You are in: eMedicine Specialties > Plastic Surgery > FACIAL FRACTURES Facial Trauma, Zygomatic Arch FracturesArticle Last Updated: Oct 3, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Adam J Cohen, MD, Assistant Professor, Department of Ophthalmology, Northwestern University Feinberg School of Medicine; Consulting Surgeon, Myers Wyse Center for the Eye; Director, Center for Facial Rejuvenation; Founding Partner, HC Consulting, Inc Adam J Cohen is a member of the following medical societies: American Academy of Ophthalmology and American College of Surgeons Coauthor(s): Michael Mercandetti, MD, MBA, FACS, Consulting Staff, Department of Surgery, Doctors Hospital of Sarasota Editors: James F Thornton, MD, Assistant Professor, Department of Plastic and Reconstructive Surgery, University of Texas Southwestern; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: zygomatic arch fracture, isolated zygoma fracture, isolated zygomatic fracture, face trauma, zygomaticomaxillary complex fracture, ZMC fracture, motor vehicle accident, MVA, motorcycle accident, sports injury, sports-related trauma, facial fracture, traumatic facial injury, tetrapod fracture INTRODUCTIONSection 2 of 11
  The zygomaticomaxillary complex (ZMC) is both a functional and aesthetic unit of the facial skeleton. This complex serves as a bony barrier, separating the orbital constituents from the maxillary sinus and temporal fossa. The zygoma has 4 bony attachments to the skull, and ZMC fractures should be referred to as tetrapod fractures. Trauma to the ZMC usually results in multiple fractures (ie, tetrapod), but solitary bony disruption may occur, as with an isolated zygomatic arch fracture, which is the focus of this article. For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center and Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article Facial Fracture. History of the ProcedureIn 1751, Dupuytren detailed an intraoral and external technique to realign a medial displaced zygomatic arch. He also discovered a crucial relationship between the temporalis muscle and fascia as a plane to realigning zygomatic arch fractures. In 1844, Stroymeyer described the percutaneous traction technique, which is still used today for repair of zygomatic arch breaks. In 1927, Gillies was first to institute the masking of incisions within the hairline. FrequencyThe prominent zygoma is the second most commonly fractured facial bone, and these fractures are eclipsed in number only by nasal fractures. The vast majority of zygomatic fractures occur in men in their third decade of life. In 1994, Covington et al reviewed 259 patients with zygoma fractures and found that ZMC fractures occurred in 78.8% of patients, while isolated orbital rim and isolated arch fractures occurred in 10.8% and 10.4% of patients, respectively. Of note, displaced or comminuted fractures were found in 59.3% of patients with isolated zygomatic arch fractures. EtiologyZygoma fractures usually result from high-impact trauma. Leading causes of fractures include assault, motor vehicle or motorcycle accidents, sports injuries, and falls. ClinicalPatients with zygomatic arch fractures are usually evaluated following traumatic injury to the face. These fractures may result in trismus and flattening of the midface. Patients report asymmetry between the malar regions or difficulty with increasing their oral aperture, and these reports may prompt a patient to seek consultation. INDICATIONSSection 3 of 11
Surgical exploration and fracture repair should be initiated in the event of (1) a displaced or comminuted fracture, (2) trismus, or (3) significant aesthetic deformity. Emergent surgical repair and decompression are necessary when exophthalmos or signs and symptoms of orbital apex syndrome are present, but these are rarely observed with isolated arch disruption. RELEVANT ANATOMYSection 4 of 11
The zygomatic arch is an integral and principal constituent of the midfacial skeleton. The zygomatic arch is bounded by the zygomaticotemporal suture line posteriorly and the malar eminence anteriorly. The arch endows a rim of bony armor to the temporalis muscle and the coronoid process of the mandible and serves as the masseter muscle origin. The zygomatic arch is part of the facial subunit known as the ZMC. The ZMC has 4 bony fusion sites with the skull, and, when insults occur, these sutures are the usual sites of disruption. CONTRAINDICATIONSSection 5 of 11
Surgical correction is contraindicated in patients who are medically unstable and unable to tolerate anesthesia. WORKUPSection 6 of 11
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TREATMENTSection 7 of 11
Medical TherapyIf surgical correction is undertaken, initiate prophylactic antimicrobial therapy if a history of endocarditis or other conditions requiring antibiotics is known. Surgical TherapyReconstruction of the zygomatic arch following injury is necessary for restoration of malar symmetry and support for the maxilla and masticatory loads. Repair of the zygomatic arch is usually performed in concert with repair of ZMC fracture stabilization. In 1999, Turk et al found that direct repair and plating of the zygomatic arch was not indicated in more than 1500 patients, secondary to spontaneous reduction with repair of other ZMC fracture components. If an aesthetic deformity is the product of an arch fracture or if trismus is present, direct repair and fixation are indicated. As with any surgical endeavor, successful outcomes are the result of a planned approach that affords excellent exposure of the operative site and of the use of meticulous surgical technique. More specifically, repair of zygomatic arch fractures requires a precise reduction and definitive stabilization to ensure positive outcomes. Fractures of the zygomatic arch have been approached by various methods. Direct cutaneous approach The least invasive approach is the direct cutaneous approach. This entails the placement of a bony hook, hemostat, or suture around the arch. Following this, the surgeon is able to reduce the fracture by applying lateral traction to the arch. Disadvantages include a lack of direct visualization of the bony insult, imprecise reduction, and a lack of fracture stabilization. The only advantage lies in the absence of a surgical incision and resultant