CRANIOMAXILLOFACIAL TRAUMA

An Algorithm for the Treatment of Isolated Zygomatico-Orbital Fractures Edward Ellis III, DDS, MS,* and Daniel Perez, DDSy Purpose:

To present algorithms for the treatment of zygomatico-orbital (ZMO) fractures and to review how many of our patients were treated using each. We have presented 2 algorithms: 1 for when intraoperative computed tomography (CT) scans are not available and 1 for when intraoperative CT scans are available.

Patients and Methods:

The data from all patients treated by us for isolated, unilateral ZMO fractures from January 1991 to December 31, 2013 with adequate medical records were retrospectively analyzed. The demographic information and treatment methods were collected and tabulated to determine how these patients’ fractures had been classified using the 2 algorithms. Simple descriptive statistics were applied.

Results:

A total of 883 patients with sufficient records who had undergone treatment of isolated, unilateral ZMO fractures were included. Of these 883 patients, 71 were classified as having high-energy ZMO fractures that had not been treated using 1 of the algorithms. A total of 758 patients with sufficient records to be included in the present study were treated using the algorithm before intraoperative CT scanning was available. Finally, 54 patients were treated using the algorithm after intraoperative CT scanning was available. The patients were similar demographically. The number of patients treated at each point in the algorithms is shown. Overall, only 40% of patients required internal orbital reconstruction.

Conclusions: The treatment of most ZMO fractures can be sequential, using an algorithm to avoid unnecessary surgical approaches and procedures that can potentially cause iatrogenic deformities. The use of intraoperative CT scans will allow the surgeon to be less invasive, with greater predictability and precision. Ó 2014 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 72:1975-1983, 2014

Fractures of the zygoma and surrounding bones are not uncommon in clinical practice. Although several names have been used, including zygomaticomaxillary compound (ZMC), zygomaticomaxillary complex, tripod, malar, and so forth, the term ‘‘zygomaticoorbital’’ (ZMO) fracture is perhaps the most appropriate because these fractures involve the orbit. They are probably the most common orbital fracture that most clinicians will see in clinical practice.1,2 ZMO fractures can cause functional and cosmetic problems. The potential functional consequences include diplopia, infraorbital nerve dysfunction, and trismus. The potential cosmetic consequences include enophthalmos, hypophthalmos, loss of malar projec-

tion, and midfacial widening. Of importance is that not all ZMO fractures cause functional and/or cosmetic problems. Therefore, not all ZMO fractures require treatment. Those that are minimally displaced with no cosmetic or functional consequences require no treatment.1,3-5 ZMO fractures have varying degrees of severity.6 Some will have minimal displacement and others, severe displacement. Some will have significant internal orbital disruption, others will not. Some will have entrapped the extraocular muscles, but most will not. Thus, it would seem that an individualized treatment plan should be developed for each ZMO fracture. However, treatment has varied widely from 1 surgeon

Received from Department of Oral and Maxillofacial Surgery,

Science Center at San Antonio 7703 Floyd Curl Drive, MC7908,

University of Texas Health Science Center at San Antonio, San

San Antonio, TX 78229-3900; e-mail: [email protected]

Antonio, TX. *Professor and Chair.

Received March 31 2014 Accepted April 16 2014

yAssistant Professor.

Ó 2014 American Association of Oral and Maxillofacial Surgeons

Conflict of Interest Disclosures: None of the authors reported any

0278-2391/14/00442-X$36.00/0

disclosures.

http://dx.doi.org/10.1016/j.joms.2014.04.015

Address correspondence and reprint requests to Dr Ellis: Department of Oral and Maxillofacial Surgery, University of Texas Health

