CLINICAL PAPER

Single Buccal Sulcus Approach With Fluoroscan Assistance for the Management of Simple Zygomatic Fractures Chih-Hao Chen, MD,* Shih-Hsuan Mao, MD,* Victor Bong-Hang Shyu, MD,* and Chien-Tzung Chen, MD*† Background: Zygomatic fractures are associated with functional and aesthetic problems. The purpose of this study was to evaluate the adequacy of management and the surgical satisfaction of patients with simple zygomatic fractures treated through a single buccal sulcus approach and fluoroscan assistance. Methods: Between 2008 and 2012, 42 patients with simple zygomatic fractures were included in the study. The surgical procedure was performed through a single buccal sulcus incision. The fracture sites were aligned under direct vision and fluoroscan assistance and stabilized with rigid internal fixation. The adequacy of reduction was evaluated based on postoperative plain radiographic films and computed tomographic scans using mirror image analyses. The satisfaction of functional and aesthetic results was also evaluated subjectively using a visual analog scale during follow-up. Results: Twenty-nine male and thirteen female patients with a mean age of 33.2 years were evaluated. Motorcycle crashes (78.6%) were the most common mechanism of trauma. Based on follow-up imaging studies, 2 patients had inadequate reduction of zygomatic body, and there was a slight depression of the zygomatic arch in one patient. Ninety-three percent (39/42) of patients had satisfactory results, although one patient complained of malar asymmetry and another felt a depression in the arch area. Two patients complained of persistent hypesthesia during follow-up at 6 months. Conclusions: Our results suggest that a single buccal sulcus approach without lower eyelid or lateral eyebrow incision in the repair of simple fractures of the zygoma can be achieved with high patient satisfaction if the reduction and fixation are adequate and stable. Key Words: zygomatic fracture, buccal sulcus approach, fluoroscan, visual analog scale (Ann Plast Surg 2015;74: S80–S84)

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he zygoma is one of the most frequently fractured bones on the face. It is a tetrapod-shaped bone located in the midfacial skeleton and is of much clinical importance. The zygoma defines the malar prominence, which contributes to facial contour. It also plays an important role in mastication by providing an origin to the masseter muscle and protecting the temporalis muscle and coronoid process of the mandible.1 Therefore, inaccurate 3-dimensional restoration of the original configuration of the zygomatic complex will consequently result in unfavorable functional and aesthetic results. Numerous surgical techniques for the repair of zygomatic fractures have been described. Generally, wide exposure through lateral

Received September 19, 2014, and accepted for publication, after revision, December 17, 2014. From the *Craniofacial Research Center, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Linkou, Chang Gung University College of Medicine, Taoyuan, Taiwan, ROC; and †Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, Keelung, Taiwan, ROC. Conflicts of interest and sources of funding: none declared. Each author has contributed original work to the article and adhered to the ethical requirements as outlined by the Journal. Reprints: Chien-Tzung Chen, MD, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital at Keelung, Chang Gung University College of Medicine, 222 Maijin Rd, Keelung 20401, Taiwan, ROC. E-mail: [email protected]. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0148-7043/15/7402–S080 DOI: 10.1097/SAP.0000000000000469

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brow, subciliary, or transconjunctival, and intraoral incisions enabled extensive exposure for reduction and rigid fixation of the zygoma.2–4 However, multiple incisions present with both potential benefits and complications. Improvements in diagnostic imaging have permitted the use of limited incision procedures, especially for simple fractures. The purpose of this study was to quantitatively evaluate patients with simple zygomatic fractures treated through a single buccal sulcus incision with fluoroscan assistance and to determine the adequacy of reduction, stability of fixation, and patients' satisfaction postoperatively.

