Treatment of 813 Zygoma-Lateral Orbital Complex Fractures New

Aspects

Markus Zingg, MD, DMD; Khalid Chowdhury, MD, FRCSC; Kurt L\l=a"\drach,MD, DMD; Franz Sutter, DMD; Joram Raveh, MD, DMD

\s=b\ A 10-year experience with surgical treatment of 813 zygomalateral orbital complex fractures is reviewed. Regardless of the type or severity of the fracture pattern, concomitant fractures of the orbital floor and rim were approached exclusively through the transconjunctival approach without a lateral canthotomy. The advantages of this approach compared with the subciliary access are the avoidance of a visible scar and markedly reduced incidence of postoperative lower eyelid complications such as ectropion and edema. Implants of lyophilized dura or cartilage and autogenous bone were used to reconstruct orbital floor defects. Malar asymmetry is a frequent complication of zygoma fractures resulting from inadequate three-dimensional reduction. Methods for accurate reduction and stabilization, indications for closed and open reduction, and management of the fractured infraorbital rim are emphasized. The indications for miniplates vs wire ligatures for the infraorbital rim are discussed. Long\x=req-\ term follow up and evaluation of the results with regard to the fracture pattern, complications, maxillary sinus dysfunction, and facial and orbital symmetry are

presented. (Arch Otolaryngol Head Neck Surg. 1991;117:611-622

zygomatic Theponent

bone is a key com¬ of structural facial es¬ thetics because it constitutes the prominence of the "cheekbone." Be¬ cause of its prominent and exposed lo¬ cation the zygoma or malar bone is Accepted for publication July 31,1990.

From the Division of Craniomaxillofacial SurDepartment of Otolaryngology, University Hospital, Bern, Switzerland (Drs Zingg, Chowdhury, Vuillemin, L\l=a"\drach,and Raveh), and the Research Center, Institute Straumann AG, Waldenburg, Switzerland (Dr Sutter). Reprint requests to Division of Craniomaxillofacial Surgery, Department of Otolaryngology, Inselspital, Bern, Switzerland CH-3010 (Dr gery,

Raveh).

Thierry Vuillemin, MD, DMD;

to fractures in fa¬ cial trauma. Failure to achieve ade¬ quate and correct reduction of dis¬ placed zygoma fractures can result in

highly susceptible

delayed complications.13 Secondary correction of complications, such as enophthalmos or malar asymmetry, is fraught with difficulties and they are best prevented.4'7 Therefore, the goal of treatment for zygoma fractures is to restore the pre-injury facial skeletal

configuration, while preventing de¬ layed visual disturbances and cosmetic deformity from developing. Tech¬ niques for accurate closed or open re¬ duction, and indications for osteosynthesis

or

lighted.

wire

ligatures

are

also

high¬

Concomitant fractures of the orbital floor and rim are common with zygoma fractures. The transconjunctival ac¬ cess to the orbital floor is a well known procedure.813 Yet, this approach enjoys limited use for simple and isolated or¬ bital floor fractures. For the majority of comminuted and multifragment fractures involving the body of the zy¬ goma or infraorbital rim, a lower eye¬ lid subciliary approach, often with a lateral canthotomy, is generally preferred.14'20 Although the subciliary approach is considered cosmetically "acceptable" it has the undesirable ef¬ fect of creating an often visible facial scar. Additional disadvantages of the

subciliary access are ectropion or entropion and persistent edema of the lower eyelid, resulting from dissection of the inferior portion of the orbicu¬ laris ocularis and injury to the lym¬ phatic vessels thus impairing drain¬ age.

The arguments

junctival concern

against

a

transcon¬

focus primarily on about limited exposure that access

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apparently makes accurate reduction and osteosynthesis of displaced in¬ fraorbital rim fragments difficult or impossible.111421 Our extensive experi¬

ence contradicts this and other con¬ ventional concepts in managing zy¬ goma and infraorbital rim fractures. The purpose of this article is to de¬ scribe our methods for the manage¬ ment of zygoma fractures and analyze their efficacy by evaluating the func¬ tional and esthetic results and compli¬ cations.