1975

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to another. Some surgeons routinely surgically expose 3 of the 4 articulations to reposition and stabilize the fractured segment, irrespective of the degree of displacement, comminution of the articulations, amount of internal orbital disruption, and so forth.5,7-9 Others will expose fewer articulations on some ZMO fractures and more on others.10-18 One might question why different surgeons provide different treatment of the same fracture. Certainly, this must be based, in part, on their training and experience. However, one must thoughtfully determine the reason for which a ZMO fracture is being treated. For those with minimal functional deficits, the surgery should be considered cosmetic.19 Therefore, the patient should be treated as if undergoing a cosmetic surgical procedure. Thus, the decision to place an incision on the face should be carefully weighed to determine whether the benefit of that incision outweighs the potential complications that the incision could create. Every surgical approach has consequences. The transoral vestibular approach to the zygomaticomaxillary buttress and an incision through the upper eyelid to provide exposure of the frontozygomatic fracture and lateral orbital wall will very rarely create a noticeable deformity. However, it has been shown that eyelid asymmetries from scleral show, lid retraction, ectropion, and so on occur in up to 42% of surgical approaches to the infraorbital rim and/or orbital floor, whether the incision is placed through (subciliary, subtarsal) or behind (transconjunctival) the lower eyelid.10,13,20-30 Given the potential to create iatrogenic injuries using surgical approaches to the floor of the orbit, one should use them only when absolutely necessary. The purpose of the present report was to present algorithms for the treatment of ZMO fractures that individualize the treatment in accordance with the pre- and intraoperative findings. Our intent was to minimize the number of surgical approaches required in an attempt to minimize the potential iatrogenic cosmetic deformities that the surgical approaches can engender. In clinical practice, most ZMO fractures can be treated in this manner. However, for severe high-energy injuries that have gross displacement, comminution of the articulations, an obvious need for internal orbital reconstruction, and, potentially, 4point fixation, the algorithms we have presented will be unnecessary, because those injuries will require multiple points of exposure, including coronal exposure, multiple points of fixation, and internal orbital reconstruction. INFORMATION ON WHICH THE ALGORITHMS WERE BASED

When treating ZMO fractures, 3 critical components must be addressed. The first is to perform an

anatomic reduction of the displaced segment. The second is to ensure that the segment is stable once reduced. The third is to perform adequate internal orbital reconstruction, when indicated. All 3 require clinical and/or radiographic judgment. Reduction No matter which technique or tool is used to reduce the displaced ZMO segment, the important question is whether the reduction has been performed anatomically. Only 2 methods are available by which this can be determined during surgery. The first is clinical examination, which can be performed by palpation and/or surgical exposure of the bony articulations of the displaced segment. The potential problem with a clinical examination is that one could be inaccurate in the assessment. However, in a patient with minimal swelling, it will usually be possible to determine that the reduction is accurate. Exposing more anatomic fracture sites can provide more information about the adequacy of the reduction, but the risk from exposing multiple sites include the potential iatrogenic cosmetic deformities that can result from the incisions. The second method to verify the reduction is accurate is intraoperative imaging. This will be difficult with plain films. However, intraoperative computed tomography (CT) has become available in many operating rooms using small, mobile, conebeam C-arm units. Stability It will be easy to intraoperatively determine the stability of a reduced ZMO segment. One has only to exert strong digital force on the malar eminence to determine whether the fracture displaces. If one has placed a transcutaneous bone screw (eg, CarrollGirard), it will become obvious by applying force to the handle. If the segment displaces, internal fixation devices will be required to resist displacement. How much fixation and where it will be applied will vary greatly depending on the amount of comminution of the articulations, the amount of displacement, and so forth. However, for an isolated ZMO fracture, the amount of fixation required to prevent displacement should not be that great.31 Often, 1 plate at the zygomaticomaxillary buttress will be adequate to prevent displacement by digital force.10-12,14,15 Internal Orbital Reconstruction Every ZMO fracture has an orbital fracture as a component. Typically, the fracture line will extend through the frontozygomatic suture, down the sphenozygomatic suture, into the inferior orbital fissure, and across the orbital portion of the maxilla until it crosses the infraorbital rim. The orbital components of some ZMO fractures will be linear, with minimal

