of our usual
that present with acute enophthalmos indicate se- protocol, they each have their role in specific sit-
vere displacement and orbital expansion (Fig. 4). uations. Sagittal reformat is particularly useful in
Zygomatic fractures that impinge into the domain assessing the effect of a complex orbital fracture
of the orbit (blow-in fracture) reduce the orbital on the inferomedial bulge of the orbital floor. In
volume and present with acute proptosis, which a busy Level I trauma center, where many patients
will improve only slightly as swelling resolves. present with neurologic compromise (head injury
Some degree of trismus is common with zy- or intoxication) and cannot comply with a com-
gomatic fractures secondary to direct injury to the plete physical examination, it is prudent to obtain
masseter and its origin on the zygomatic arch. a complete scan at the time that the head com-
When the arch is severely collapsed or impacted, puted tomographic scan is obtained; doing so
it can cause a trismus secondary to mechanical takes only a few seconds.
impedance of the coronoid process as it slides
upward, preventing closure of the mouth, but this PRINCIPLES OF SURGICAL PLANNING
is less common than trismus secondary to direct AND REPAIR
muscle injury. The zygoma has five articulations that can be
Secondary deformities related to untreated or used to guide anatomical reduction: (1) the lateral
mistreated fractures of the zygoma are not un- orbital rim, (2) the inferior orbital rim, (3) the
common. These deformities are especially com- zygomaticomaxillary buttress, (4) the zygomatic
mon in the patient with associated panfacial in- arch, and (5) the lateral orbital wall. Rigid internal
juries. The patient with a malpositioned zygoma fixation can be achieved at four of these articula-
typically presents with an underprojected cheek tions through limited access incisions. Fixation of
and a wide face, but overprojection is also possible. fractures through the lateral orbital wall requires
Failure to evaluate and treat the concomitant or- extensive exposure by means of a coronal incision,
bital deformity usually results in globe malposition with elevation of the temporalis muscle out of the
if the fascial support of the eyeball has been dis- sphenopalatine fossa. This exposure is reserved
rupted. Enophthalmos is the usual result, but oc- for rare cases with severe comminution and dis-
casionally exophthalmos can occur if the orbital placement of the zygomatic arch and lateral or-
volume is decreased by a blow-in type fracture. bital wall. In theory, reduction and fixation of
Secondary deformities can also result from iatro- three of the four potential points of fixation (but-
genic malposition of the overlying soft tissues. tresses) will correct both translation and rotation
Even with accurate reduction of the bone anat- of the zygoma in three-dimensional space. When
omy, soft-tissue deformities can result from inad- one or more of the buttresses is comminuted,
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Plastic and Reconstructive Surgery December Supplement 2, 2007
exposure and reduction of all four buttresses be- frontal branch. If the zygomatic arch has a green-
comes increasingly important. The use of estab- stick fracture with minimal displacement or is me-
lished craniofacial techniques to achieve wide ex- dially displaced, it is not necessary to expose the
posure and mobilization of the entire zygoma is of zygomatic arch, and the entire open reduction can
paramount importance to accurate anatomical re- be performed from an anterior approach without
duction of the severely displaced and comminuted the need for a coronal incision (Fig. 6). An ante-
zygoma. rior approach in our center involves three inci-
With a careful assessment of a fine-cut com- sions, including an upper buccal sulcus, a mid-
puted tomographic scan of the facial skeleton, eyelid (subtarsal) or transconjunctival, and the
examining both the axial and coronal cuts, the lateral part of an upper blepharoplasty incision.
surgeon should be able to accurately diagnose the The zygomaticosphenoid alignment at the lat-
exact fracture pattern and search for any degree eral orbital wall is recognized as a fundamental key
of separation or comminution at the multiple frac- to the proper reduction of orbitozygomatic inju-
ture sites. All five points of assessment listed above ries. Displacement at this surface indicates a re-
should be evaluated carefully on the computed sidual rotational deformity. As mentioned earlier,
tomographic scan for the degree of displacement the thick lateral orbital wall is rarely comminuted.
and comminution. Simple elevation of the frac- Accurate reduction of the lateral orbital wall in
ture by means of a Gillies or intraoral approach is combination with inspection of the other three or
usually reserved for minimal displacement at all four sites as necessary will allow the surgeon to
fives buttresses with no comminution. In these achieve a very accurate reduction of the fracture
cases, the periosteal hinge is still present at the before the application of rigid fixation. Subperi-
majority of the fracture sites, and the zygoma osteal dissection at the exposed buttresses is lim-
should be stable in reduction. If there is a signif- ited to the minimum required to assess reduction
icant degree of displacement at any of the five and achieve fixation but always adequate to allow
sites, particularly if there is associated comminu- full assessment of the fracture character.
