TECHNICAL STRATEGY
‘‘Roller Coaster Maneuver via Lateral Orbital Approach’’ for Reduction of Isolated Zygomatic Arch Fractures Ozgur Pilanci, MD,* Karaca Basaran, MD,* Asli Datli, MD,* and Samet Vasfi Kuvat, MD*Þ Abstract: Numerous techniques have been reported for the reduction of zygomatic arch fractures. In this article, we aimed to describe a technique we named as ‘‘roller coaster maneuver via lateral orbital approach’’ to closed reduction of the isolated-type zygomatic arch fractures. Surgical outcomes of 14 patients treated with this method were outlined. Key Words: Zygomatic arch fracture, closed reduction, lateral orbital approach, roller coaster (J Craniofac Surg 2013;24: 2082Y2084)
T
he zygomatic bone occupies an important position in the facial skeleton.1Y3 It plays a key role in determining facial width and acts as a major transverse buttress of the mid face. This bony component of the face is susceptible to trauma because of its prominent configuration. In fact, among fractures of the facial skeleton, the prevalence of zygomatic bone fractures is second only to those of the nasal bone.4,5 All zygomatic fractures comprise approximately 10% of isolated zygomatic arch fractures.6Y8 Arch fractures result in noticeable depression at the impact site. The mechanism of the injury usually involves a blow to the side of the face from a fist or an object or a fracture that develops secondary to occupational work or motor vehicle accident. In the literature, numerous techniques have been reported for the reduction of zygomatic arch fractures such as that of Gillies et al4 (temporal), that of Dingman and Natvig5 (lateral brow), Keen6 (intraoral) approaches or closed reduction with towel clip,7,8 bone hook,9 and Carroll-Girard bone screw.10 In this article, we present a simple and an effective method for the reduction of isolated zygomatic arch fractures, namely, the lateral orbital access.
MATERIALS AND METHODS Fourteen patients with type 2 isolated zygomatic arch fractures have been operated on with the previously mentioned procedure between May 2012 and January 2013. Approval of the ethics committee of the hospital was obtained, and informed consent was
From the *Bagcilar Research and Training Hospital; and †Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Faculty of Medicine, Istanbul, Turkey. Received May 23, 2013. Accepted for publication June 16, 2013. The authors report no conflicts of interest. Address correspondence and reprint requests to Ozgur Pilanci, MD, Eski Londra Asfalti, Emlak Konut Sitesi, A 5, Daire 21, Bahcelievler, Istanbul, Turkey; E-mail: [email protected] Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2430a
2082
taken from each participant. The inclusion criterion of the study was the presence of isolated zygomatic arch fractures. Patients with other zygomatic or facial fractures were excluded from the study for having a homogenous group. All patients except 1 were men, and the mean age was 35.7 (range, 21Y75). The injury was caused by an assault in 10 patients and traffic accidents in 4 patients. Five patients were treated on the day they had their injuries, whereas the remaining patients received surgical treatment within 3 days after the injury. In terms of symptoms, 4 patients had limited mouth openings. The remaining 10 patients complained of a depression on the arch area. None of the patients had a neurosensory disturbance, periorbital ecchymosis, malar depression, subconjunctival hemorrhage, or diplopia. Workup included preoperative and postoperative plain radiographs and axial plane computed tomography (CT).