MATERIALS AND METHODS The patients treated for isolated, unilateral, displaced, and noncomminuted zygomatic fractures at the Chang Gung Memorial Hospital by the same surgeon between January 1, 2008, and December 31, 2012, were retrospectively reviewed. The following data were obtained from chart records: age, sex, mechanism of trauma, side of the injury, radiographic studies obtained preoperatively and postoperatively, details of the repair, complications, and length of follow-up. Zygomatic fractures were confirmed and documented on plain radiographic films, such as Waters and submentovertex views. Computed tomographic (CT) scan was routinely performed to depict the extent of fracture site and degree of displacement for determination of severity of the zygomatic fracture. In this study, the definition of “simple” zygomatic fracture referred to the fracture line interrupting the lateral and inferior orbital rim at 2 points only, disregarding the fracture patterns at zygomatic arch and zygomaticomaxillary buttress (Fig. 1). Comminuted or segmented fractures of the orbital rims and fractures of internal orbital walls requiring orbital reconstruction were excluded.

Surgical Technique Under general anesthesia with oral intubation, local anesthetic was infused into the upper buccal sulcus. A horizontal incision was made in the upper buccal sulcus for a distance of approximately 5 cm over the anterior maxillary wall. Subperiosteal dissection was then performed to expose the anterior maxillary wall and zygomatic body until the inferior orbital rim was exposed. During the procedure, the infraorbital nerve was also identified and well protected. The anterior portion of the masseter muscle was partially detached from its origin to facilitate reduction and fixation. A Dingman elevator was oriented under the junction between zygomatic body and arch. As an assistant stabilized the head, the depressed zygoma was elevated and manipulated into its proper anatomic alignment by assessing the infraorbital rim and zygomaticomaxillary buttress. The elevator was angled more posteriorly to elevate the depressed segmental arch fracture as needed. The C-arm of the fluoroscan was positioned over the patient's head with the axis along a tangent transversing the zygomatic arch. The x-ray tube was placed under the mandible, and the target tube was placed lateral to the ipsilateral cranial vertex.5 Under dynamic visualization, adequate reduction of the zygomatic arch was confirmed immediately (Fig. 2). The fluoroscopic image from the uninjured side was also examined for comparison to achieve a more symmetric result. Once the entire zygomatic complex was properly reduced, osteosynthesis was performed using a miniplate (2.0 mm) on the zygomaticomaxillary buttress. Further fixation at the anterior maxillary wall was performed if necessary to enhance the stability of comminuted fractures of the anterior Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015

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Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015

FIGURE 1. Simple fracture indicates the fracture line interrupting the lateral and inferior orbital rim at 2 points only (arrows). The arrowhead indicates fracture of zygomatic arch.

maxillary wall or the zygomaticomaxillary buttress. The fluoroscan was then used to recheck the adequacy of arch reduction. Finally, the sulcus incision was closed with a catgut suture. Patients were nursed on the side opposite to the fracture during recovery and advised to avoid direct force over the lesion site.

Outcomes Assessment The adequacy of reduction was determined by assessing the postoperative plain films including both Waters and submentovertex views taken on the second day after surgery. Comparisons were made with the contralateral side and recorded in millimeters of difference. On the Waters view, approximation of the frontozygomatic suture, contour of the infraorbital rim, and alignment of the zygomaticomaxillary buttress were assessed. On the submentovertex film, the projection of the malar eminence was assessed. The vertical portion of a clear T-ruler was aligned along midline structures within the cranium, and the horizontal limb of the Twas aligned with the uninjured malar prominence (Fig. 3). The distance between the 2 limbs was measured, and any asymmetry on the radiographs measuring less than 2 mm in magnitude was considered an acceptable reduction of the zygoma.6,7 The contour of the zygomatic arch was assessed in relation to the opposite, uninjured side. The injured zygomatic arch was classified as aligned, bowed laterally, or bowed posteriorly, with no measurement made for quantification. The immediate postoperative plain films were compared with those obtained at least 3 months after surgery to determine the stability of fixation. The coronal and axial CT scans for outcome analysis were

