Zygomatic Orbital Fracture Treatment & Management

The aims of treatment of zygomatic complex fractures include the restoration of normal facial form, normal sensory nerve function, normal globe position, and normal masticatory function. Indications for repair of zygomatic complex fractures include displacement or instability of the fracture, mechanical restriction of mandibular movement (chewing), alteration in facial contour, globe dystopia, enophthalmos, diplopia, or sensory nerve deficit.^[9]

• The literature indicates that 10-50% of all zygomaticomaxillary complex fractures require no surgical intervention. This is suitable for fractures that are nondisplaced or minimally displaced or where systemic status precludes operative intervention.
• Stable, nondisplaced fractures may be observed weekly for healing.
• Avoidance of nose blowing is mandatory in the medical care of these patients. The disrupted orbital walls can allow air to be forced into the retrobulbar space and cause pain and visual loss.
• The routine use of systemic antibiotics for isolated zygomatic arch fractures generally is not recommended.

Generally, it is suggested to avoid surgery during times of maximum edema but prior to the adhesion of displaced bony fragments and scarring of soft tissues into bony defects. Most surgeons advise surgical intervention prior to the formation of dense scar tissue. As a general guideline, surgery should be undertaken prior to 3 weeks postinjury.^{[4, 10, 11]}

Traditionally, closed-reduction techniques were the method of choice for nearly all zygomatic fractures. In the past, simple techniques, such as exerting pressure under the zygomatic arch and resetting the bones in their anatomic position (eg, Gilles approach), were hindered by unsatisfactory cosmetic results and persistent diplopia. Although open techniques currently are favored, closed-reduction techniques may be suitable for isolated arch fractures and minimally displaced noncomminuted fractures.^[12]

A more aggressive approach using open-reduction techniques and rigid stabilization with plating systems (eg, Synthes or Leibinger) is the standard of care today, particularly for unstable or potentially unstable fractures.^[13]

• This approach provides direct access to the frontozygomatic suture, orbital floor, and infraorbital rims.
• The inferior orbital rim and floor can be exposed via an infraciliary approach or a transconjunctival approach. The transconjunctival incision gives excellent exposure and saves the patient a visible scar on the face.
• The floor of the orbit is routinely explored and reconstructed, if needed, to restore orbital volume. At this point, the zygomatic arch and orbital rims should be aligned.^[14]
• Typically, the inferior rim defects are visible through the orbital incision. The lateral rim fracture frequently occurs at the frontozygomatic suture line. This sometimes can be reached via the lateral lid crease or canthal incision. Rarely, a second incision may be needed under the lateral brow. This can be used to approach the lateral fracture and to provide access to elevate that bony fragment.
• Once proper access to the lateral rim has been achieved, an elevator is passed along the lateral rim and under the zygomatic arch at its anterior origin. Firm anterior pressure, not prying, is applied to the elevator to align the lateral and inferior fragments.
• Once these are positioned, they are fixated with miniplates.
• Precise reconstruction with rigid internal fixation of the zygoma at 2 or 3 points (across the frontozygomatic suture, the inferior orbital rim, and the lateral midfacial buttress) is needed to counter the force of the masseter muscle. The orbital contents can be supported as for simple orbital floor fractures.

Consultations with other services, such as otolaryngology, the oral maxillofacial service, facial plastic surgery, and neurosurgery, may be needed if significant concomitant nasal, oral, and/or cranial fractures are present.

Patients commonly are placed on a soft diet for several days to weeks. A dietary consultation may be warranted.

Advise patients to avoid nose blowing for several weeks after the surgery. All contact sports and most strenuous activity also should be avoided for several weeks.