PATIENTS AND METHODS

During the 10-year period between 1978 and 1988, 813 zygoma-lateral orbital com¬ plex fractures were surgically treated and followed up postoperatively for a minimum of 1 and a maximum of 5 years by the De¬ partment of Craniomaxillofacial Surgery and Otolaryngology at the University Hos¬ pital in Bern (Switzerland). Preoperative ophthalmology consultation is desirable and the patients were subsequently also followed by the ophthalmology depart¬ ment. Standard radiographs including Caldwell, Waters, and submentovertex views were obtained in all patients preop¬ eratively. For more extensive fractures of the orbit and midface these were supple¬ mented by computed tomographic scan of the orbit, in both the axial and coronal planes. The following findings, based on clinical and radiological assessment, were consid¬ ered indications for urgent surgical inter¬ vention: (1) signs of orbital compression such as increasing exophthalmos or devel¬ opment of the orbital apex syndrome with or without optic nerve involvement mani¬ fested by progressive diminution of visual acuity. Deferral of surgery in such cases may lead to irreversible damage with per¬ manent loss of vision despite the use of high-dose steroids.2223 (2) Patients with clinical and radiological evidence of en-

trapped periorbital tissue or extraocular muscles. For these cases surgical interven¬ tion was preferably within 24 hours. Anti¬ biotic therapy, beginning intraoperatively, was maintained for 8 days with amoxicillin combined with clavulanacid (Augmentin, Beecham, Bern, Switzerland). Treatment Modalities Closed Reduction.—This was successfully attempted in 149 (18%) highly selected simple zygomatic fractures without exten¬ sive disruption of the orbital floor and rim as determined by clinical and radiographie assessment (Fig 1). Prolapse or incarcera¬

tion of orbital contents must be excluded preoperatively, since this would be a con¬ traindication to closed reduction alone. Open Reduction.—Indications for open re¬ duction were as follows: multifragmentary fractures involving the body of the zygoma or zygomaticomaxillary buttress, as well as the infraorbital rim and orbital floor. Ad¬ ditionally, insufficient stability following attempted closed reduction was also an in¬ dication for proceeding with open reduc¬ tion.

Surgical Technique Closed reduction is performed by a Jshaped curved hook elevator inserted through an intraoral access or a stab inci¬ sion just below the arch of the zygoma (Fig 1). The elevator is then engaged directly under the body of the zygoma and traction is applied to reduce the fracture. The site of insertion for the elevator hook depends on the fracture configuration and the force vectors required for reduction. For exam¬ ple, in simple distocaudal dislocations of the zygoma an intraoral insertion usually enables advancement of the zygoma for¬ ward and into the correct reduced position. But, if the fractured zygoma is displaced distally with medial collapse, then lateral traction will need to be applied to the body and arch of the zygoma. Therefore, in this instance a preauricular insertion of the el¬ evating hook is more appropriate (Fig 1). Injury to the facial nerve can be avoided if (1) the hook is inserted anterior to the ar¬ ticulate eminence of the temporomandibular joint, but not too close to the body of the zygoma. No facial nerve branches run in between the two points. (2) Before applying lateral traction one must be aware of the fact that the hook must be engaged under¬ neath the arch and/or the body of the zygo¬ ma. If the hook is not adequately engaged it may slide along the surface of the body of the zygoma thus damaging the nerve branches. If these guidelines are strictly followed no injury to the nerve will occur. Inadequate three-dimensional reduction or instability with digital pressure following

Fig 1.—Left, Insertion of hook for reduction of zygoma fracture. Cross-hatched area should be avoided to prevent penetration into the sinus or orbit. Right, External insertion of hook (H) for frac¬ ture reduction (see Surgical Technique section). reduction mandates proceeding with open reduction. Open reduction of dislocated and multifragment zygoma-lateral orbital complex fractures (shown in Figs 2 through 4) were approached as follows: (1) lateral intrabrow incision for the frontozygomatic fractures; (2) an intraoral (buccal) approach for the zygomaticomaxillary buttress area; (3) a transconjunctival approach for exposure of the infraorbital rim and orbital floor; and (4) where extensive comminuted nasoethmoid complex or f rontobasal fractures were also present, a coronal flap exposure is uti¬ lized in concert with a transconjunctival access for the orbital floor and rim. The transconjunctival approach is part of the regular resident training program with particular caution paid to the tarsal plate, cornea, and lacrimal duct. Initially, the zy¬ goma is reduced and held in place with a hook elevator, while the fracture borders are aligned and the three-dimensional as¬ pects of the reduction are evaluated. Place¬ ment of a temporary wire ligature at the frontozygomatic fracture site helps to maintain this position. Next, the infraor¬ bital rim and orbital floor, up to the apex, are exposed, and the alignment of the zygo¬ maticomaxillary buttress can be assessed through a buccal approach. Note that a transconjunctival approach was used exclu¬ sively for access to the infraorbital rim and orbital floor regardless of the fracture se¬ verity or displacement (Fig 2, center left and right and 3). This exposure permits op¬ timal reduction of even major multifragment disruptions of the orbital floor and rim. Even tiny infraorbital rim fragments are saved and included while the fracture borders are meticulously adapted (Fig 3, bottom right) and wedged in. Only this cor¬ rect repositioning of fragments can provide the exact reproduction of the pretraumatic

