CME/MOC

MOC-PSSM CME Article: Zygomatic FracturesBrogan G. A. Evans

Gregory R. D. Evans, M.D.

Orange, Calif.

Learning Objectives: After studying this article, the participant should be able to:1. Understand the common signs, symptoms, and treatment options for zygomaticfractures. 2. Answer basic questions on therapy for zygomatic fractures.Summary: This maintenance of certification article on zygomatic fractures attemptsto review the current approaches to the treatment of these fractures. Although thearticle does not deal with extended approaches to treatment, it does in a generalsense present the preoperative, intraoperative, and postoperative thinking for theplastic surgeon approaching these patients in general practice. A further in-depthreview can be obtained through the references at the end of the article.

The Maintenance of Certification module series is designed to help the clinician structurehis or her study in specific areas appropriate to his or her clinical practice. This article is preparedto accompany practice-based assessment of preoperative assessment, anesthesia, surgical treat-ment plan, perioperative management, and outcomes. In this format, the clinician is invitedto compare his or her methods of patient assessment and treatment, outcomes, and complicationswith authoritative, information-based references.

This information base is then used for self-assessment and benchmarking in partsII and IV of the Maintenance of Certification process of the American Board of PlasticSurgery. This article is not intended to be an exhaustive treatise on the subject. Rather,it is designed to serve as a reference point for further in-depth study by review of thereference articles presented. (Plast. Reconstr. Surg. 121: 1, 2008.)

The cause of facial fractures in the United Statesis primarily trauma, most frequently motor ve-hicle accidents. Despite the decrease in prev-

alence attributable to increased seat belt use alongwith airbags, facial injury continues to present asignificant alteration in the psychosocial aspect ofpatients.1–77 Zygomatic fractures are not only associ-ated with motor vehicle accidents but are also seenwith sports injuries. Outside the United States, theoccurrence of such injuries may be associated withother causes (i.e., bicycles).6,12,53,59

The face is the cornerstone for each patient’sindividualism, and alterations in its form and func-tion secondary to facial injury may lead to detri-mental changes in perceptions of how a patientfeels, interacts, and present themselves in socialenvironments. It is imperative then that we as plas-tic surgeons must restore not only the soft-tissueinjury but the bony infrastructure to each patient’sidentity. Technology has advanced our ability totreat facial injury. With the advent of computedtomography, three-dimensional reconstructions,

plate-and-screw fixation, and bone grafting, theability to restore structures to their original statehas never been more feasible. Furthermore, withthe advent of new bone cements, reshaping thecontour lost secondary to these injuries has be-come commonplace. It is the purpose of this main-tenance of certification article to evaluate theapproach, treatment, and outcomes of facial frac-tures, specifically, the zygoma.

From the Aesthetic and Plastic Surgery Institute, Universityof California, Irvine.Received for publication June 29, 2006; accepted October 13,2006.Copyright ©2007 by the American Society of Plastic Surgeons

DOI: 10.1097/01.prs.0000294655.16607.ea

Disclosures: Neither author has any commercialassociations that might pose or create a conflict ofinterest with information presented in this article.Neither author has any consultancies, stock owner-ship or other equity interests, patent licensing ar-rangements, or payments of stipends for conductingor publicizing this article.

The test for the MOC-PS–aligned CME article“Zygomatic Fractures” by Evans and Evans isavailable at http://www1.plasticsurgery.org/ebusiness4/OnlineCourse/CourseInfo.aspx?Id�12795.