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comminution; others will have a significant amount of comminution. The question is whether internal orbital reconstruction will be required for a given ZMO fracture. This can be determined intraoperatively using surgical ‘ exploration’’ of the orbital floor or by analyzing either the preoperative or intraoperative CT scan. It has been shown that the preoperative CT scan can be used to reliably determine whether internal orbital reconstruction will be necessary.10,11,32 An even better method is to use intraoperative CT scanning after reduction of the displaced ZMO segment.33 Given these factors, it is not possible for a single algorithm to be used for ZMO fractures, because it will depend on the availability of intraoperative CT scanning. Thus, 1 algorithm included intraoperative CT scanning and the other assumed intraoperative CT would not be available. ALGORITHM 1: NO INTRAOPERATIVE CT AVAILABLE

The first algorithm (Fig 1) will likely be the one used most commonly for the next several years until intraoperative CT scanning has become universally available. Algorithm 1 relies heavily on a careful analysis of the preoperative CT scans. The main goal of the analysis should be to determine whether internal orbital reconstruction will be required.10,11,32 If deemed unnecessary, the algorithm will minimize the surgical approaches required, with the main goal of avoiding the use of an incision to expose the infraorbital rim and/or orbital floor, omitting the

possibility of an iatrogenic cosmetic deformity (ie, lid shortening, scleral show, ectropion, entropion, palpebral asymmetry). When it has been deemed that no internal orbital reconstruction is required, the first step in algorithm 1 is to reduce the fracture. This can be performed ‘‘closed’’ using a number of techniques, including a Gillies temporal approach, a transcutaneous hook or bone screw (Carroll-Girard), and so forth. If the displaced fragment reduces and resists displacement using digital pressure applied to the malar eminence, the surgery can be completed. If, after elevation of the fracture, one is either not sure that the fragment has been reduced appropriately or the fragment reduces, but is unstable and falls back into a malreduced position, a transoral open reduction should be performed. The reason for choosing this surgical approach as the first point of exposure is twofold. First, the scar will be hidden within the oral cavity; thus, the chance of an iatrogenic deformity will be nil. Second, the zygomaticomaxillary buttress is a key point for alignment of the displaced zygoma. Not only can one see the alignment along the buttress, but one can also easily dissect superiorly to expose the infraorbital rim and verify the reduction at this location. Commonly, comminution will be present at the buttress; however, most often, one can achieve a good sense of the adequacy of the reduction by considering both the infraorbital rim and the articulation along the buttress. After verification that the fracture has been reduced,

FIGURE 1. Algorithm for zygomatico-orbital fractures when intraoperative computed tomography scanning is not available. Fx, fracture; FZ, frontozygomatic; Int Orb Reconstr, internal orbital reconstruction; Redn, reduction; SZ, sphenozygomatic; ZM, zygomaticomaxillary. Ellis III and Perez. Isolated Zygomatico-Orbital Fracture Treatment Algorithm. J Oral Maxillofac Surg 2014.

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a bone plate can be placed in this location to provide stability. From a biomechanical standpoint, a plate placed in this location will have the greatest mechanical advantage in maintaining the position of the zygoma.10-12,14,15 If, after transoral exposure of the displaced zygoma, one is still unsure of the adequacy of the reduction, the second surgical approach is through the upper eyelid. This surgical approach is the most cosmetic approach to the frontozygomatic area and provides broad exposure to the internal aspect of the lateral orbit. It is extremely rare for an iatrogenic deformity to occur using this surgical approach. Alignment of the displaced fracture along the sphenozygomatic and frontozygomatic suture lines, in concert with alignment along the transorally exposed zygomaticomaxillary buttress and infraorbital rim will provide accurate reduction of the displaced segment. One can then place fixation at the frontozygomatic and zygomaticomaxillary buttress areas and close. When internal orbital reconstruction has been deemed necessary from the analysis of the preoperative CT scans, a similar algorithm can be used to potentially minimize the number of surgical approaches. However, unlike the previous scenario, a surgical approach to the internal orbit will be required to reconstruct the orbital floor. It might be possible, however, to avoid other incisions, although, in practice, most cases that require internal orbital reconstruction will also require transoral exposure of the zygomaticomaxillary buttress and, often, exposure of the frontozygomatic and sphenozygomatic suture areas. Thus, potentially, 3 incisions will be required to manage such cases. ALGORITHM 2: INTRAOPERATIVE CT AVAILABLE