Surgical Technique All patients were prepared in a supine position in the operating room. Preoperative markings included mainly the lateral brow access incision and displaced segments of the zygomatic arch pointing out to the depression palpated on the skin (Fig. 1). Under light sedation (2Y4 mg of midazolam), approximately 4 to 6 mL of 2% lidocaine with 1/160,000 adrenaline was infiltrated from the incision site down to the zygomatic arch and also to the tip of the type 2 fractured segment subperiosteally. A sharp dissection was performed with the help of no. 15 blade in all the layers including the periosteum of the lateral orbital rim. A curved periosteal elevator was inserted through the incision on the lateral edge of the lateral orbital rim (Fig. 2). A blunt closed subperiosteal dissection was then performed, sweeping over the bone from the posterolateral aspect of the orbital process of the zygomatic bone to the caudal surface of the medial fractured segment. After an adequate space was created underneath the center of the fracture, the bone was slightly elevated upward. This maneuver that we call ‘‘roller coaster’’ should proceed without interruption (Fig. 3). After reduction, the contralateral zygomatic arch was checked for comparison. After alignment of the segment was assured, the elevator was taken out precisely. The incision was closed with 2 single 6/0 polypropylene sutures (Fig. 4).
FIGURE 1. Preoperative marking.
The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
RESULTS The mean operative time beginning from the initiation of sedation until the end of wound closure was 5 minutes. All patients were discharged on the day of the surgery. The patients were advised to sleep in a supine position and protect their cheek area for 2 weeks. A nonsteroidal anti-inflammatory drug was prescribed upon discharge. The mean follow-up period was 7 months (range, 3Y13 mo). Postoperative evaluation included an occipitomental plain x-ray and an axial plane CT in addition to physical examination.
Roller Coaster Maneuver
Thirteen of the 14 patients had a complete recovery, and the zygomatic arch regained its original shape. In 1 patient, only a small improvement was observed. We attributed this situation to a small bone fragment running into the reduction zone when we checked the postoperative radiogram. The preoperative gagging of the mouth of the 4 patients returned to reference range. Functional and cosmetic results were excellent in all patients. None of the patients complained of a scar except for 1 patient. This patient was reassured, and the scar was handled with conservative measures.
DISCUSSION
FIGURE 2. The reduction of the fracture with lateral orbital incision.
The zygomatic bone occupies a prominent and important position in the facial skeleton. It plays a key role in providing contour and symmetry to the mid face. Zygomatic bone fractures are the second most common facial fractures after nasal bone fractures and cause a noticeable depression at the impacted site.4,11 Several classifications for arch fractures have been described. Some authors classify isolated zygomatic bone fractures using the degree of displacement. A 2-mm displacement of bone segments in radiographic evaluation has been used as a guide to classify patients into open and closed reduction treatment groups by some authors. Yamamoto et al12 classified the zygomatic arch fractures into 5 types according to the degree of displacement. In type 1, there is no displacement. Type 2 fractures are in a typical M shape, and there is a displacement with bone contact at all fracture lines. Displacement without bone contact at 1 fracture line is grouped as type 3. In type
FIGURE 3. A to C, Roller coaster maneuver.
FIGURE 4. A, Postoperative view of the elevated arch. B and C, The CT images before and after the operation.
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
2083
Pilanci et al
The Journal of Craniofacial Surgery
4, there is a displacement without bone contact at 2 fracture lines. Finally, in type 5, there is comminution or displacement without bone contact at 3 or more fracture lines. In this article, what we presented actually included the patients with only type 2 M-shaped fractures where a bony contact is still present. In types 3, 4, and 5 injuries, open reduction may be needed to reduce comminuted bone fragments, followed by fixation or stabilization to maintain their alignment.12 In other types of isolated zygomatic arch fractures, there is a lack of agreement on the treatment options. Numerous techniques have been reported for the closed reduction of zygomatic arch fractures, but the Gillies approach is the most common of all.4 Gillies et al4 proposed an incision within the temporal hair and a dissection of a plane underneath the deep temporal fascia for closed reduction of isolated zygomatic arch