www.PRSJournal.com 1

PREOPERATIVE ASSESSMENTAlthough zygomatic fractures can be isolated,

they are frequently associated with other facial in-juries (Carlin et al. recently demonstrated only an 11percent isolated zygomatic fracture injury rate with-out other concomitant injuries).42 The emergencycare of facial injuries identifies conditions that re-quire immediate treatment for the prevention oflife-threatening complications. These conditions in-clude maintenance of the airway, prevention of hem-orrhage, identification and prevention of aspiration,and identification of other injuries.1 Maintenance ofthe airway is perhaps the most critical. Isolated zy-gomatic fractures are more commonly associatedwith localized trauma such as a fist, baseball, or lat-eral movement of the head during a motor vehiclecollision. Although tracheotomy is not frequentlyrequired for isolated zygomatic injury, associatedother facial injuries may require control of the airwaythrough this mechanism. Major hemorrhage accom-panying maxillofacial injuries can occur from openwounds or associated closed fractures. Control ofthese bleeding wounds is critical in assessing thepatient and can be controlled by reduction of thefracture segments. Although not frequently required,anteroposterior nasal packing, soft wraparound facialcompression dressings, and external carotid artery li-gation are all measures that can be performed to con-trol bleeding. Monitoring of the blood volume is crit-ical in assessing patients, and each should be typed andcross-matched for potential transfusions. Accompany-ing regional injuries such as cervical spine injuries arefrequentandtendtooccurateither theupperor lowerend of the spine. If the entire cervical spine is notvisualized radiographically and the patient is unableto verbally demonstrate symptoms, one must assumethat the spine is injured. Computed tomographyof the spine may assist in confirming theinjury.1,4,9,11,12,21–24,27,29,32,33,35–39,41,44,47,49,56,57,61,63,64,66,70,71,

74,76,77

Intracranial injuries associated with facial frac-tures require special intracranial monitoring andevaluation. Remote injuries are also common in mo-tor vehicle–related trauma. Trauma associated withthe head, chest, extremity, and pelvis must be man-aged and considered with regard to the timing offacial bone repair.1,4,9,11,12,21–24,27,29,32,33,35–39,41,44,47,49,56,57,

61,63,64,66,70,71,74,76,77

A thorough history and physical examinationare part and parcel to any operative procedure. Ahistory of smoking, hypertension, coronary arterydisease, chronic obstructive pulmonary disease,diabetes, hepatitis, facial asymmetry, or paralysis iscritical to determine. All of these factors can alter

the healing of both bone and soft tissues. An ac-curate clinical examination begins with an evalu-ation of facial symmetry. Determination of septalhematomas, mobility of the bony segments, sta-bility of the maxilla, alignment of teeth and thebite (although not usually altered in isolated zy-gomatic fractures), visual acuity, and clear fluiddraining from the nose or open wounds must beidentified. Evaluation for entrapment of the globeis critical along with diplopia if the patient isalert and able to respond.1,4,9,11,12,21–24,27,29,32,33,35–39,41,

44,47,49,56,57,61,63,64,66,70,71,74,76,77

Radiographic examination provides impor-tant evidence to confirm the findings of the phys-ical examination.3,31,46 This occurs through plainradiographs and includes a Water’s view, Townesview, posteroanterior (Caldwell) view, lateral skullfilm, and Panorex examination. Although theseplain films are important, computed tomographicexamination with or without three-dimensionalreconstruction has replaced most of these earlyradiographs. Advances in ultrasonography andcomputed tomography allows better visualizationof orbital fractures, often associated with zygo-matic fractures, for better preoperative evalua-tion, planning, and intraoperative repair.15,21 Thecreation of models based on these computed to-mographic examinations may assist with preoper-ative planning.

Although isolated zygomatic fractures shouldnot alter dentition, more extensive zygomatic in-juries may require the creation of dental impres-sions and models that can assist with reductionand fixation. These associated injuries may re-quire intermaxillary fixation as the standard im-mobilization technique for fractures involving theupper and lower jaws.1,4,9,11,12,21–24,27,29,32,33,35–39,41,44,

47,49,56,57,61,63,64,66,70,71,74,76,77

Symptoms of zygomatic fractures usually in-clude a combination of periorbital and subcon-junctival hematoma and numbness in the distri-bution of the infraorbital nerve (Fig. 1). Theabsence of these two symptoms makes the diagnosisquestionable. Recent studies on facial trauma indi-cate the most frequently associated maxillofacialfracture accompanying zygomatic fractures was themandible (21 percent) and the most common fea-ture was subconjunctival ecchymosis (64 percent).12