adequate

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three-dimensional esthetic relations at the time of primary surgery. Preservation of such small fragments is preferable to, and in contrast with, simple primary bone grafting. Even minor changes in the size, angulation, or configuration of this area may produce relatively marked displace¬ ment of the malar prominence. Alignment and repeated inspection of both surfaces of the lateral orbital wall and all the remaining buttresses is performed. Next, the initial frontozygomatic wire liga¬ ture is replaced with a titanium miniplate for the sake of enhanced stability. The pol¬ icy of the senior author (J.R.) is to restrict and minimize the utilization of allomateri-

als, including miniplates. Therefore, a miniplate is applied to the zygomaticomaxillary buttress area only if alignment of the

buttress cannot be maintained or if the stability of the achieved three-dimensional reduction is questionable. Following this three-dimensional reduction and fixation, the zygomatic arch is repositioned with the help of a hook elevator inserted below the arch. Lateral traction enables the correct repositioning as the arch is located in be¬ tween both the superficial and the deep fas¬ cia layers of the temporal and the masseter muscles. The reduced arch is thus kept in place. Thus there is no indication for expo¬ sure and plate osteosynthesis in this region. In none of our cases was such a procedure necessary.

Following elevation of prolapsed orbital tissue, depressed orbital floor bone frag¬ ments are elevated from the maxillary sinus and repositioned if possible. If no de¬ fect exists after repositioning the frag¬ ments and the floor is stable, no implants may be necessary. Small defects, generally less than 5 mm in diameter are covered with lyophilized dura. Larger defects in the or¬ bital floor are bridged with lyophilized car-

(Fig 4, top left). The right malar promi¬ contained multiple fragments and, on the left side, both the supraorbital rim and the frontozygomatic area were fractured. nence

Fig 2.—Top left and right, Displaced left zygoma fracture (arrows). Center left and right, Transconjunctival approach is illustrated with reduction of inferior orbital rim fragments (white ar¬ rows) and bottom left, wire fixation (black arrow). Note, the upper eyelid is closed for corneal pro¬ tection. Bottom right, Postoperative roentgenogram showing miniplate fixation sites and infraor¬ bital rim wires (arrows).

tilage implants (Fig 4). Autogenous bone grafts (calvarial outer table) have also been used, although we now tend to favor lyo¬ philized cartilage as our experience with this material has grown.23'25 During the early years of the study (1978 through 1981) Silastic implants were used and, subse¬ quently, use of this material was discontin¬ ued because of problems with extrusion and foreign body reactions in our patients, and as reported by others.26-27

REPORT OF CASES The following cases highlight key aspects and special problems in the management of zygoma-lateral orbital complex fractures. Case 1,—Figure 4 demonstrates a case with bilateral zygomalateral orbital com¬ plex fractures and a Lefort I fracture. The right zygoma fracture was unusual because the frontozygomatic suture area was intact, while the supraorbital rim fracture ex¬ tended into the lateral orbital area instead