fractures. In a study with 105 zygomatic arch fractures treated using the Gillies temporal approach, 92% of the reductions were found to be successful.13 However, the Gillies approach has certain disadvantages. The long distance between the reduction zone and the access site as well as the risk for inserting the elevator in a wrong layer of the temporal fascia are some examples.4 In addition, this technique requires experience and specialized elevators. Finally, the middle temporal vein has been reported to be within the blunt maneuver area, potentially leading to a hazardous bleeding.14 Although epistaxis balloon catheter, Foley balloon catheter, and silicone nasogastric tube can be used successfully for unstable arch fractures, these may carry high infection risks because of the introduction of a foreign body into the affected area.15 In 1909, Keen6 described a personal approach that has become the preferred technique by some authors. In this technique, he described an intraoral approach to the zygomatic arch via a gingivobuccal sulcus incision. One of the main advantages of this technique is the absence of visible scars on the face. There is also minimal dissection and an excellent vector for reduction. However, it has certain disadvantages. Getting in contact with the intraoral mucosa and introducing oral flora into the infratemporal fossa may result in increased rates of infection. Special care is required to prevent infection. Masseter muscle bleeding may occur along with ocular injury if the instrument is placed too high. The restricted nutrition in the following days might be another disadvantage of the intraoral approach. Furthermore, we believe that extensive dissection of neighboring soft tissues, such as the buccal fat pad underneath the zygomatic arch, to gain access to the reduction zone is another drawback of this method. Zygomatic arch reduction is not limited to the previously mentioned techniques. For example, in cases where a laceration of the buccal skin is present below the affected zygomatic arch, hook reduction can also be chosen. A bone hook is introduced underneath the fractured arch through a laceration or an incision. A similar method where reduction is performed using a towel clamp to directly grasp the bone fragments has also been defined in the literature.7,8 However, these rather traumatic techniques might be insufficient in some cases because of the lack of direct visualization of the fracture site and reduction. The risks for damaging soft tissues and creating visible widened scars are possible serious risks. In addition, grasping the bone with sharp instruments may cause hemorrhage and a longlasting edema. Dingman and Natvig5 also described a closed reduction method in 1964 in which the lateral brow incision was used to introduce a urethral sound such as heavy elevator to reduce the arch. They reached the temporal fossa from the inner aspect of the zygoma and reduced the arch fracture. However, we were unable to find any evaluation of the clinical applications or outcomes of the method. Our approach was very similar to theirs, albeit with a different incision closer to the fracture. Thus, we were able to show the clinical results of such an approach.
2084
& Volume 24, Number 6, November 2013
We believe that the method we named roller coaster maneuver by a lateral orbital access is simple and effective for the reduction of a depressed M-shaped zygomatic arch fractures. This method offers several advantages including easy application under local anesthesia. This is mainly caused by the short distance between the incision site and the fracture line. Therefore, the fracture zone can be easily felt using the dissector. This feature is actually the main advantage over the Gillies approach. In the Gillies approach, the dissector may not be moved in all directions freely because of the vector of insertion. In addition, this approach carries less risk for infection in contrast to the Keen approach. Other risks such as facial nerve damage or direct trauma to the globe are eliminated. This method can be easily performed under local anesthesia or sedation in an emergency department or an operating room. However, the technique we described does have some drawbacks. The main disadvantage of this method is the scar placed in the lateral eyebrow, but the incision is small and almost always heals with a good scar in most patients (93%).The other disadvantage is the limited use of this technique in type 2 M-shaped arch fractures. In conclusion, the roller coaster maneuver with the lateral orbital approach may be another option for the reduction of zygomatic arch fractures. Although there are certain advantages, a visible scar is the main disadvantage. We believe that larger studies with a high number of patients may be required to prove the reliability of the procedure.