Ipsilateral epistaxis is common, as is inferior dis-placement of the zygoma, which alters the positionof the lateral canthus, producing an inferior cant tothe palpebral fissure. Numbness of the infraorbitalnerve involves the upper lip and side of the nosealong with the anterior teeth. Motion of the man-dible may be inhibited because of impingement on

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the coronoid process. Loss of the prominence of themalar eminence may be perceptible if there is not asignificant component of cheek swelling. A hema-toma in the buccal sulcus may also be present. Ifthere is a significant component of an orbital frac-ture, impairment of the extraocular muscles may benoted or the position of the globe altered. Enoph-thalmos can occur secondary to loss of orbital floorsupport. Globe position can be formally measuredor estimated by standing at the head of the bed andcomparing eye projection. Enophthalmos may bemore evident from this position. Surgical indicationsfor repair of the orbital floor include entrapment,enophthalmos, or orbital floor defects that will in-crease the likelihood of a larger orbital volume andenophthalmos following trauma (usually �2 cm).Step deformities of the orbital rim may also be pal-pable.1,4,9,11,12,21–24,27,29,32,33,35–39,41,44,47,49,56,57,61,63,64,66,70,71,

74,76,77

ANESTHESIAGeneral anesthesia is usually used for reduc-

tion of zygomatic fractures. The time after injuryand the extent of the trauma and associated med-ical problems ultimately determine the best methodof anesthesia for fixation. Associated injuries such ascomplex zygomatic fractures involving the orbitaland nasal bones may dictate methods of intubation(i.e., oral, nasal, or fiberoptic approaches). Injury tothe nose may indicate fractures of the cribriformplate, negating nasal intubation. In contrast, associ-ated maxillary and mandibular injuries may pre-clude oral intubation because of the necessity for

intermaxillary fixation. Severe multiple injuriesmay require tracheotomy.1,4,9,11,12,21–24,27,29,32,33,35–39,41,

44,47,49,56,57,61,63,64,66,70,71,74,76,77 The length of intubationis based on the multitude of injuries.

Isolated fractures requiring isolated approachesmay be performed under local anesthesia and/orintravenous sedation. Ultimately, the age of the pa-tient, the extent of the injury, and patient preferencedetermines anesthetic approaches.7,15,16,25,26,55,73

SURGERY LOCATIONThe operation may be performed in a hospital

or an accredited freestanding outpatient facility asan inpatient or outpatient. The location will bedictated by the severity of the injury. Regardless oflocation, ability to admit the patient to a hospitalis critical with these potentially severe associatedinjuries.

ANESTHESIA TIMESAnesthesia and surgery start and stop times

along with in and out of room times are docu-mented and recorded.

SURGICAL TREATMENTApproaches to the zygoma can be variable and

will depend on the extent of injury.7,15,16,25,26,55,73

The zygoma forms the lateral structure of the mid-facial skeleton and comprises the lateral and in-ferior orbital rim and malar eminence. The pro-jections articulate with the sphenoid bone in thelateral orbit and with the frontal bone superiorly,the maxilla medially, and the maxillary alveolus in-feriorly. The zygoma’s prominent position makes itsusceptible to traumatic injury and accounts for itsfrequent injury (Fig. 2). Zygomatic fractures with theexception of arch fractures always include a compo-nent of the orbital floor. These injuries may be linearor more severe, such as orbital blowout fractures.General classification of zygomatic fractures includethe following: group I, no significant displacement;group II, zygomatic arch fractures; group III, unro-tated body fractures; group IV, medially rotatedbody fractures with outward displacement at the zy-gomatic prominence or inward at the zygomaticfrontal suture; group V, laterally rotated body frac-ture with upward displacement at the infraorbitalmargin or outward displacement at the zygomatico-frontal suture; and group VI, complex comminutedinjury (Fig. 3).1 Orbitozygomatic fractures can berepaired early (up to 3 to 4 weeks) after injury usingprimary reduction and fixation techniques. In theyounger patient population, this time frame may beshorter. Osteotomies may be required after thisacute phase and can be used successfully up to ap-

Fig. 1. Classic clinical finding demonstrating periorbital ecchy-mosis associated with fractures of the zygomatico-orbital area.