The availability of intraoperative CT scanning (Fig 2) has the potential to make treatment of ZMO fractures less invasive, because one will not have to visualize the bony articulations to determine whether the displaced segment has been adequately reduced. Furthermore, the need for internal orbital reconstruction can be determined intraoperatively using CT after reduction of the displaced zygoma.33 The algorithm for simple ZMO fractures begins with reduction of the displaced bone. This can be performed ‘‘closed’’ using a number of techniques, including a Gillies temporal approach, a transcutaneous hook, or a bone screw (Carroll-Girard). If the displaced fragment reduces and resists displacement using digital pressure applied to the malar eminence, an intraoperative CT scan should be obtained to determine the adequacy of the reduction and the need for internal orbital reconstruction. If the fragment has been reduced, is stable, and internal orbital

reconstruction is not needed, the operation can be completed. If the fragment is not well reduced, one can proceed to perform open reduction internal fixation (ORIF), beginning with the zygomaticomaxillary buttress and, if necessary, the frontozygomatic area. Similarly, if, after closed reduction, one is unsure whether the reduction is adequate or the fragment reduces but is unstable in its reduced position, transoral open reduction should be performed. If the fragment can be reduced, a bone plate should be applied. If still unsure of the reduction, open reduction of the frontozygomatic area through an upper eyelid approach can be performed and a bone plate placed. An intraoperative CT scan should then be obtained to determine the adequacy of the reduction and the need for internal orbital reconstruction (Fig 3). Additional intervention will be decided from the findings on the intraoperative CT scan (Fig 4). If the fragment has not been well reduced, one can revise the ORIF. If the internal orbit requires reconstruction, that can be performed. In any of these situations, if internal orbital reconstruction is necessary, it should be performed and another CT scan obtained to verify the accuracy of the reconstruction. A comparison with the opposite side, if uninjured, can serve as a guide to the adequacy of the reconstruction. If software is available to allow preoperative virtual planning in which the uninjured side is mirrored to the fractured side, that plan can be used intraoperatively to fuse with the intraoperative CT scan to determine the adequacy of the zygomatic reduction and internal orbital reconstruction. If the internal orbital reconstruction is inadequate, revision should be performed, followed by another CT scan.

Patients and Methods The data from all patients treated by us for isolated, unilateral ZMO fractures from January 1991 to December 31, 2013 and with adequate medical records were retrospectively analyzed. The following demographic information was collected and tabulated: age, gender, cause of the injury, and side of the injury. The treatment provided was tabulated to determine how these patients’ fractures had been classified using the 2 algorithms. Simple descriptive statistics were applied. No inferential statistics or treatment outcomes were collected. The institutional review board determined that their review of this project was unnecessary owing to the removal of the patient identifiers.

Results During the 23 years of the present study, 883 patients were treated for isolated, unilateral ZMO fractures with sufficient medical records to be included in the present audit. Of these patients, 71 had fractures

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FIGURE 2. Algorithm for zygomatico-orbital fractures when intraoperative computed tomography scanning is available. CT, computed tomography; Fx, fracture; FZ, frontozygomatic; ORIF, open reduction internal fixation; Reconstr, reconstruction; Redn, reduction; ZMB, zygomaticomaxillary buttress. Ellis III and Perez. Isolated Zygomatico-Orbital Fracture Treatment Algorithm. J Oral Maxillofac Surg 2014.