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Fixation of the Lefort I fracture with miniplates adjacent to the pyriform aper¬ ture created sufficient stability for subse¬ quent miniplate fixation of both zygomas at the zygomaticomaxillary buttresses. This was sufficiently stable to permit wire fixa¬ tion of the remaining fractures rather than using miniplates. The multiple fragments of the right malar prominence were reduced and fixed by a miniplate-wire ligature com¬ bination (Fig 4, bottom left). The anterior maxillary sinus wall fragments were stabi¬ lized with vicryl sutures. The postoperative result (Fig 4, bottom right) shows malar symmetry and demonstrates the cosmetic advantage of a transconjunctival approach to the infraorbital rim. Case 2.—Figure 5 shows a case with ex¬ tensive disruption of the midface, bilateral multifragment zygoma-lateral orbital wall fractures, and associated frontobasal skull base fractures (Fig 5, top left and right). Following subcranial management of the frontobasal skull base fractures,2328 reduc¬ tion of the nasal skeleton was performed. Only then was three-dimensional reduction of the zygoma performed. On the left side, the zygoma fragments were rotated, mark¬ edly displaced, and devoid of periosteal at¬ tachment. These fragments were removed, miniplates were applied (Fig 5, center), and the whole complex was reimplanted and fixed to the previously reduced maxillary and frontozygomatic articulations (Fig 5, bottom left). The temptation to substitute primary bone grafts in this situation should be resisted, since only the original frag¬ ments can guarantee a correct three-di¬ mensional reduction. The 1-year postoper¬ ative result is shown (Fig 5, bottom right). Case 3.—The case shown in Fig 6 demon¬ strates the need for a coronal flap, as well as indications for primary bone grafting and the use of miniplates for the infraorbital rim. Nasoethmoid-frontobasal fractures with cerebrospinal fluid leakage, displaced right supraorbital and infraorbital rim fractures, and an open left zygoma-orbital fractures with considerable bone loss were present. Coronal flap exposure allowed management of the anterior skull base23·28 with reduction and miniplate fixation of the right supraorbital-frontal bone fractures (Fig 6, top right). The right infraorbital rim fragments were wedged in and fixed with wire ligature. The left side presented a re¬ constructive challenge due to the extensive bone loss including the malar prominence, infraorbital rim, and zygomaticomaxillary buttress (Fig 6, center left). Iliac crest bone grafts and miniplates (Fig 6, center right)

Fig 3.—Top left, Patient with bilateral infraorbital rim and floor fractures (arrows) with concomitant nasoethmoid complex frac¬ Top right, Illustrates management of comminuted infraorbital rim and floor fractures. U indicates upper eyelid; L, lower eyelid; F, medial fracture border; and I, infraorbital nerve. Bottom left, Dried skull demonstration of techniques for drilling burr holes for wire fixation. F indicates orbital floor; B, caution when drilling in this direction because of risk to vessels and nerves in the infratemporal fossa. Bottom right, Bone fragment (black triangle) interpositioned with wire fixation (dotted line shows path of wire) to reconstruct infraorbital rim. tures.

used to reconstruct these areas as il¬ lustrated (Fig 6, bottom left). The postop¬ erative result at 6 months (Fig 6, bottom right) is shown, with some unfavorable scars from the facial lacerations. Despite the periorbital fat and soft-tissue loss, no

were

diplopia was present. Case 4.—The patient in Fig 7 had a dislo¬ cated zygoma-lateral orbital complex frac¬ ture extending into the frontotemporal skull with lateral displacement (Fig 7, top left and right). A coronal flap exposure for reduction and fixation was used (Fig 7, bot¬ tom left). Due to the periorbital injuries, a slight strabismus is present 6 months post¬ operatively (Fig 7, bottom right), but with¬ out diplopia. RESULTS Motor vehicle accidents, personal al¬ tercations, and sports injuries were the most common causes of zygoma and lateral orbital complex fractures

in this series of 813 fractures. These 813 fractures represent slightly over 90% of patients in compliance with a minimum postoperative follow up of 1 year by our department and the de¬ partment of ophthalmology. The range of patient follow up was between 1 and 5 years. The clinics for ophthalmology and otolaryngology-head and neck surgery and our department were in¬ tegrated in the evaluation. The data were currently included in the text. Table 1 portrays the breakdown of the types of fractures in our series. Simple fractures were defined to in¬ clude zygomatic fractures of the clas¬ sical "tripod" (actually tetrapod) type. Patients with multifragment frac¬ tures of the zygoma, or extensive con¬ comitant disruption of the orbital floor were defined as having complex zygo-

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ma-lateral orbital fractures. Associ¬ ated extensive midface and naso-orbital fractures (62% vs 16% of simple

fractures) were more common, as ex¬ pected with the higher velocity impact associated with such fractures.

Figure 8 shows closed reduction was

performed successfully with 29% (149/ 518) of the simple zygoma fractures, representing 18% of all these frac¬

Open reduction with osteosynthesis and reconstruction of the or¬ bital floor where necessary was re¬ quired in 82% (664) of our cases. All multifragment zygoma fractures were treated by open reduction. In none of the procedures was any temporary or permanent facial nerve dysfunction manifest. Table 2 displays the complications related to using the transconjunctival tures.