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proximately 4 months after injury. After 4 months,successful repair may require onlay bone grafting.64

The strongest articulation of the zygoma is that at thezygomaticofrontal suture. The articulations with themaxilla, the inferior orbital rim, and the maxillary

alveolus at the zygomaticomaxillary buttresses usu-ally fracture first, with the more incomplete fracturegenerally occurring through the zygomaticofrontaljunction. The presence of this incomplete fracture isthe basis for the success of closed reduction tech-niques by manipulation. Other displaced fracturesrequire open reduction. Inward displacement of zy-gomatic fractures may cause impingement on thecoronoid process and limit oral excursion. Reduc-tion is required to allow resumed mandibularmobility.

Complex Zygomatic InjuryClassic treatment of zygoma fractures has in-

volved reduction and interfragment wiring at thezygomaticofrontal suture and infraorbital rim. Smalldrill holes were placed adjacent to the fracture siteand wire was used to link the fragments together.Today, plate-and-screw fixation at the zygomatico-maxillary buttresses, zygomaticofrontal suture, andzygomatic arch are used.8,10,14,18,19,28,34,54,60 A coronalapproach to the fractures may be indicated withlateral displacement of the arch (Fig. 4).7,15,16,25,26,55,73

Care is taken to ensure that the frontal branch ofthe facial nerve is not injured during elevation ofthis flap. The initial incision is placed through acurving S incision to avoid potential linear scar-ring postoperatively. The dissection continuesalong the deep temporal fascia until the superfi-cial layer of the deep temporal fascia is incised.This keeps the frontal branch of the facial nervesuperficial to the dissection. Care is taken not tointerfere with the temporal fat pad. Despite thesebest efforts, atrophy of the temporal fat pad canoccur following surgery. This can create perma-nent indentation in the temporal area that is no-ticeable postoperatively. With the incision underthe superficial layer of the deep temporal fascia,dissection continues without fear of injury to thefrontal branch of the facial nerve as dissectioncontinues onto the zygomatic arch. Removing thesupraorbital nerve from its bony notch may alloweasier access to the fragment segment (Fig. 5).Plating then occurs under wide exposure. Thisallows accurate placement of the arch and fixationwith a large plate, reestablishing the shape of thelateral face. Fixation of the arch to the temporalbone also allows accurate reduction through thisapproach. Alternatively, rigid internal fixationmay be performed throughout the zygomaticarch. Alopecia is not uncommon with a coronalincision, and the patient should be aware of thispotential complication.

Fig. 2. Position of the zygoma and its relationship to the otherfacial bones.

Fig. 3. Complex comminuted zygomatic injury.

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At times, displacement of the zygomatic frac-ture does not extensively involve the arch (Fig. 6).A lesser approach using multiple facial and oralincisions allows good exposure for those patients

who do not have extensive facial traumatic injury.A patient’s fear of scarring may also preclude theuse of a coronal incision. Alternative approachesto the zygomatic complex include a subciliary or

Fig. 4. Complex zygomatic arch fracture demonstrated by computed tomographic scanning. A coronal approach isrequired for accurate reduction.

Fig. 5. Freeing of the supraorbital nerve from the orbital notch.