classified as high-energy ZMO fractures that were not subjected to treatment using 1 of the algorithms. These patients required surgical approaches to all anatomic areas of the complex, including coronal exposure, transoral exposure, and an approach to address the internal orbital defects. Of the patients who did not have high-energy injuries and who were treated using 1 of the algorithms, 758 patients with sufficient records to be included in the present study had been treated by the first algo-

FIGURE 3. Intraoperative photograph showing a patient undergoing C-arm cone-beam computed tomography scanning. Ellis III and Perez. Isolated Zygomatico-Orbital Fracture Treatment Algorithm. J Oral Maxillofac Surg 2014.

rithm (Fig 1) before intraoperative CT scanning was available. Of the 758 patients, 581 (76.6%) were male and 177 (23.4%) were female. The mean age was 29.6 years (range 12 to 88). The left side was involved in 463 patients (61%) and the right side in 295 (39%). Interpersonal violence was the cause in 549 patients (72.4%), followed by motor vehicle accidents (n = 128; 16.9%), falls (n = 31; 4%), sport injuries (n = 22; 2.9%), and other (n = 28; 3.7%). During the study period, 54 patients with isolated, unilateral ZMO fractures were treated with the use of intraoperative CT scans using the second algorithm. They were similar demographically to the previous sample. The treatment provided before CT scanning became available is listed in the first algorithm (Fig 1). The treatment provided after CT scanning became available is listed in the second algorithm (Fig 2). The main finding was that internal orbital reconstruction was deemed necessary and provided in only 40% of the patients. This included 71 patients classified as having high-energy fractures, 263 treated using algorithm 1 and 19 using algorithm 2. The other 60% of patients were not treated by reconstruction of the internal orbit in accordance with the findings from either the preoperative or intraoperative CT scans. For those patients treated with the aid of intraoperative CT scans, 6 patients required 3, 13 required 2, and 35 required only 1 intraoperative scan.

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FIGURE 4. Intraoperative image of a patient with a zygomatico-orbital fracture after open reduction. The imaging monitor shows 3 planar views (sagittal, axial, coronal) and 3-dimensional reconstruction. Note the alignment of the orbital floor (white arrows) and the displacement at the frontozygomatic area (black arrow). Ellis III and Perez. Isolated Zygomatico-Orbital Fracture Treatment Algorithm. J Oral Maxillofac Surg 2014.

Discussion The wide availability of small bone plates approximately 25 years ago sparked a major revolution in the treatment of midfacial fractures. Open reduction and stable internal fixation became popular, especially with ZMO fractures. Surgeons have enjoyed exposing multiple articulations of the displaced fragment to ensure a perfect reduction; placing plates and screws is so much more rewarding than placing transosseous wires. Even today, many surgeons routinely open 3 of 4 articulations to assist in reduction and placement of stable internal fixation devices.

Although stable internal fixation can help maintain the position of fractured bony segments, the consequences of ORIF on the soft tissues of the face were long neglected. In the late 1980s, surgeons began to notice that despite the perfect bony reduction, the face might appear lifeless.34-36 It became apparent that the soft tissue disruption necessary to reduce and stabilize fractures can impart their own unique set of consequences in the form of visible scars, nonpliability of soft tissues, displacement and sagging of soft tissues, and eyelid deformities and malpositions. The soft tissue deformities that can