Fig 4.—Top left, Patient with bilateral zygoma and midface fractures (white arrowheads). Note the uncommon location of the right supraorbital fracture. Concomitant maxillary fracture (black arrow¬ heads). Top right, Wire fixation of infraorbital rim (arrows) with C indicating lyophilized cartilage implant reconstruction of orbital floor. Bottom left, Postoperative roentgenogram. Miniplate fixa¬ tion of maxillary fracture with wire fixation of both inferior orbital rims, left zygomaticofrontal and right supraorbital fractures (arrowheads). Right zygomaticomaxillary buttress wire and bone graft (arrow). Bottom right, One-year postoperative appearance of patient. Bilateral external lateral eyebrow incisions were used. route. The two tarsal

plate injuries

directly the result of technical error on the part of the operating sur¬ geon. Fortunately this was recognized intraoperatively and the tarsus was repaired. Especially worthy of note is the low incidence of ectropion and entropion, 1.2% vs a reported 10% with the subciliary approach.21 Most of the eight patients with this complication were treated by residents during their training period. These cases needed secondary corrective surgery. Their postoperative course was uneventful. Table 3 outlines the materials used for reconstruction of the orbital floor. Silastic was used during the early years (1979 through 1981) of this study as an orbital floor implant. Long-term follow up of these patients resulted in extrusion and removal of the Silastic implant in 17% (8/48) of these pa¬ tients. As a result, we switched to uti¬ lizing lyophilized dura or cartilage and

were

autogenous bone during the latter

(1982 through 1988). Note the paucity of complications related to the biocompatibility of these materials. Table 4 outlines complications re¬ lated to maxillary sinus dysfunction. Patients developing postoperative maxillary sinus infection/sinusitis were considered to have dysfunction from impaired drainage (1.6% ). After application of a tube for drainage pro¬ truding into the nasal lumen, no fur¬ ther complications were observed. Four patients with multifragment zy¬ goma fractures extending into the midface developed persistent oroantral fistulas requiring secondary sur¬ gical closure. In 5.3% of the patients with radiographie opacification of the maxillary sinus no further treatment years

was

necessary

as

normal function was

established. Tables 5 and 6 show the incidence of infraorbital nerve dysfunction associ-

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ated with these fractures and their treatment. Patients were tested pre¬ operatively and postoperatively dur¬ ing their follow up visits. Anesthesia was defined to mean the absence of sensation to touch and sharp pin test¬ ing over the ipsilateral cheek, maxil¬ lary dentition, and upper lip persisting 1 year postoperatively. Dysesthesia in¬ cludes the presence of sensation, but an altered level compared with preop¬ erative testing or in comparison with the contralateral side at 1 year. Both the severity of the fracture and the ex¬ tent of surgical manipulation required for reduction are clearly related to postoperative infraorbital nerve dys¬ function. Distinguishing between the relative contributions of these two fac¬ tors was difficult. Table 7 shows the incidence of post¬ operative complications related to the reduction of zygomatic fractures. Pa¬ tients with malar asymmetry were subdivided into two groups. First, were those patients with significant malar asymmetry that was obvious to the patient and to us on casual inspection during follow up visits (4.3% ). These patients were considered to have an unsatisfactory cosmetic result and many agreed to have secondary recon¬ structive procedures using malar os¬ teotomies or onlay grafts. The second group of patients had minor degrees of malar asymmetry undetected by both the patients and their families, and not apparent on casual observation. Yet critical inspection and measurements performed on all patients revealed mi¬ nor but clinically insignificant dispar¬ ities between the malar prominences in 9.7% of our patients. Late enophthalmos and hypophthalmos with varying degrees of diplopia developed in 4.7% of our patients. Many of these patients with enophthalmos and diplo¬ pia had secondary corrective proce¬ dures that are beyond the scope of this article. We currently have a study in progress regarding enophthalmos and

diplopia.