cutaneous scarring. Gillies approach A 3-cm incision placed 4 cm superior to the zygomatic arch and posterior to the temporal hairline can be fashioned to allow direct access to the arch. This approach (ie, Gillies approach) allows accurate fracture reduction via a bimanual technique. After creating a skin incision, the dissection is carried down through the superficial temporal fascia and the temporalis muscle fascia (deep temporal fascia). A plane is carried forward, superior to the temporalis muscle to the zygomatic arch. Once this conduit is created, a periosteal elevator is positioned beneath the zygoma. Lateral traction is placed on the elevator while the surgeon's free hand palpates the fracture site during reduction. Once hemostasis is ensured, the fascia and skin are closed in the usual fashion. Take care to close the wound with all layers reanastomosed to their respective anatomic partners. Advantages of the Gillies approach include a scar camouflaged by the patient's hair; accurate, bimanual fracture reduction; and a remote chance of injury to the temporal branch of cranial nerve VII. Hemicoronal approach The most invasive approach offering excellent visualization is the hemicoronal approach. This method is usually reserved for comminuted arch fractures, and the potential for insult to the temporal branch of the facial nerve is ever looming. The initial skin incision traverses the scalp from the vertex of the skull to the helical root. Make the scalp incision at least 4 cm behind the hairline. Following incision of the scalp and superficial temporal fascia, the surgical plane must remain above the fascia of the temporalis muscle fascia (deep temporal fascia). As the zygoma is descended upon, a horizontal incision through the temporalis muscle fascia is created 2 cm superior to the zygomatic arch. A subperiosteal dissection permits excellent visualization and protects the facial nerve from inadvertent injury. Once the break has been remedied, the wound is meticulously closed in a layered fashion. Advantages include excellent visualization, accurate fracture reduction, and stabilization. Disadvantages include scarring, possible alopecia, and insult to cranial nerve VII. Open reduction and internal fixation is warranted with an unstable zygomatic arch, trismus, or diplopia secondary to muscle entrapment. Following reduction, unstable zygomatic arch fractures may necessitate temporary support to allow for bony union. Several techniques have been described, including percutaneous snaring of the medial aspect of the arch fracture with a wire, which is cinched around a padded external splint. A temporal incision may be used to introduce packing, for instance a Foley catheter, which, when inflated, provides an internal buttress to align the fracture. Preoperative DetailsBefore undertaking the repair, review and carefully document the complete knowledge of the patient's medical status and pertinent signs and symptoms pertaining to the injury. Taking photographs of the preoperative appearance of the patient is prudent. Offer a clear and thorough explanation of the procedure and outline the risks, benefits, and alternatives. Document that such an explanation was provided. Explain to the patient the possibility of a poor cosmetic result and possible asymmetry following surgery. Assessing the patient's expectations helps avoid a situation in which the surgical outcome is successful but with which the patient is dissatisfied. A meticulous review of imaging with a neuroradiologist, if necessary, is essential for planning the surgical approach and identifying surrounding structures that may serve as anchoring sites for reconstructive materials. Intraoperative DetailsAs for any surgical procedure, be aware of the patient's overall status as monitored by the anesthesiologist. At all times, maintain a complete and thorough understanding of the anatomic locale and surrounding vital structures that may be inadvertently insulted. For instance, paresis of orbicularis oculi and zygomaticus muscles can occur when excessive force is placed during posterior arch dissection. Postoperative DetailsElevate the patient's head 30° in the postanesthesia care area. To reduce edema, the authors prefer to use sterile gauze soaked in iced saline immediately following surgery because the weight and manipulation of ice packs can be a source of trauma to the surgical site. A cephalosporin or penicillin-based agent may be administered with antibiotic ointment for 1 week postoperatively. The authors prefer cephalexin monohydrate (500 mg bid) and an aminoglycoside and steroid-based ointment twice per day for 1 week. Follow-upEvaluate all patients on the first postoperative day to assess the wound status, amount of patient discomfort, range of oral motion, edema, and the presence of paresthesia or motor weakness. If a hematoma is present, exercise clinical judgment when deciding on management (ie, evacuation vs observation). The cutaneous sutures may be removed 1 week following surgery if wound healing progresses in a normal fashion. COMPLICATIONSSection 8 of 11
As with any surgical procedure, bleeding, infection, and the need for additional surgery are ever-looming risks. Paresis of the orbicularis oculi and zygomaticus muscles may be a transient complication, as can sensory deficits secondary to insult of the zygomaticofacial and zygomaticotemporal branches of the first division of the trigeminal nerve. Although the surgery may be a complete success in the eyes of the surgeon, the patient may view the outcome as unsatisfactory. To minimize this possibility, the surgeon and patient should be in mutual agreement as to the realistic outcome that results from the repair. FUTURE AND CONTROVERSIESSection 9 of 11
As surgeons develop a facility with endoscopic surgical principles and subperiosteal dissection techniques, smaller incisions will be used to reduce and stabilize fractures. Fixation materials and instruments will continue to evolve and allow for stronger, smaller, and more malleable implants. These advances will permit the surgeon to repair fractures with greater efficiency and less scarring and trauma. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
Facial Trauma, Zygomatic Arch Fractures excerpt Article Last Updated: Oct 3, 2006 | ||||||||||||||