ELLIS III AND PEREZ

result from open exposure in and around the orbit could be more noticeable than the bony defects or malpositions treated.10,13 The pendulum has slowly been shifting away from extended ORIF to ‘ less’’ or even ‘ minimally’’ invasive approaches for the management of ZMO fractures.10-18,33 Three factors have spurred this shift. The first has been the recognition that every incision has consequences. The second has been the recognition that the treatment of many ZMO fractures will essentially be a form of cosmetic surgery. The third has been the availability of intraoperative CT scanning in many operating rooms worldwide. Although most of the surgical approaches used today for the management of ZMO fractures will be cosmetically ‘‘acceptable,’’ each has the potential to become problematic, whether from surgical misadventure or an unfavorable healing process. Czerwinski et al13 found that patients treated with ORIF had a 33% (4 of 12) incidence of visible cutaneous scarring and a 25% (4 of 12) incidence of lower lid shortening. Ellis and Kittidumkerng10 found a 20% incidence of palpebral asymmetries 6 weeks after surgical approaches to the infraorbital rim and orbital floor. If one individualizes the treatment of zygoma fractures and considers why the fracture is being treated, one will note that a large percentage of cases will be treated for cosmetic concerns only.19 Therefore, minimizing the surgical approaches to those absolutely necessary can minimize the risk for an unfavorable cosmetic outcome. The surgical approaches with the most complications are those that access the infraorbital rim and/or orbital floor. This has been especially true with subciliary incisions, for which the rate of scleral show, lid shortening, and/or ectropion has reached 17 to 42% in some studies.22-25,29 Even the subtarsal approach has had a 2.7 to 7.7% rate of these complications.21,24 Although the incidence of complications with the transconjunctival approach might be less than that with transcutaneous approaches, when complications have developed, they tend to be more difficult problems, such as entropion rather than ectropion.20,21,25,28-30,37 Thus, it would make sense to, when possible, avoid any surgical approach to the orbital floor. In the present sample, it was possible to avoid approaches to the orbital floor for 60% of the patients presenting with ZMO fractures. Others have reported similar data.10-12,15-18,33 The data presented in algorithm 1 showed that surgical approaches to the orbital floor were avoided in 65.3% of the patients. Thus, the potential for an iatrogenic eyelid deformity was also avoided for that same percentage of patients. Also, 34.7% of the patients required internal orbital reconstruction and had an approach to the orbital floor for reconstructive pur-

1981 poses. The data in algorithm 1 also showed that the fractures requiring internal orbital reconstruction were more severe than those not requiring internal orbital reconstruction. This can be best exemplified by the need for exposure of the frontozygomatic area between the sample requiring orbital reconstruction and the sample not requiring orbital reconstruction. Exposure of the frontozygomatic and sphenozygomatic area was required in 71.4% of the patients who underwent internal orbital reconstruction, but in only 21% of those who did not. It was not surprising, therefore, that more intervention was required for fractures deemed preoperatively to require internal orbital reconstruction. The real innovation in the treatment of ZMO fractures has been the availability of intraoperative CT scanning. CT truly means that closed reduction is a reality, because no longer must the patient rely on the skill of the surgeon to determine whether a fracture that was reduced using a ‘‘closed’’ method has been properly repositioned. Although experienced surgeons can usually be accurate in this determination, inexperienced surgeons cannot. When the fracture is visualized on imaging, anyone can determine whether the reduction has been adequate. An orthopedic surgeon would never leave the operating room after treating a fracture without imaging evidence that the reduction has been adequate; however, oral and maxillofacial surgeons have been doing so for 100 years. This has mainly been because of the difficulty encountered in imaging the complicated anatomy of the face using plain radiographs and/or fluoroscopic units. CT, however, provides a very clear view of the delicate bones around the orbit, and the new C-arm conebeam CT scanners are easy to use, fast and use low radiation amounts. Algorithm 2 for ZMC fractures with intraoperative CT scanning available showed that 1 to 3 CT scans could be required. If, after the first scan, the ZMC has been properly reduced and internal orbital reconstruction is not needed, the operation can be completed. If the ZMC has not been properly reduced, a second surgical approach might be required, which was the case for only 3 patients. Two of these underwent reduction only, and it was found that the reduction was inadequate. These patients then underwent ORIF of the zygomaticomaxillary buttress, and the subsequent CT scan showed a good reduction. In the third without a good reduction on the first CT scan, the initial treatment had been ORIF of the zygomaticomaxillary buttress, and the CT scan showed some displacement at the frontozygomatic suture (Fig 4). An approach to this area was thus required, and the subsequent CT scan showed a good reduction. Thus, only 3 of the 54 patients required 2 CT scans to verify adequate reduction. The others had required only 1.