COMMENT

Fractures of the zygoma

are

rela¬

tively common; unfortunately, postoperative complications following surgical treatment.1 Late cosmetic de¬ formity and asymmetry following reso are

"

duction apparently occurs in 20% to 40% of cases.1'4 Additionally, enoph¬ thalmos, diplopia, infraorbital nerve paresthesias, and lower eyelid prob¬ lems are not uncommon.24'29 Failure to conceptualize the threedimensional anatomy and relation¬ ships of the zygoma-lateral orbital complex will undoubtedly lead to in¬ adequate reduction of these fractures. The zygoma has been described as a four-sided pyramid.24 Accordingly, zy¬ goma fractures are described as being tetrapod. Correct alignment of three of these pillars during fracture reduction is thought to be necessary.2·4 Further confounding the achievement of accu¬ rate reduction and malar symmetry is rotation of the fractured segment. Ro¬ tation often occurs along the axis of the zygomaticofrontal pillar and infe¬ riorly because of the pull of the masseter muscle.130 Failure to consider this rotation of the zygoma threedimensionally during reduction may be a major cause of postoperative ma¬ lar asymmetry. This can be a major pitfall especially when only singlepoint stabilization of the zygoma at the frontozygomatic area is attempted as advocated by some.30 Closed reduction is indicated for se¬ lected simple zygoma fractures (Fig 1). Prolapse or incarceration of orbital contents

Fig 5.—Top left, Patient with combined Lefort l-lll extensive midface fractures (arrows) with infraorbital rim involvement. Dotted lines with arrows show extensively disrupted maxillary fractures. Note lateral displacement of left zygoma (large black arrow). Top right, Computed to¬ mography of same patient. Center, Zygoma complex prior to replacement as free bone graft. indicates body of zygoma; M, maxillary sinus anterior wall; and L, lateral wall of maxillary sinus. Bottom left, Roentgenogram taken 1 week postoperatively. Three plates (arrowheads) are stabi¬ lizing the maxilla, two of them are at the zygomaticomaxillary buttresses. Bottom right, Photograph taken 1 year

postoperatively.

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through accompanying

or¬

bital floor fractures represents a con¬ traindication to closed reduction. In¬ traoperative inspection and digital pressure applied to the zygoma after closed reduction is used to ascertain stability. Failure to maintain stability mandates open reduction and osteosynthesis. Adequate and critical follow up after reduction will confirm the ef¬ ficacy of this method. For three-dimensional conceptual¬ ization considering the exact align¬ ment of the zygomaticofrontal suture, zygomaticomaxillary buttress, and in¬ fraorbital rim is crucial. Despite the importance of three-point align¬ ment,2·4 fixation at all three pillars is not always necessary. The fracture pattern and the correct adaptation of the fragment borders dictate the fixa¬ tion points necessary to maintain re¬ duction, rather than having precon¬ ceived notions regarding one-, two-, or three-point fixation.2·4·30 This decision

Fig 6.—Top left, Computed tomogram of patient with severely comminuted multifragment fractures of the left midface and lat¬ eral orbital complex. Top right, A coronal flap was used since a right supraorbital and frontobasal fracture involving the frontal sinus was also present. D indicates exposed dura above the gap of the right frontal sinus fracture; N, nose; and S, supraor¬ bital rims. Center left, Exposure of the midface and inferior orbital rim was through facial lacerations. Note extensiveness of soft-tissue injury with loss of bone. Dotted line represents approximate level of missing inferior orbital rim. I indicates infraor¬ bital nerve; L, lateral orbital rim; and N, nose. Center right, Midface, inferior and lateral orbital rims reconstructed with split calvarial bone grafts and titanium miniplates. Bottom left, Postoperative roentgenogram showing miniplates (arrowheads) and wire fixation (arrow) of right inferior orbital rim fracture. This case illustrates a rare and exceptional situation where miniplates are also necessary for the inferior orbital rim. Bottom right, Six-month postoperative photograph of patient. Surprisingly, this patient has no diplopia.

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Fig 7.—Top left and right, A 7-year-old boy with depressed zygoma-lateral orbital complex and supraorbital rim fracture extending into the left frontobasis. Bottom left, Intraoperative lateral indi¬ view through coronal flap exposure. cates nasal dorsum. Note temporal skull and lateral orbital rim fractures. Bottom right, Pho¬ tograph of patient taken 6 months postopera¬ tively.