REFERENCES 1. Hwang K, Kim DH. Analysis of zygomatic fractures. J Craniofac Surg 2011;22:1416Y1421 2. Swanson E, Vercler C, Yaremchuk MJ, et al. Modified Gillies approach for zygomatic arch fracture reduction in the setting of bicoronal exposure. J Craniofac Surg 2012;23:859Y862 3. Moon SH, Lee JH, Oh DY, et al. Reduction of zygomatic fracture segment with intermaxillary fixation screw. J Craniofac Surg 2012;23:842Y844 4. Gillies HD, Kilner TP, Stone D. Fractures of the malar-zygomatic compound: with a description of a new x-ray position. Br J Surg 1927;14:651Y656 5. Dingman RO, Natvig P. Surgery of facial fractures. Philadelphia: Saunders, 1964:211Y243 6. Keen WW. Surgery: its principles and practice. Philadelphia; Saunders, 1909 7. Carter TG, Bagheri S, Dierks EJ. Towel clip reduction of the depressed zygomatic arch fracture. J Oral Maxillofac Surg 2005;63:1244Y1246 8. Manzon S, Choudhary N, Philbert R. Towel clip reduction of the depressed zygomatic arch fracture [comment]. J Oral Maxillofac Surg 2006;64:1323Y1324 9. Kaastad E, Freng A. Zygomatico-maxillary fractures. Late results after traction-hook reduction. J Craniomaxillofac Surg 1989;17:210Y214 10. Baek JE, Chung CM, Hong IP. Reduction of zygomatic fractures using the Carroll-Girard T-bar Screw. Arch Plast Surg 2012;39:556Y560 11. Iqbal HA, Chaudhry S. Choice of operative method for management of isolated zygomatic bone fractures; evidence based study. J Pak Med Assoc 2009;59:615Y618 12. Yamamoto K, Murakami K, Sugiura T, et al. Clinical analysis of isolated zygomatic arch fractures. J Oral Maxillofac Surg 2007;65:457Y461 13. Ogden GR. The Gillies method for fractured zygomas: an analysis of 105 cases. J Oral Maxillofac Surg 1991;49:23Y25 14. Longmore RB, McRae DA. Middle temporal veinsVa potential hazard in the Gillies’ Operation. Br J Oral Surg 1981;19:129Y131 15. El-Hadidy AM. The use of a Foley catheter in isolated zygomatic arch fractures. Plast Reconstr Surg 2005;116:853Y856
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
‘‘Roller Coaster Maneuver via Lateral Orbital Approach’’ for Reduction of Isolated Zygomatic Arch Fractures Ozgur Pilanci, MD,* Karaca Basaran, MD,* Asli Datli, MD,* and Samet Vasfi Kuvat, MD*Þ Abstract: Numerous techniques have been reported for the reduction of zygomatic arch fractures. In this article, we aimed to describe a technique we named as ‘‘roller coaster maneuver via lateral orbital approach’’ to closed reduction of the isolated-type zygomatic arch fractures. Surgical outcomes of 14 patients treated with this method were outlined. Key Words: Zygomatic arch fracture, closed reduction, lateral orbital approach, roller coaster (J Craniofac Surg 2013;24: 2082Y2084)
T
he zygomatic bone occupies an important position in the facial skeleton.1Y3 It plays a key role in determining facial width and acts as a major transverse buttress of the mid face. This bony component of the face is susceptible to trauma because of its prominent configuration. In fact, among fractures of the facial skeleton, the prevalence of zygomatic bone fractures is second only to those of the nasal bone.4,5 All zygomatic fractures comprise approximately 10% of isolated zygomatic arch fractures.6Y8 Arch fractures result in noticeable depression at the impact site. The mechanism of the injury usually involves a blow to the side of the face from a fist or an object or a fracture that develops secondary to occupational work or motor vehicle accident. In the literature, numerous techniques have been reported for the reduction of zygomatic arch fractures such as that of Gillies et al4 (temporal), that of Dingman and Natvig5 (lateral brow), Keen6 (intraoral) approaches or closed reduction with towel clip,7,8 bone hook,9 and Carroll-Girard bone screw.10 In this article, we present a simple and an effective method for the reduction of isolated zygomatic arch fractures, namely, the lateral orbital access.