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In the 54 patients treated when intraoperative CT was available, internal orbital reconstruction was required in 19 (35%). A CT scan was taken after internal orbital reconstruction, and of those 19 patients for whom it was performed, 3 had inadequate internal orbital reconstruction requiring revision and another CT scan. In the overall sample of 54 patients treated with intraoperative CT available, 32 underwent 1, 20 underwent 2, and 2 underwent 3 intraoperative CT scans to confirm both adequate reduction and the need for and/or quality of the internal orbital reconstruction. This might seem to be a large radiation dosage. However, the radiation dosage from the C-arm cone-beam CT scanner currently in use at our facility has been 12.8 mSv/scan. This is approximately one third to one fourth of the dosage provided by a typical fan-beam medical CT scanner (36 mSv).38 One must consider that even if 3 intraoperative scans will be obtained, the radiation dosage will be equal to, or less than, the dosage from the postoperative CT scan in the radiology department, which, with intraoperative CT scanning, will no longer be necessary. Furthermore, if a problem has been noted on the postoperative scan, the surgeon might be reluctant to return the patient to surgery for correction because of the costs and problems involved. In essence, the surgeon might have accepted a less accurate result. However, when a problem has been noted intraoperatively, it can be quickly remedied. The other interesting finding was that a reduction in the need for a second point of surgical exposure occurred from 21 to 71% for the patients treated using algorithm 1 to 15% for the patients treated using algorithm 2. This, undoubtedly, was because the frontozygomatic and sphenozygomatic area was previously exposed when it was uncertain that the ZMC fracture had been properly reduced. With the reduction shown using intraoperative imaging, surgical exposure to determine the adequacy of the reduction was unnecessary. A weakness of the present study was that no outcomes were reported. One could, therefore, argue that the algorithms presented might not provide accurate reconstructions. However, every patient in our study had, if not intraoperative CT scans, postoperative CT scans to verify the accuracy of the reduction and the status of the internal orbit or its reconstruction. We believe that accurate reconstruction was achieved in all but a few patients. The only patients who required another surgical procedure were 2 patients whose postoperative CT scans showed poor orbital reconstruction. Thus, regardless of whether intraoperative CT is available, the treatment of ZMO fractures can be individualized, and most can be treated without the need

for 3- or 4-point exposure and fixation or internal orbital reconstruction. When required, however, such treatment must be provided. Knowing when to perform which approach is key, and studying the preoperative CT scans and using a methodical, structured approach to the surgery can provide good results with minimal surgical intervention for most cases.