Table 1.—Types of Fractures Type of Fracture Simple zygoma fracture Multifragment zygoma fracture

n (%) 518(64) 295 (36)

Total

813

Multifragment Zygoma

Associated Extensive Midface and/or Naso-orbital Fractures, No. (%)

Fractures

(16) (62) 266 (33)

Simple Zygoma

Fractures

83 183

Closed

Open

Reduction,

J§

.Reduction, PP 149

295 Table

2.—Complications Related

to

Transconjunctival Approach

Lacrimal Duct No. of Incisions Injuries 369 1 Simple zygma fractures 295 2 Multifragment zygoma fractures 3 (0.5%) Total 664

Type of

Corneal

Tarsus Lesion

Fracture

Abrasion

1 1

2

(0.3%)

Open

Reduction,

3 5

1

0 1

Postoperative Ectropion

(0.2%)

8

369

(1.2%)

Fig 8.—Treatment modalities in 813 zygoma fractures. Materials Used for Floor of Orbit Reconstruction

Table 3. —

Material Local Bone

No. of

*

Year

Cases

1979-1981 1982-1988 Total implants

469 545

76

Silastic

Lyodura

Lyocartilage

48

2 238

2 117

Eight of these implants were rejected, requiring curred with any of the other Implant materials.

25

119

240 removal. Silastic

Transplants

was

not used after 1981. No

rejection

oc¬

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Table 4.

—

Maxillary Sinus Complications Persistent

Roentgenographic Clouding After 6 Months

Symptomatic Asymptomatic Oroantral Fistula Clouding Clouding

No. of

Type of Fracture Simple zygoma fractures Closed reduction reduction

Open Multifragment

Total

Cases

zygoma fractures

Total

149

4

369 295 813

13

3 9

12(1.6%)

55(6.8%)

Table 5.—Infraorbital Nerve Dysfunction and No. of

Type of

Fracture

Type

4

4

(0.5%)

of Fracture

Dysesthesia of V2

Anesthesia of V,

Cases

zygoma fractures closed reduction Simple zygoma fractures open

31 43 (5.3%)

38

Focal

Dysesthesia

Simple

49

369

reduction

Multifragment

295 813

zygoma fractures

Total

Table 6.—Infraorbital Nerve

8 57 (7.0%)

(2.1

23

Dysfunction in Relation

to

Dysesthesia

Anesthesia of V,

fixation

65 42 118 (14.5%)

Osteosyntheses of V,

Focal

Dysesthesia 12 12

162

Total

Table

23

No. of Cases 84

Closed reduction of infraorbital rim Open reduction of infraorbital rim No osteosyntheses Wire fixation

Miniplate

11

149

21

414 4

2

813

3(0."

69 1

1

7.—Postoperative Complications Related

23

(2.8%)

94 (IU

to Inaccurate Reduction

Malar Asymmetry

Type of Fracture zygoma fracture Closed reduction Open reduction Multifragment zygoma fracture

Simple

Total

No. of Cases 149 369 295 813

Minor

Asymmetry

7

19 14

(9.7%)

only be made intraoperatively. Titanium miniplate osteosynthesis at the frontozygomatic area may be sufficient to guarantee stabilization of the reduction and alignment of the re¬ maining zygomatic pillars in some cases.30·31 Inspection of the infraorbital rim and medial surface of the lateral orbital wall is crucial. If stability is still inadequate, particularly in multifragment fractures, with uneven ad¬ aptation of the fracture borders, then miniplate stabilization of the zygo¬ maticomaxillary buttress is indicated. If multiple fragment fractures involvcan

Enophthalmos With Diplopia

2

15 28

36 79

Major Asymmetry (Noticeable to Patient)

35

(4.3%)

31 38 (4.7%)

ing the infraorbital rim exist, then the wedged in fragments are fixed into the correct position with polyglactin (Vicryl) suture or wire ligatures. Although miniplate osteosynthesis of the in¬

fraorbital rim may be easier to accom¬ plish, this is best avoided. Only in those rare situations where the in¬ fraorbital rim is severely comminuted with loss of bone do we resort to miniplate fixation, with or without bone grafts, to achieve restoration of the proper rim contour. The importance of saving even small bone fragments cannot be emphasized

enough. Replacing and wedging in of all the small fragments is a key to achieving accurate restoration of the pretraumatic configuration. Further¬ more, although using primary bone grafting may be easier, it is bound to be less accurate. This may explain why our experience regarding the need for primary bone grafting (Fig 6) is low compared with some reports.15·32·33 European maxillofacial surgeons have long favored miniplate fixation and, in the past 10 years, this has also become widespread in North America3437 The senior author (J.R.) has noticed an increasing tendency to use miniplates for fixation of infraor¬ bital rim fractures that, in our opinion, is an unhealthy trend,1415 since these should be limited to the load bearing