tion, the pull of the masseter muscle will cause a The pull of the masseter can often frustrate
collapse at the area of comminution, particularly adequate mobilization of the fracture fragment.
if it is at the zygomaticomaxillary buttress. Our This can be overcome by either chemical paralysis
preferred method for mobilizing the displaced or partial or complete release of the anterior por-
zygoma, whether it requires extensive exposure or tion of the masseter from the zygoma by means of
limited exposure, is to place a mayo scissors pos- the intraoral or coronal incision. The correct re-
terior to the body of the zygoma by means of the duction is best accomplished by placing a tempo-
upper buccal sulcus incision. This affords an ex- rary interosseous wire at the frontozygomatic su-
cellent purchase on the body of the zygoma and ture on the lateral orbital rim to set the vertical
mobilization is usually associated with an audible height of the zygoma, followed by rotation of the
clunk. A Carroll-Jerrard screw can be used to entire complex into correct position. Failure to
achieve the same effect. accurately reduce the fractures will result in the
If significant displacement or comminution is zygomatic complex being stabilized in an unre-
present at any of the five sites, an open reduction duced position otherwise known as an open in-
and internal fixation is indicated. The surgeon ternal fixation without reduction.
then decides how many of the five points of frac- Rigid fixation with plates and screws is the
turing need to be exposed and assessed intraop- accepted standard of fixation of reduced fractures
eratively. The condition of the zygomatic arch is a of the zygoma. There is no consensus, however, on
key element in the decision tree as to which inci- the strength of plates required at each fracture site
sions are required. The arch establishes the outer that will provide sufficient rigidity to resist the
facial frame (facial width and midface projection). regional deforming forces (Fig. 7). All currently
A careful analysis of patients who present with available internal fixation systems have a large se-
secondary midface depression and increased fa- lection of plates of various thicknesses, sizes, and
cial width reveals that all had untreated deformity strengths. The benefit of a smaller plate is less
of the zygomatic arch. Segmentation, lateral dis- dissection required to place it and potentially less
placement, telescoping, and comminution of the palpability. These benefits must always be weighed
arch are indications for exposure, reduction, and against the fundamental goal of rigid fixation to
fixation (Fig. 5). retain reduction and promote osseous union.
The safest approach to the zygomatic arch is by Thus, it is always safer to err on a slightly larger and
means of a coronal incision with protection of the stronger plate than a smaller plate that will not be
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Volume 120, Number 7 Suppl. 2 Zygomatic Fractures
Fig. 5. Segmentation, lateral displacement, telescoping, and comminution of the arch are indications for exposure, reduction, and
fixation.
strong enough to withstand the forces acting at of the masseter. The infraorbital rim is an impor-
that specific fracture site. The best site for rigid tant site for fracture reduction but is the least
fixation is the zygomaticomaxillary buttress, be- important site for fracture fixation, and either an
cause this is the direct antagonist to the pull of the interosseous wire or a small plate can be used in
masseter muscle. In addition, this site of fixation this site quite safely.
is deep, and plates are rarely felt in this area. Thus, The frontozygomatic suture line represents
a longer and stronger fixation plate (2.0 mm) very thick bone that is ideal for rigid fixation.
should usually be used at this site. Likewise, it is Unfortunately, plates in this area are readily pal-
very important to primarily bone graft any sites of pable, and therefore it is usually advisable to use
bone loss, especially the zygomaticomaxillary but- smaller plates at this location, provided that the
tress, because of its antagonistic effect on the pull fracture is not too unstable. It is very important to
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Plastic and Reconstructive Surgery December Supplement 2, 2007
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Volume 120, Number 7 Suppl. 2 Zygomatic Fractures
Fig. 8. Accurate reduction and fixation of the base of the zygomatic arch is important for reestablishing the correct facial width and
projection. Care must be taken when fixating fractures at the base of the zygomatic arch to avoid penetration of screws into the
glenoid fossa. Correct position of hardware is demonstrated in this coronal image.
fractured posteriorly from the zygomatic process tached in a slightly overcorrected position when it
of the temporal bone, care must be taken not to has been detached in the dissection.
place screws into the adjacent glenoid fossa and
mandibular condyle (Fig. 8). APPROACH TO THE ARCH
Once the entire orbitozygomatic complex has Safe exposure of the entire zygomatic arch
been reduced and rigidly fixed in its correct align- and assessment of its exact relationship to the
ment, the orbit then needs to be carefully evaluated remaining craniofacial skeleton can be accom-
for possible bony loss and needs to be anatomically plished only through an extended coronal in-
reconstructed to accurately restore the correct or- cision. The scalp flap must be dissected metic-
bital volume. We generally use a thin sheet of Med- ulously to prevent postoperative morbidity
por (Porex Surgical, Inc., Newnan, Ga.) to recon- relating to the following:
struct simple disruptions of a single orbital wall.