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transconjunctival incision, a lateral brow or upperblepharoplasty incision, and a gingival buccal in-cision. Naturally, any external lacerations can as-sist with exposure to the facial skeleton. Fixationat the zygomaticofrontal suture can occur throughthis coronal approach or through a lateral eye-brow or upper lid incision. The tendency towardanupper lid incision has been a recent preference. Fix-ation of the infraorbital rim can occur through a sub-ciliary or transconjunctival incision.7,15,16,25,26,55,73 Thisallows accurate placement of the bony fragments,with the potential of adding prosthetic materialfor the orbital floors.40,51,58,65,69,72 Recent data sup-port the use of transconjunctival incisions andlateral cantholysis to avoid visible scarring andpotential complications.25,26 The zygomaticofron-tal suture can also be addressed through this in-cision; however, taking down the lateral canthusmay be required. When repositioned, the lateralcanthus should be reanchored through a drillhole into the lateral orbital wall at a slightly higherposition or on the inner aspects of the orbital rimto the periosteum. The zygomaticomaxillary but-tresses are approached through a gingivobuccalsulcus (Caldwell-Luc) incision (Fig. 7).55 Bonegrafts can be used for additional support.

Alteration in occlusion may require intermax-illary fixation. This usually proceeds before zygo-

matic fracture reduction. Critical issues to resolveinvolve evaluation of the class of occlusion beforesurgery. If mandibular fractures are associatedwith zygomatic fractures and intermaxillary occlu-

Fig. 6. Minimal fracture of the zygomatic arch as seen on this computed tomographicscan.

Fig. 7. Approach to the lateral and medial buttresses through agingivobuccal incision.

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sion is not accurate, creation of palatal splints andorthognathics may be necessary before fracturereduction.

Variable sizes of plates for fixation are avail-able (1.0 to 2.0 mm). Smaller plates at the zygo-maticofrontal and infraorbital rim are critical toavoid patient complaints of feeling the platespostoperatively.8,10,14,18,19,28,34,54,60 Although not com-mon, lag screw fixation provides quick, stable, effec-tive reduction of obliquely oriented zygomaticfractures.8 Recent studies by Wittwer et al. have dem-onstrated that there is no difference in complica-tions between biodegradable osteosynthesis materi-als or between biodegradable materials and titaniumfixation with respect to fracture healing.2 Duringopen reduction of zygomatic fractures, reducing thesphenozygomatic suture first combined with otherfracture lines will reconstruct the zygomatic complexprecisely for better aesthetic outcomes.7,15,16,25,26,55,73

Three-point fixation is indicated only in exceptionalcases.4 Despite these complicated cases, there still isdisagreement as to fixation points for zygomatic frac-tures. Lastly, as more noninvasive procedures areexpanding, fractures that are not large enough tocause functional or severe aesthetic deformities maynot require any treatment. Recent studies indicatethat for low-impact fractures, patients who did notundergo fixation of the inferior orbital rim were freeof deformity, diplopia, and postreduction rotation.16

Perfect alignment of bony segments may not be re-quired and soft-tissue changes may not be significantenough to require operative treatment.

Associated Orbital Floor InjuriesAs indicated previously, repair of the orbital

floor is indicated if the defect is greater than 2 cm,if enophthalmos is present, if there is entrapment, orif the increase in orbital volume will lead to furthercomplications. The combination of computed to-mography as a baseline measurement and opticalthree-dimensional imaging for the follow-up exam-inations reveals more realistic data in cases of zygo-matic fractures than Hertel measurements.31 In ad-dition to reduction of the infraorbital segments,placement of material in the orbital floor to restorevolume may be indicated.40,51,58,65,69,72 This may in-clude placement of an orbital floor plate with orwithout bone grafts. Further placement of other ma-terial such as Medpor (Porex Surgical, Inc., Newnan,Ga.) or some other type of synthetic polymers maybe indicated. It is critical to test for forced ductionfollowing this placement of orbital floor material toensure that the placement of the orbital floor cor-rection does not impinge on eye motion. Recent

studies indicate that endoscopic repair has been suc-cessful in reconstruction of the orbital floor.48 Place-ment of an endoscope through the maxillary sinusallows adequate visualization of the orbital floor andreduction of the bony fragments if pushed into themaxillary sinus. Furthermore, the placement of ma-terial in the orbital floor through the same approachallows stabilization of the orbital contents and a de-crease in volume. In many cases of associated blow-out fractures, surgery is not indicated.