MATERIALS AND METHODS Fourteen patients with type 2 isolated zygomatic arch fractures have been operated on with the previously mentioned procedure between May 2012 and January 2013. Approval of the ethics committee of the hospital was obtained, and informed consent was
From the *Bagcilar Research and Training Hospital; and †Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Faculty of Medicine, Istanbul, Turkey. Received May 23, 2013. Accepted for publication June 16, 2013. The authors report no conflicts of interest. Address correspondence and reprint requests to Ozgur Pilanci, MD, Eski Londra Asfalti, Emlak Konut Sitesi, A 5, Daire 21, Bahcelievler, Istanbul, Turkey; E-mail: [email protected] Copyright * 2013 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e3182a2430a
2082
taken from each participant. The inclusion criterion of the study was the presence of isolated zygomatic arch fractures. Patients with other zygomatic or facial fractures were excluded from the study for having a homogenous group. All patients except 1 were men, and the mean age was 35.7 (range, 21Y75). The injury was caused by an assault in 10 patients and traffic accidents in 4 patients. Five patients were treated on the day they had their injuries, whereas the remaining patients received surgical treatment within 3 days after the injury. In terms of symptoms, 4 patients had limited mouth openings. The remaining 10 patients complained of a depression on the arch area. None of the patients had a neurosensory disturbance, periorbital ecchymosis, malar depression, subconjunctival hemorrhage, or diplopia. Workup included preoperative and postoperative plain radiographs and axial plane computed tomography (CT).
Surgical Technique All patients were prepared in a supine position in the operating room. Preoperative markings included mainly the lateral brow access incision and displaced segments of the zygomatic arch pointing out to the depression palpated on the skin (Fig. 1). Under light sedation (2Y4 mg of midazolam), approximately 4 to 6 mL of 2% lidocaine with 1/160,000 adrenaline was infiltrated from the incision site down to the zygomatic arch and also to the tip of the type 2 fractured segment subperiosteally. A sharp dissection was performed with the help of no. 15 blade in all the layers including the periosteum of the lateral orbital rim. A curved periosteal elevator was inserted through the incision on the lateral edge of the lateral orbital rim (Fig. 2). A blunt closed subperiosteal dissection was then performed, sweeping over the bone from the posterolateral aspect of the orbital process of the zygomatic bone to the caudal surface of the medial fractured segment. After an adequate space was created underneath the center of the fracture, the bone was slightly elevated upward. This maneuver that we call ‘‘roller coaster’’ should proceed without interruption (Fig. 3). After reduction, the contralateral zygomatic arch was checked for comparison. After alignment of the segment was assured, the elevator was taken out precisely. The incision was closed with 2 single 6/0 polypropylene sutures (Fig. 4).
FIGURE 1. Preoperative marking.
The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 24, Number 6, November 2013
RESULTS The mean operative time beginning from the initiation of sedation until the end of wound closure was 5 minutes. All patients were discharged on the day of the surgery. The patients were advised to sleep in a supine position and protect their cheek area for 2 weeks. A nonsteroidal anti-inflammatory drug was prescribed upon discharge. The mean follow-up period was 7 months (range, 3Y13 mo). Postoperative evaluation included an occipitomental plain x-ray and an axial plane CT in addition to physical examination.
Roller Coaster Maneuver
Thirteen of the 14 patients had a complete recovery, and the zygomatic arch regained its original shape. In 1 patient, only a small improvement was observed. We attributed this situation to a small bone fragment running into the reduction zone when we checked the postoperative radiogram. The preoperative gagging of the mouth of the 4 patients returned to reference range. Functional and cosmetic results were excellent in all patients. None of the patients complained of a scar except for 1 patient. This patient was reassured, and the scar was handled with conservative measures.
DISCUSSION
FIGURE 2. The reduction of the fracture with lateral orbital incision.