Single Approach for Simple Zygomatic Fractures

FIGURE 3. Distance between bone and line on injured and uninjured side on submentovertex view.

routinely performed at 6 months after operation. Any differences in malar projection or arch contour between the immediate postoperative submentovertex films and follow-up axial CT scans were also recorded. Each patient was asked to complete a questionnaire at follow-up 6 months after surgery. The questionnaire focused on satisfaction with mastication, cheek sensation and aesthetic result, and their overall satisfaction with the reconstruction process. Patients' satisfaction was scored using a visual analog scale. The scale consisted of a 10-cm line with both ends labeled as extremes of the issue in question. The patients were then asked to mark an “X” along the line at the point that they felt most closely represented their level of satisfaction with that particular issue.

RESULTS Over a 5-year period, data on 305 patients with zygomatic fractures treated by one senior surgeon were collected. After exclusion of patients with other associated facial bone fractures, only 65 patients received the same simple buccal sulcus incision approach as previously detailed. Of these, after excluding patients with incomplete records, 42 patients with unilateral, isolated, displaced, and noncomminuted zygomatic fractures were available for analysis. The group comprised of 29 male and 13 female patients. The mean age of the patients was 33.2 years, ranging from 17 to 69 years. The mean follow-up was 8.7 months, with a range of 7 to 15 months. Motorcycle crashes accounted for 78.6% of the fractures, followed by motor vehicle crashes (11.9%) and falls (7.1%). The left-toright ratio of the fractures was 22:20. Malar depression, trismus, and cheek numbness were the most common clinical presentations on initial examination; no patient had significant ophthalmic findings. All patients underwent upper buccal sulcus elevation for depressed fractures of the zygoma. Thirteen and 29 patients were found

FIGURE 2. A, B, Correlation between fluoroscopic images and axial CT scans on zygomatic arch is excellent. The arrow indicates the fracture site of zygomatic arch. C, Intraoperative view of fluoroscan after reduction. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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with segmental and simple zygomatic arch fractures, respectively. Thirtythree patients were treated by one-point fixation at the zygomaticomaxillary buttress, and 9 patients underwent further fixation at the anterior maxillary wall to enhance the stability. Based on the criteria set forth in the outcomes assessment section previously stated, 2 patients showed asymmetries or malalignments greater than 2 mm of malar prominence. With the assistance of fluoroscan, all patients obtained good alignment of arch reduction, except one patient with segmental zygomatic arch fracture showed slightly inadequate reduction (>2 mm) of arch owing to lateral rotation of zygomatic complex. Hence, 39 (93%) of 42 patients had good alignment postoperatively with discrepancy of less than 2 mm. For assessment of stability of fixation, no patient had any perceptible change in zygoma position. As for functional recovery, all 42 patients returned to their preinjury mouth opening subjectively with a mean maximal mouth opening of 41.5 ± 2.1 mm. Chewing function also recovered progressively without any disturbance. The visual analog scales were obtained and measured with a caliper in millimeters. Measurements were converted to a satisfaction percentage on a scale from zero to 100%. The mean patients' satisfaction rates with mastication, aesthetic results, and sensation were 97.6%, 83.3%, and 64.3%, respectively. The overall satisfaction with the zygomatic fracture repair at follow-up was 85.7%.

CASE REPORT A 21-year-old man sustained right facial assault injury and resulted in a zygomatic fracture. Through single buccal sulcus incision, his simple zygomatic fracture was reduced under fluoroscan assistance and was stabilized with one 2.0-mm miniplate at the zygomaticomaxillary buttress and another one at the anterior maxillary wall to enhance the stability. The postoperative result at 1 year showed good facial symmetry (Fig. 4).