References 1. Ellis E, El-Attar A, Moos K: An analysis of 2,067 cases of zygomatico-orbital fracture. J Oral Maxillofac Surg 43:417, 1985 2. Hammer B: Orbital Fractures: Diagnosis, Operative Treatment, Secondary Corrections. Seattle, Hogrefe & Huber Publishers, 1995 3. Kristensen S, Tveter as K: Zygomatic fractures: Classification and complications. Clin Otolaryngol 11:123, 1986 4. Kaastad E, Freng A: Zygomatico-maxillary fractures. J Craniomaxillofac Surg 17:210, 1989 5. Covington DS, Wainwright DJ, Teichgraeber JF, et al: Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma 37:243, 1994 6. Manson PN, Markowitz B, Mirvis S, et al: Toward CT-based fracture treatment. Plast Reconstr Surg 85:202, 1990 7. McCarthy JG (ed): Plastic Surgery. New York, WB Saunders, 1990. pp 991–1009 8. Rohrich RJ, Hollier LH, Watumull D: Optimizing the management of orbitozygomatic fractures. Clin Plast Surg 19:149, 1992 9. Makowski GJ, Van Sickels JE: Evaluation of results with three point visualization of zygomaticomaxillary complex fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80:624, 1995 10. Ellis E, Kittidumkerng W: Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg 54: 386, 1996 11. Shumrick KA, Kersten RC, Kulwin DR, Smith CP: Criteria for selective management of the orbital rim and floor in zygomatic complex and midface fractures. Arch Otolaryngol Head Neck Surg 123:378, 1997 12. Fujioka M, Yamanoto T, Miyazato O, Nishimura G: Stability of one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg 109:817, 2002 13. Czerwinski M, Martin M, 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 14. Yaremchuk MJ: Quantitative comparison of open reduction and internal fixation versus the Gillies method in the treatment of orbitozygomatic complex fractures: Discussion. Plast Reconstr Surg 115:1855, 2005 15. Yonehara Y, Hirabayashi S, Tachi M, Ishii H: Treatment of zygomatic fractures without inferior orbital rim fixation. J Craniofac Surg 16:481, 2005 16. Soejima K, Sakurai H, Nozaki M, et al: Semi-closed reduction of tripod fractures of zygoma under intraoperative assessment using ultrasonography. J Plast Reconstr Aesthet Surg 62:499, 2009 17. Forouzanfar T, Salentijn E, Peng G, van den Bergh B: A 10-year analysis of the ‘Amsterdam’’ protocol in the treatment of zygomatic complex fractures. J Craniomaxillofac Surg 41:616, 2013 18. Uda H, Kamochi H, Sugawara Y, et al: The concept and method of closed reduction and internal fixation: A new approach for the treatment of simple zygoma fractures. Plast Reconstr Surg 132:1231, 2013 19. Ellis E: Discussion: The concept and method of closed reduction and internal fixation: A new approach for the treatment of simple zygoma fractures. Plast Reconstr Surg 132:1241, 2013 20. Wray RC, Holtmann B, Ribaudo M, et al: A comparison of conjunctival and subciliary incisions for orbital fractures. Br J Plast Surg 30:142, 1977 21. Holtmann B, Wray RC, Little AG: A randomized comparison of four incisions for orbital fractures. Plast Reconstr Surg 67:731, 1981

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ELLIS III AND PEREZ 22. Pospisil OA, Fernando TD: Review of the lower blepharoplasty incision as a surgical approach to zygomatico-orbital fractures. Br J Oral Maxillofac Surg 22:261, 1984 23. Lacy MF, Pospisil DA: Lower blepharoplasty post-orbicularis approach to the orbit: A prospective study. Br J Oral Maxillofac Surg 25:398, 1987 24. Bahr W, Bagambisa FB, Schlegel G, et al: Comparison of transcutaneous incisions used for exposure of the infraorbital rim and orbital floor: A retrospective study. Plast Reconstr Surg 90:585, 1992 25. Appling WD, Patrinely JR, Salzer TA: Transconjunctival approach vs. subciliary skin-muscle flap approach for orbital fracture repair. Arch Otolaryngol 119:1000, 1993 26. Netscher DT, Patrinely JR, Peltier M, et al: Transconjunctival versus transcutaneous lower eyelid blepharoplasty: A prospective study. Plast Reconstr Surg 96:1053, 1995 27. Mullins JB, Holds JB, Branham GH, et al: Complications of the transconjunctival approach: A review of 400 cases. Arch Otolaryngol Head Neck Surg 123:385, 1997 28. Patel PC, Sobota BT, Patel NM, et al: Comparison of transconjunctival versus subciliary approaches for orbital fractures: A review of 60 cases. J Craniomaxillofac Trauma 4: 17, 1998 29. De Riu G, Meloni SM, Gobbi R, et al: Subciliary versus swinging eyelid approach to the orbital floor. J Craniomaxillofac Surg 36: 439, 2008 30. Raschke G, Rieger U, Bader R-D, et al: Outcomes analysis of eyelid deformities using photograph-assisted standardized

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An algorithm for the treatment of isolated zygomatico-orbital fractures.

To present algorithms for the treatment of zygomatico-orbital (ZMO) fractures and to review how many of our patients were treated using each. We have ...
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