The zygomatic bone occupies a prominent and important position in the facial skeleton. It plays a key role in providing contour and symmetry to the mid face. Zygomatic bone fractures are the second most common facial fractures after nasal bone fractures and cause a noticeable depression at the impacted site.4,11 Several classifications for arch fractures have been described. Some authors classify isolated zygomatic bone fractures using the degree of displacement. A 2-mm displacement of bone segments in radiographic evaluation has been used as a guide to classify patients into open and closed reduction treatment groups by some authors. Yamamoto et al12 classified the zygomatic arch fractures into 5 types according to the degree of displacement. In type 1, there is no displacement. Type 2 fractures are in a typical M shape, and there is a displacement with bone contact at all fracture lines. Displacement without bone contact at 1 fracture line is grouped as type 3. In type
FIGURE 3. A to C, Roller coaster maneuver.
FIGURE 4. A, Postoperative view of the elevated arch. B and C, The CT images before and after the operation.
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
2083
Pilanci et al
The Journal of Craniofacial Surgery
4, there is a displacement without bone contact at 2 fracture lines. Finally, in type 5, there is comminution or displacement without bone contact at 3 or more fracture lines. In this article, what we presented actually included the patients with only type 2 M-shaped fractures where a bony contact is still present. In types 3, 4, and 5 injuries, open reduction may be needed to reduce comminuted bone fragments, followed by fixation or stabilization to maintain their alignment.12 In other types of isolated zygomatic arch fractures, there is a lack of agreement on the treatment options. Numerous techniques have been reported for the closed reduction of zygomatic arch fractures, but the Gillies approach is the most common of all.4 Gillies et al4 proposed an incision within the temporal hair and a dissection of a plane underneath the deep temporal fascia for closed reduction of isolated zygomatic arch fractures. In a study with 105 zygomatic arch fractures treated using the Gillies temporal approach, 92% of the reductions were found to be successful.13 However, the Gillies approach has certain disadvantages. The long distance between the reduction zone and the access site as well as the risk for inserting the elevator in a wrong layer of the temporal fascia are some examples.4 In addition, this technique requires experience and specialized elevators. Finally, the middle temporal vein has been reported to be within the blunt maneuver area, potentially leading to a hazardous bleeding.14 Although epistaxis balloon catheter, Foley balloon catheter, and silicone nasogastric tube can be used successfully for unstable arch fractures, these may carry high infection risks because of the introduction of a foreign body into the affected area.15 In 1909, Keen6 described a personal approach that has become the preferred technique by some authors. In this technique, he described an intraoral approach to the zygomatic arch via a gingivobuccal sulcus incision. One of the main advantages of this technique is the absence of visible scars on the face. There is also minimal dissection and an excellent vector for reduction. However, it has certain disadvantages. Getting in contact with the intraoral mucosa and introducing oral flora into the infratemporal fossa may result in increased rates of infection. Special care is required to prevent infection. Masseter muscle bleeding may occur along with ocular injury if the instrument is placed too high. The restricted nutrition in the following days might be another disadvantage of the intraoral approach. Furthermore, we believe that extensive dissection of neighboring soft tissues, such as the buccal fat pad underneath the zygomatic arch, to gain access to the reduction zone is another drawback of this method. Zygomatic arch reduction is not limited to the previously mentioned techniques. For example, in cases where a laceration of the buccal skin is present below the affected zygomatic arch, hook reduction can also be chosen. A bone hook is introduced underneath the fractured arch through a laceration or an incision. A similar method where reduction is performed using a towel clamp to directly grasp the bone fragments has also been defined in the literature.7,8 However, these rather traumatic techniques might be insufficient in some cases because of the lack of direct visualization of the fracture site and reduction. The risks for damaging soft tissues and creating visible widened scars are possible serious risks. In addition, grasping the bone with sharp instruments may cause hemorrhage and a longlasting edema. Dingman and Natvig5 also described a closed reduction method in 1964 in which the lateral brow incision was used to introduce a urethral sound such as heavy elevator to reduce the arch. They reached the temporal fossa from the inner aspect of the zygoma and reduced the arch fracture. However, we were unable to find any evaluation of the clinical applications or outcomes of the method. Our approach was very similar to theirs, albeit with a different incision closer to the fracture. Thus, we were able to show the clinical results of such an approach.