1. Weakness or permanent paralysis of the
More extensive fractures of the orbit involving large
frontal branch of the facial nerve
bone loss or multiple walls are more commonly re-
2. Temporal depression related to atrophy of
constructed with cranial bone graft harvested from
the temporal fat pad
the outer cranial cortex. Achieving the correct or-
3. Displacement of the lateral canthal ligament
bital volume in complex fractures is more challeng-
resulting in an antimongoloid slant of the
ing and is more commonly associated with the need
palpebral fissure
for secondary procedures to fine tune the position
4. Inferior descent of the lateral cheek tissues
of the globe. Secondary surgery in a primarily bone
secondary to failure to reconstruct the inci-
grafted orbit is much easier to perform because a
sion in the temporal fat pad
perfect dissection plane develops between the bone
5. Preauricular scar and injury to the superfi-
graft and periorbita.
cial temporal vessels
Finally, the midfacial soft tissue needs to be
repositioned in relation to the bony reconstruc- Our approach to the zygomatic arch based
tion and skeleton framework by the insertion of primarily on the location of the frontal branch of
multiple drill holes in the inferior and lateral or- the facial nerve (deep to the superficial muscu-
bital rims to enable suspension of the muscular loaponeurotic system, below the arch; superficial
periosteal envelope to these drill holes. We use at to the temporoparietal fascial, above the arch) has
least four 2-0 resorbable sutures that attach to been previously described. It is based on dissection
independent drill holes starting in the region of one plane deeper than the nerve, entering the
the mid inferior orbital rim and extending to the subperiosteal plane 2 cm above the orbital rims
lower lateral orbital rim below the lateral canthal and entering the plane deep to the superficial
attachment. The lateral canthal tendon is reat- layer of the deep temporal fascia 1 cm above the
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Plastic and Reconstructive Surgery December Supplement 2, 2007
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Volume 120, Number 7 Suppl. 2 Zygomatic Fractures
Although the inferomedial orbit is often involved in sure of all fractures and the accurate reduction of
orbitozygomatic fractures, the medial orbital wall is these fractures in a three-dimensional fashion. Fa-
not a component of pure orbitozygomatic injuries. cial symmetry is achieved by restoring the three-
Fractures involving the medial orbit should alert the dimensional position of the malar prominence,
examiner to the possible presence of an ipsilateral and orbital volume is restored by alignment of the
naso-orbito-ethmoid fracture. zygoma with the sphenoid. If this is not done, the
The displaced naso-orbito-ethmoid should be fractures will merely be rigidly plated in an unre-
addressed before final reduction of the zygoma. If duced position. All craniofacial surgeons today
the fracture at the nasofrontal junction is a green- dealing with a significant volume of facial fractures
stick fracture, no additional fixation of this site is have noticed that there is a rapidly increasing ep-
required because the nasomaxillary buttress can idemic of patients seen with fractures plated rig-
be used as a guide to assist with proper positioning idly in the wrong position. The complications we
of the naso-orbito-ethmoid fragment. A strong are now seeing with fractures plated in the unre-
plate on the nasomaxillary buttress will stabilize duced position are much more disastrous for the
the naso-orbito-ethmoid segment once it is cor- patient than those that used to be seen with simple
rectly reduced. The plate on the inferior orbital elevation or when fixation using interosseus wires
rim will further stabilize the naso-orbito-ethmoid was used. It is essential for the surgeon treating
segment in proper reduction because there are these very common injuries to thoroughly under-
minimal muscular deforming forces acting on the stand that there is no substitute for accurate ex-
naso-orbito-ethmoid complex. However, if the posure and reduction of the fractures. Only once
naso-orbito-ethmoid component is displaced and this is done will rigid fixation with plates and
unstable at the nasofrontal suture, additional fix- screws accomplish its planned objective.
ation at this site will be required, usually through
Joseph Gruss, M.D.
a coronal incision. Childrens Hospital CH-78
It is extremely important to preserve the at- 4800 Sandpoint Way N.E.
tachment of the medial canthal ligament to the Mail Stop G-0035
lacrimal bone during dissection. The medial can- Seattle, Wash. 98115
thus is rarely avulsed from its bony attachment at joseph.gruss@seattlechildrens.org
the time of the actual injury; rather, it is usually REFERENCES
stripped from its insertion during exposure of the
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5. OHara, D. E., DelVecchio, D. A., Bartlett, S. P., and Whitaker,
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the entire treatment protocol in these patients. All 6. Phillips, J. H., Gruss, J. S., Wells, M. D., and Chollet, A. Peri-
the plates and screws represent are the most so- osteal suspension of the lower eyelid and cheek following
phisticated and best form of fixation of the frac- subciliary exposure of facial fractures. Plast. Reconstr. Surg. 88:
145, 1991.
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