DISCUSSION To achieve anatomic reduction, full exposure of all articulations of the zygoma and rigid fixation of all possible buttresses are the most

convincing approaches theoretically. Perhaps the most important principle is adequate reduction; otherwise, the zygoma is only stabilized in an unreduced position. Many approaches have been proposed for management of zygomatic fractures, ranging from reduction without direct visualization of alignment at any fracture site to wide surgical access with direct visual alignment of all articulating buttresses and rigid fixation using miniplates. The efficacy between extensive open reduction and rigid fixation techniques and limited approaches, such as closed reduction and the use of wire fixation has been debated. Approach through lateral brow, subciliary or transconjunctival, and intraoral incisions are commonly used by most surgeons for multiple-point fixation, affording better visualization for appropriate introduction of plates and screws.8 However, wide exposure with multiple incisions such as this may potentially present adverse effects, such as scarring, soft tissue atrophy, and lower eyelid ectropion and entropion.9,10 Indeed, complications arising from the incisions performed were the reason for our initial reconsiderations of the necessity of multiple incisions to approach simple zygoma fractures. There are 5 articulations that can be used to guide anatomic reduction, from best to worst, including the zygomaticomaxillary buttress, the lateral orbital wall, the infraorbital rim, the zygomatic arch, and the zygomaticofrontal suture.11 From preoperative CT imaging, the zygomaticofrontal suture typically has minimal displacement in simple fractures. The alignment of the infraorbital rim and the zygomaticomaxillary buttress can be evaluated under direct visualization through a buccal sulcus incision. The adequacy of zygomatic arch reduction can then be assessed and adjusted under fluoroscan. Theoretically, reduction of 3 of 5 potential checkpoints will correct both the translation and rotation of the zygoma in 3-dimensional space. Mobile fluoroscopic devices have been used in the field of orthopedic surgery for a long time and can be beneficial to maxillofacial trauma surgeon. The main concern of this equipment is the radiation exposure to patients, surgeons, and nurses. Badman et al12 documented the safety of a fluoroscan and strongly advised the use of this equipment whenever clinically feasible. Compared with traditional plain films and CT scans, the fluoroscan is also much less expensive. From our experience, the correlation between fluoroscopic images and CT scans on

FIGURE 4. A, View of patient showing right malar depression preoperatively. B, Preoperative radiograph showing right zygomatic complex fracture. C, Computed tomographic scan 6 months postoperatively showing stable fixation. D, Patient showing good symmetry 1 year postoperatively. S82

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Annals of Plastic Surgery • Volume 74, Supplement 2, May 2015