buttresses of the facial skeleton. In our opinion, advocating the use of miniplates for the infraorbital rim cannot be rationally justified, especially since no functional loads are exerted in this area.35·38 Further points against the use of miniplates in this area include the following: (1) The bone at the infraor¬ bital rim is so thin that only a few threads of the screw can be anchored. (2) Since the fragments are often poorly held by the screws and com¬ pression is not possible, there are fewer advantages. Simple wire liga¬ tures may be more efficient in achiev¬ ing reduction, congruency, and some compression. The fact that miniplates are easier to apply is a rather poor in¬ dication. (3) The periosteum of this thin bone may be separated from the bone surface by the miniplate. The un¬ dersurface of the fragments is covered only by thin and usually injured mucoperiosteum with compromised revascularization and the miniplate screws protrude into the maxillary si¬ nus lumen. Resorption of the bone fragments may occur or an inflamma¬ tory reaction may be incited. (4) Miniplates in this area may result in more lower eyelid problems (edema and inflammation), especially when used with the old subciliary approach. Recently, authors have emphasized the necessity of miniplate osteosyn¬ thesis of the zygomatic arch with the help of a coronal flap.39 In our opinion, there is no indication for such a proce¬ dure. Reduction of the three buttresses

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of the zygoma are the only guarantee for a correct three-dimensional con¬ figuration and thus the repositioned zygomatic arch fractures (see the Pa¬ tients and Methods section) are kept in place. Accordingly, such a procedure was unnecessary in any of the cases. The transconjunctival approach was used exclusively in our series, in the absence of facial lacerations, and fa¬ cilitates simple and reliable exposure of the orbital floor and inferior rim. Meticulous attention to proper tech¬ nique avoids corneal abrasions and tarsal plate or lacrimal duct injury. A lateral canthotomy for exposure is un¬ warranted and never performed in conjunction with this approach, as ad¬ vocated by some.11·14·20·21 Ectropion, entropion, and lower eyelid edema, re¬ lated to the subciliary approach,21 are rarely encountered following the transconjunctival access, while no scar is better than a cosmetically "accept¬ able" scar. Orbital floor defects were recon¬ structed with lyophilized carti¬ lage23·4042 or dura and autogenous bone with no complications (Fig 4). We have abandoned the use of Silastic for or¬ bital floor defects since 1981 because of the 16% complication rate resulting from extrusion of the implants over time and foreign body reactions.26·27 Our experience with these materials and further aspects involved in the re¬ construction of orbital walls to prevent enophthalmos is the subject of another article. Other methods for stabilization of the orbital floor and zygoma, such as gauze packing, balloon catheters,29 or single-pin fixation1·43 are considered by us to be less accurate and stable com¬ pared with modern osteosynthesis

techniques. Also, severe complica¬ tions, including blindness, can result.29

The meticulous restoration of the max¬ illary sinus walls resulted in a very low incidence of postoperative maxillary sinus dysfunction. Finally, in contrast to others,43·44 we are fortunate that, due to the favorable social and geographic circumstances of a small country such as Switzerland, we have over 90% compliance in achieving follow up between 1 and 5 years. We believe that without longterm follow up results it is difficult to

make meaningful statements and rec¬ ommendations regarding the treat¬ ment of zygoma and other facial frac¬ tures. References 1. Matsunaga RS, Simpson W, Toffel PH. Simplified treatment of malar complex fractures. Facial Plastic Surg. 1988;5:269-274. 2. Karlan MS, Cassisi NJ. Fractures of the zygoma. Arch Otolaryngol Head Neck Surg. 1979; 105:320-327. 3. Stanley RB, Mathog RH. Evaluation and correction of combined orbital trauma syndrome.

Laryngoscope. 1983;93:856-865. 4. Karlan MS. Complications of malar fractures. In: Mathog R, ed. Maxillofacial Trauma. Baltimore, Md: Williams & Wilkins; 1984:350-359. 5. Kawamoto HK. Late posttraumatic enophthalmos: a correctible deformity. Plast Reconstr Surg. 1982;69:423-432. 6. Mathog RH, Hillstrom RP, Nesi FA. Surgical correction of enophthalmos and diplopia. Arch Otolaryngol Head Neck Surg. 1989;115:169-178. 7. Powell NB, Riley RW, Lamb DR. A new approach to evaluation and surgery of the malar complex. Ann Plast Surg. 1988;20:206-214. 8. Converse JM, Firman F, Wood-Smith D. The

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