2084
& Volume 24, Number 6, November 2013
We believe that the method we named roller coaster maneuver by a lateral orbital access is simple and effective for the reduction of a depressed M-shaped zygomatic arch fractures. This method offers several advantages including easy application under local anesthesia. This is mainly caused by the short distance between the incision site and the fracture line. Therefore, the fracture zone can be easily felt using the dissector. This feature is actually the main advantage over the Gillies approach. In the Gillies approach, the dissector may not be moved in all directions freely because of the vector of insertion. In addition, this approach carries less risk for infection in contrast to the Keen approach. Other risks such as facial nerve damage or direct trauma to the globe are eliminated. This method can be easily performed under local anesthesia or sedation in an emergency department or an operating room. However, the technique we described does have some drawbacks. The main disadvantage of this method is the scar placed in the lateral eyebrow, but the incision is small and almost always heals with a good scar in most patients (93%).The other disadvantage is the limited use of this technique in type 2 M-shaped arch fractures. In conclusion, the roller coaster maneuver with the lateral orbital approach may be another option for the reduction of zygomatic arch fractures. Although there are certain advantages, a visible scar is the main disadvantage. We believe that larger studies with a high number of patients may be required to prove the reliability of the procedure.
REFERENCES 1. Hwang K, Kim DH. Analysis of zygomatic fractures. J Craniofac Surg 2011;22:1416Y1421 2. Swanson E, Vercler C, Yaremchuk MJ, et al. Modified Gillies approach for zygomatic arch fracture reduction in the setting of bicoronal exposure. J Craniofac Surg 2012;23:859Y862 3. Moon SH, Lee JH, Oh DY, et al. Reduction of zygomatic fracture segment with intermaxillary fixation screw. J Craniofac Surg 2012;23:842Y844 4. Gillies HD, Kilner TP, Stone D. Fractures of the malar-zygomatic compound: with a description of a new x-ray position. Br J Surg 1927;14:651Y656 5. Dingman RO, Natvig P. Surgery of facial fractures. Philadelphia: Saunders, 1964:211Y243 6. Keen WW. Surgery: its principles and practice. Philadelphia; Saunders, 1909 7. Carter TG, Bagheri S, Dierks EJ. Towel clip reduction of the depressed zygomatic arch fracture. J Oral Maxillofac Surg 2005;63:1244Y1246 8. Manzon S, Choudhary N, Philbert R. Towel clip reduction of the depressed zygomatic arch fracture [comment]. J Oral Maxillofac Surg 2006;64:1323Y1324 9. Kaastad E, Freng A. Zygomatico-maxillary fractures. Late results after traction-hook reduction. J Craniomaxillofac Surg 1989;17:210Y214 10. Baek JE, Chung CM, Hong IP. Reduction of zygomatic fractures using the Carroll-Girard T-bar Screw. Arch Plast Surg 2012;39:556Y560 11. Iqbal HA, Chaudhry S. Choice of operative method for management of isolated zygomatic bone fractures; evidence based study. J Pak Med Assoc 2009;59:615Y618 12. Yamamoto K, Murakami K, Sugiura T, et al. Clinical analysis of isolated zygomatic arch fractures. J Oral Maxillofac Surg 2007;65:457Y461 13. Ogden GR. The Gillies method for fractured zygomas: an analysis of 105 cases. J Oral Maxillofac Surg 1991;49:23Y25 14. Longmore RB, McRae DA. Middle temporal veinsVa potential hazard in the Gillies’ Operation. Br J Oral Surg 1981;19:129Y131 15. El-Hadidy AM. The use of a Foley catheter in isolated zygomatic arch fractures. Plast Reconstr Surg 2005;116:853Y856
* 2013 Mutaz B. Habal, MD
Copyright © 2013 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