zygomatic arch is excellent. Moreover, visualization of arch alignment under the fluoroscan can help achieve a more accurate reduction during surgery, especially for correction of rotational deformities, and provide a real-time feedback until designation is reached. The mobile fluoroscopic devices are now routinely used in the management of simple zygoma fractures in our practice to assist reduction due to its portability, convenience, and safety. With respect to fixation, many investigators have proposed that multiplate fixation would provide satisfactory postoperative results in preventing late displacement of the zygoma.13,14 However, multiplate fixation requires a more extensive approach and periosteal stripping, which may increase the inherent morbidity of the procedure. According to reports by Tarabichi15 and Fujioka et al,16 in which the zygoma fractures were not comminuted or did not involve the orbital floor, no significant difference in the postoperative movement of the zygoma occurred between one-plate and multiplate fixation groups. The results suggested that one-plate fixation was sufficiently rigid when the fracture was not comminuted and anatomic reduction was achieved. In our study, we preferred to apply at least one 2.0-mm titanium plate at the zygomaticomaxillary buttress. The stability of the reduced zygoma can be determined by the Dingman elevator at the time of surgery. No significant movement on follow-up images in comparison with immediate postoperative images supported this approach. The zygoma plays an important role in mastication by providing an origin for the masseter muscle. However, the strong masseter muscle is the major warping force acting on the fractured zygoma. The masseter muscle may interfere with mobilization and reduction and contribute to relapse in an unstable fixation.11 The pull of the masseter muscle can be overcome by either chemical paralysis or partial detachment of the anterior portion of the masseter from the zygoma. We prefer the latter method of weakening the pull force not only to facilitate mobilization and reduction of the zygoma but also to prevent early relapse of the fixation. Although the mastication force should be decreased for several weeks after surgery, all patients in our study group returned to their preinjury masticatory functions gradually. The best point for rigid fixation of the zygoma is the zygomaticomaxillary buttress because it provides a direct antagonist to the pulling force of the masseter muscle. Although the vector of plating is not perfect against the pulling force, compared to the other fixation points, we believe that the zygomaticomaxillary buttress is the optimal site. In addition, plating at the zygomaticomaxillary buttress is rarely palpable because of the thick cheek tissues. Aesthetic deformity is one of the surgical indications for zygomatic fracture repair. However, most surgeons focus mainly on the bony part of the fracture repair and neglect the subjective assessment of appearance from the patient. This is most often due to the surgeon being unable to realize the relationship between the bone and soft tissues. The visual analog scale has been used successfully for measuring pain intensity and as an alternative method for assessing patients' satisfaction in our study. Results using the scale were measured in millimeters, with as many as 101 points evaluated. The high number of response categories makes the visual analog scale more sensitive to small changes in opinion than conventional grading systems (ie, verbal graphic or numerical graphic rating scales).17 According to the criteria mentioned in the outcomes assessment section, 2 patients had asymmetry or misalignment greater than 2 mm on imaging studies. However, only one of the 2 patients complained of an observable asymmetry in the facial profile; the other patient who presented with thick soft tissues was satisfied with the result. On the other hand, one 62-year-old female patient who was evaluated as “adequate reduction” on imaging study complained of slight bulginess in the arch area. The relative old age of the patient with thin soft tissues covering the area might explain the result. Although good results come from adequate bony reduction with stable fixation, soft tissues may play a certain role in contributing to the final appearance. © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Single Approach for Simple Zygomatic Fractures

Infraorbital nerve dysfunction is one of the most common presenting symptoms in zygomatic fractures. Most patients will recover gradually by 6 months, and the incidence of long-term deficits has been variably reported from 10% to 50%.18–22 A highly significant beneficial effect on nerve function was noted when plates were used to stabilize fractures compared to fractures that were reduced without fixation.23 Of 15 patients who presented initially with the complaint of cheek numbness preoperatively, only two of them still complained of persistent hypesthesia during follow-up at 6 months. Although most of the patients improved gradually after surgery, the slow recovery may explain the relative low satisfaction rate regarding sensation (64.3%), and which might potentially influence the overall satisfaction of patients. According to the results of the current study and our experience, the single buccal sulcus incision approach to simple zygomatic fractures not only creates adequate exposure for anatomic reduction and stable fixation but also provides access for arch reduction to achieve a more accurate alignment of the zygoma under fluoroscan assistance. In addition, through the same incision, the infraorbital nerve can be identified, which allows for decompression if the nerve is entrapped by fractured bone. However, comminuted fractures of the zygoma, segmented fractures of orbital rim, or blowout fractures of the orbital walls require more aggressive exposure, for which lower eyelid or even coronal incisions should be considered. From preoperative CT scans, one can determine which type of fracture should be treated more aggressively or which may even require orbital reconstruction.

