Zygomatic Arch Fractures Treatment & Management
- Author: Adam J Cohen, MD; Chief Editor: Deepak Narayan, MD, FRCS more...
If surgical correction is performed, prescribe prophylactic antimicrobial therapy if a history of endocarditis or other conditions requiring antibiotics is known.
Reconstruction 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 zygomaticomaxillary complex (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 all surgical procedures, 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.
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 by means of a bimanual technique. The surgeon creates a skin incision, the surgeon carries down a dissection 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.
See the image below.
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.
Fluroscopy may aid in proper fracture reduction with closed reduction.
The most invasive approach offering excellent visualization is the hemicoronal approach. This method is usually reserved for comminuted arch fractures, and the procedure carries potential for insult to the temporal branch of the facial nerve.
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. A more posterior placement allows for incision extension behind the ear. This provides added flap mobility.
After the scalp incision and superficial temporal fascia, the surgical plane must remain above the fascia of the temporalis muscle fascia (deep temporal fascia). As the zygoma is approached, 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 are 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, an inflated Foley catheter that provides an internal buttress to align the fracture.
Endoscopic approach [8, 9, 4, 10, 6, 11, 12, 13, 14, 15, 16, 17]
An optical cavity is created between the superficial and deep temporal fascias using a periosteal elevator. This blind dissection terminates a the level of the superior orbital rim parallel to the crux of the helix.
The endoscope is introduced and dissection continues to the zygomatic arch. The periosteum of the arch is incised and the arch repaired.
Review and document 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 leaves the patient is dissatisfied.
A review of imaging is essential for planning the surgical approach and identifying surrounding structures that may serve as anchoring sites for reconstructive materials.
Intravenous antibiotics and dexamethasone (10 mg) are the authors' usual practice for open reduction and internal fixation of facial bones.
As 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.
A prospective study by Czerwinski indicated that C-arm imaging allows accurate realignment in zygoma fracture repair, with a low complication rate. The study involved 20 patients who underwent repair for isolated, displaced, unilateral zygoma fracture, with only one patient demonstrating clinically noteworthy differences between the uninjured and repaired zygomas with regard to projection, width, and height. None of the patients showed a difference in ocular globe projection of more than 2 mm between the two sides of the face. There were no major surgical complications.
Elevate the patient's head 30° in the postanesthesia care area.
To reduce edema, the authors prefer using sterile gauze soaked in iced saline immediately following surgery rather than using ice packs, whose weight and manipulation can be a source of trauma to the surgical site.
A cephalosporin or penicillin-based agent may be prescribed for 1 week postoperatively (eg, cephalexin monohydrate [500 mg tid] 3 times daily for 1 week.
However, a study by Baliga et al suggested that postoperative antibiotics may offer no benefit against infection risk following open reduction and internal fixation of zygomatic or mandibular fracture. In the study, in which 60 patients underwent the procedure, 30 patients received antibiotics before, during, and after surgery, while the rest of the patients received only preoperative and intraoperative antibiotics. The investigators evaluated the patients at 1 and 3 weeks postoperatively, finding that just one patient in each group had developed an infection.
Evaluate all patients on the first postoperative day to assess the wound status, amount of patient discomfort, range of oral motion, edema, and 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.
Paresis of the orbicularis oculi and zygomaticus muscles, as well as sensory deficits secondary to insult of the zygomaticofacial and zygomaticotemporal branches, may be a transient complications.
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 Controversies
As surgeons develop a facility with endoscopic surgical principles and subperiosteal dissection techniques, they can use smaller incisions 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.
Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. Changing patterns in the epidemiology and treatment of zygoma fractures: 10-year review. J Trauma. 1994 Aug. 37(2):243-8. [Medline].
Manson PN, Clark N, Robertson B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. 1999 Apr. 103(4):1287-306; quiz 1307. [Medline].
Terino EO. Alloplastic contouring in the malar-midface-middle third facial aesthetic unit. Terino EO, Flowers RS, eds. The Art of Alloplastic Facial Contouring. St. Louis, Mo: Mosby Year-Book; 2000. 79-96.
Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic fractures. Plast Reconstr Surg. 2007 Dec. 120(7 Suppl 2):5S-15S. [Medline].
Laine FJ, Conway WF, Laskin DM. Radiology of maxillofacial trauma. Curr Probl Diagn Radiol. 1993 Jul-Aug. 22(4):145-88. [Medline].
Turk JB, Ladrach K, Raveh J. Repair of zygomaticomalar complex fractures. The Swiss method. Arch Facial Plast Surg. 1999 Apr-Jun. 1(2):123-6. [Medline].
Chen RF, Chen CT, Hao Chen C, Liao HT, Chen YR. Optimizing closed reduction of nasal and zygomatic arch fractures with a mobile fluoroscan. Plast Reconstr Surg. 2010 Aug. 126(2):554-63. [Medline].
Honig JF, Merten HA. Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg. 2004 Nov. 15(6):986-9. [Medline].
Gruss JS, Van Wyck L, Phillips JH, Antonyshyn O. The importance of the zygomatic arch in complex midfacial fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast Reconstr Surg. 1990 Jun. 85(6):878-90. [Medline].
Czerwinski M, Lee C. The rationale and technique of endoscopic approach to the zygomatic arch in facial trauma. Facial Plast Surg Clin North Am. 2006 Feb. 14(1):37-43. [Medline].
Gülicher D, Krimmel M, Reinert S. The role of intraoperative ultrasonography in zygomatic complex fracture repair. Int J Oral Maxillofac Surg. 2006 Mar. 35(3):224-30. [Medline].
Cohen AJ, Mercandetti M. Facial Trauma, Orbital Floor Fractures (Blowout). Medscape Reference. [Full Text].
Mercandetti M, Cohen AJ. Orbital Tumors. Medscape Reference. [Full Text].
Matsunaga RS, Simpson W, Toffel PH. Simplified protocol for management of malar fractures. Trans Am Acad Ophthalmol Otolaryngol. 1977 Sep-Oct. 84(5):ORL818-9. [Medline].
Shaw GY, Khan J. Precise repair of orbital maxillary zygomatic fractures. Arch Otolaryngol Head Neck Surg. 1994 Jun. 120(6):613-9. [Medline].
Shumrick KA, Campbell AC. Management of the orbital rim and floor in zygoma and midface fractures: criteria for selective exploration. Facial Plast Surg. 1998. 14(1):77-81. [Medline].
Pham AM, Strong EB. Endoscopic management of facial fractures. Curr Opin Otolaryngol Head Neck Surg. 2006 Aug. 14(4):234-41. [Medline].
Czerwinski M. C-Arm Assisted Zygoma Fracture Repair: A Critical Analysis of the First 20 Cases. J Oral Maxillofac Surg. 2014 Dec 27. [Medline].
Baliga SD, Bose A, Jain S. The evaluation of efficacy of post-operative antibiotics in the open reduction of the zygomatic and mandibular fracture: a prospective trial. J Maxillofac Oral Surg. 2014 Jun. 13(2):165-75. [Medline]. [Full Text].
Donald PJ. Zygomatic fractures. GM English, ed. Otolaryngology. Philadelphia, Pa: JB Lippincott; 1990.
Evans BG, Evans GR. MOC-PSSM CME article: Zygomatic fractures. Plast Reconstr Surg. 2008 Jan. 121(1 Suppl):1-11. [Medline].