Isolated Zygomatic FracturesIf the arch is displaced medially, reduction can

occur through the Gillies approach, allowing lat-eral displacement for the reduction (Fig. 8). Anincision is carried through the temporal hair-bear-ing scalp and an elevator slipped between the deepfascia and the temporalis muscle. In addition, thisreduction could occur through a gingivobuccalsulcus approach. This approach is only successfulif comminution does not exist in the arch and if

Fig. 8. The Gillies approach for minimally displaced fractures ofthe zygomatic arch.

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there is intact periosteum allowing interconnec-tions of bony segments. If these conditions are notpresent, it is possible then to have isolated seg-ments with lateral displacement and misalignmentto the arch. A Carol-Girad screw can also be placedin the zygoma, allowing ease of reduction by ma-nipulation of the fractured bones through a sub-ciliary or transconjunctival incision. Lastly, a towelclamp can be placed around the zygoma to pulland reduce the segment.54 Ankylosis of the zygomato the coronoid process is occasionally seen withsevere injuries and may be managed by intraoralresection of the coronoid process.

Newer approaches to reduction and fixationof the zygoma include endoscopic techniques. En-doscope-assisted realignment of the arch and fixa-tion allow anatomical repair without sustaining thedrawbacks of extensive access incisions.5,20,48 This canbe done through a Gillies approach or through dis-section of the midface. Correct anatomical reduc-tion is necessary. Finally, bone grafts may be indi-cated for the zygomatic arch or maxillary segments.Extensive soft-tissue loss may require error on theside of delayed bone grafting. In the pediatric pop-ulation, a requirement for more resorbable platesfor fixation may be necessary.44

In addition to management of the bony seg-ments, soft-tissue management is critical. Resus-pension of the midface and prevention of ectro-pion are vital to an acceptable outcome. Elevationof the midface can occur with stripping of theperiosteum off of the maxilla. This may alreadyhave been performed to access the lateral or med-ical buttresses for fracture stabilization. Fixationcan occur by a suture ligature around the perios-teum or around a plate screw to prevent pullingand potential ectropion. Prevention of scarringshould be performed by gentle handling of tissueand diminution of tension. Resuspension and fix-ation of the lateral canthus is important for res-toration of appropriate symmetry.

It is becoming clearer that our aggressive ap-proach to these fractures may not be necessary.Nondisplaced or minimally displaced fractures maynot require operative repair. One has to discuss theoptions with the patient and determine by clinicalexamination what the appropriate course of actionshould be. Occasionally, some patients may be will-ing to exchange a bit of asymmetry for avoidance ofsurgery. One must be careful to treat the clinicalissues and signs more than the radiographic ones.

Evaluation of a patient’s bony reduction is al-ways appropriate. This can be performed by mag-netic resonance imaging, computed tomography,facial films, clinical examination, or a combina-

tion of these methods. Alterations in the bonyfixation may or may not require further revisionsof the reduction. The ultimate goal is to work withthe patient and determine whether the results areacceptable.

OUTCOMEImmediate complications include uneven heal-

ing, infection, hematoma, seroma, and visual changes.It is critical to have an accurate assessment of visualacuity before surgery. Changes in light perceptionor visual loss may indicate optic nerve compres-sion, which demands emergent correction andconsultation. Treatment may include the releaseof sutures to allow expansion of the orbital con-tents, lateral canthotomy, or the use of high-dosesteroids. Placement of any orbital floor plates ormaterial would demand immediate removal to re-duce compression on the nerve. Decompression,if performed and indicated, is urgent. This fre-quently can be performed through an endoscopeplaced and manipulated through the ethmoidsinus.