CONCLUSIONS Zygomatic fractures can be associated with functional and aesthetic problems. Many treatment strategies had been proposed to obtain satisfactory results. Based on the results of the current study, we strongly suggest that isolated, simple fractures of the zygoma can be approached through a single buccal sulcus incision with fluoroscan assistance to achieve adequate reduction and stable fixation at the zygomaticomaxillary buttress. Further incisions with multipoint fixations should probably be reserved for patients with significant comminution of the orbital rim, zygomatic body, or with associated orbital fractures, which require reconstruction. REFERENCES 1. Czerwinski M, Martin M, Lee C. Quantitative topographical evaluation of the orbitozygomatic complex. Plast Reconstr Surg. 2005;115:1858–1862. 2. Rohrich RJ, Hollier LH, Watumull D. Optimizing the management of orbitozygomatic fractures. Clin Plast Surg. 1992;19:149–165. 3. 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. 1995;80:624–628. 4. Covington DS, Wainwright DJ, Teichgraeber JF, et al. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. 1994;37:243–248. 5. Chen RF, Chen CT, Chen CH, et al. Optimizing closed reduction of nasal and zygomatic arch fractures with a mobile fluoroscan. Plast Reconstr Surg. 2010;126: 554–563. 6. Ellis E 3rd, Kittidumkerng W. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 1996;54:386–400. 7. Burcal RG, Laskin DM, Sperry TP. Recognition of profile change after simulated orthognathic surgery. J Oral Maxillofac Surg. 1987;45:666–670. 8. Yonehara Y, Hirabayashi S, Tachi M, et al. Treatment of zygomatic fractures without inferior orbital rim fixation. J Craniofac Surg. 2005;16:481–485. 9. Manson PN, Ruas E, Iliff N, et al. Single eyelid incision for exposure of the zygomatic bone and orbital reconstruction. Plast Reconstr Surg. 1987;79:120–126. 10. Manson PN. Analysis of treatment for isolated zygomaticomaxillary complex fractures. J Oral Maxillofac Surg. 1996;54:386–400; discussion 400–401. 11. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg. 2007;120:5S–15S.

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12. Badman BL, Rill L, Butkovich B, et al. Radiation exposure with use of the mini-C-arm for routine orthopaedic imaging procedures. J Bone Joint Surg Am. 2005;87:13–17. 13. Holmes KD, Matthews BL. Three-point alignment of zygoma fractures with miniplate fixation. Arch Otolaryngol Head Neck Surg. 1989;115:961–963. 14. Karlan MS, Cassisi NJ. Fractures of the zygoma. A geometric, biomechanical, and surgical analysis. Arch Otolaryngol. 1979;105:320–327. 15. Tarabichi M. Transsinus reduction and one-point fixation of malar fractures. Arch Otolaryngol Head Neck Surg. 1994;120:620–625. 16. Fujioka M, Yamanoto T, Miyazato O, et al. Stability of one-plate fixation for zygomatic bone fracture. Plast Reconstr Surg. 2002;109:817–818. 17. Losken A, Mackay GJ, Bostwick J 3rd. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108:361–369. 18. Jungell P, Lindqvist C. Paraesthesia of the infraorbital nerve following fracture of the zygomatic complex. Int J Oral Maxillofac Surg. 1987;16:363–367.

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19. Taicher S, Ardekian L, Samet N, et al. Recovery of the infraorbital nerve after zygomatic complex fractures: a preliminary study of different treatment methods. Int J Oral Maxillofac Surg. 1993;22:339–341. 20. Nordgaard JO. Persistent sensory disturbances and diplopia following fractures of the zygoma. Arch Otolaryngol. 1976;102:80–82. 21. De Man K, Bax WA. The influence of the mode of treatment of zygomatic bone fractures on the healing process of the infraorbital nerve. Br J Oral Maxillofac Surg. 1988;26:419–425. 22. Zachariades N, Papavassiliou D, Papademetriou I. The alterations in sensitivity of the infraorbital nerve following fractures of the zygomaticomaxillary complex. J Craniomaxillofac Surg. 1990;18:315–318. 23. Benoliel R, Birenboim R, Regev E, et al. Neurosensory changes in the infraorbital nerve following zygomatic fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2005;99:657–665.

© 2015 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

Single buccal sulcus approach with fluoroscan assistance for the management of simple zygomatic fractures.

Zygomatic fractures are associated with functional and aesthetic problems. The purpose of this study was to evaluate the adequacy of management and th...
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