Soft-tissue loss resulting from the initial injurymay occur. Because of the vibrant blood supply ofthe face, preservation of as much soft tissue aspossible is critical during the initial operation.However, all devitalized tissue during the initialoperation should be debrided. Extensive hema-toma or seroma formation may require reopera-tion. Patients who have extensive injury and re-quire intubation nasally or through a tracheotomymay require prolonged assistance with breathing.Extensive operative intervention may also requireprolonged intubation. If maxillomandibular fixa-tion is performed, wire cutters should be placed bythe bedside for those patients in case vomiting orother airway compromise occurs.2,43,45,62,67,68,75

Early complications may include plate expo-sure, facial asymmetry, malocclusion resultingfrom inadequate reduction or a lack of intermax-illary fixation, malposition of the fracture seg-ments, soft-tissue deformities at the surgical sites,ectropion, blindness, and infection. In the acutestage of infection, supportive care and antibioticsare important treatment options. Tissue and scarmassage and waiting for edema to decrease areappropriate in the early stage after surgery. Un-dercorrection or overcorrection of orbital floorfractures may occur and require repositioning ofthe plate and screws and re-reduction of the bonysegment. This may be seen by continued enoph-thalmos or orbital proptosis. Placement of addi-tional material in the orbital floor may be re-quired. Alternatively, overcorrection may require

Plastic and Reconstructive Surgery • January 2008

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removal of the material. Resorption of bone in theorbital floor may lead to undercorrection, requir-ing further surgery. The best time to correct post-traumatic orbital deformities is during the acutephase.45

Late complications can include the above;however, enophthalmos may be more obvious asthe edema decreases and bone resorption occurs.Late infections are uncommon but may indicate aloose screw or infection of the material placed inthe orbital floor or infection of the maxillary sinus.Maxillary sinusitis, although not common, can oc-cur following zygomatic and midfacial fractures.24

Nonunion of fractures is uncommon in the facialarea; however, small bone segments or grafts thatlack adequate vascular supply may not heal and/orresorb. Palpation of the plates at the infraorbital andfrontal locations may occur and patients may requestremoval. Correction of enophthalmos may requirefurther placement of bone in the orbital floor orrecorrection of the orbital volume. Assessment ofectropion may require additional soft-tissue place-ment or elevation of the midface. Frequently, injuryleads to scarring in the anterior lamellae, requiringplacement of mucosal, cartilage, or buccal grafts tofree the tissues and reduce continued scar contrac-tures. Loose screws or plates demand removal tocontrol infections and draining sinuses. Injury to theinferior oblique muscle or lacrimal system obstruc-tion may also occur. Epiphora or tearing may becaused by nasolacrimal obstruction, ectropion, dam-age to the orbicularis oculi muscle, or medial canthalmalposition and may necessitate repair.

Pain related to infraorbital nerve injury maydictate local injections or desensitization. Ther-mal sensitivity may be a predictive measurement

to determine postoperative infraorbital nerverecovery.13 Plate fixation allows for significantlybetter restoration of infraorbital nerve function.17

Reoperation is indicated for exposed plates,loose screws, palpable plates, malalignment of thebony segments, and tissue loss. Loss of fixationmay require a change from wires to plates andscrews or vice versa. Correction of any malocclu-sion by refracturing the segments or orthognathicsurgery may be required.

Ultimately, the patient’s satisfaction is criticalin the long-term result. The moderate or dissat-isfied patient will require consultation to deter-mine whether their dissatisfaction is surgically cor-rectable.

Measured with patient satisfaction is surgeonsatisfaction. Again, discussion with the patient iscritical in determining whether further surgery isindicated. Asymmetry, malocclusion, chronic pain,or plate palpation may be issues for the patient,surgeon, or both. Although postoperative radio-graphic imagining may assist with determining ap-propriate bony alignment, studies indicate that rou-tine postoperative radiography in the managementof factures of the zygomatic complex is not sup-ported clinically.3

Finally, self-evaluation for improvement is criti-cal to any of our operations. Evaluation of the clin-ical and radiographic results may lead to changes inour approach and postoperative management. Bothclosed and open reductions are good treatment mo-dalities and have been frequently used. Balancingpostoperative facial deformity with closed reductionversus more complications related to incisions inopen reduction continues to be our challenge. Frac-tures with more unstable and/or markedly displaced

CPT Codes Commonly Used in Zygomatic Fracture Treatment

Code Descriptor

21355 Percutaneous treatment of fracture of malar area, including zygomatic arch and malar tripod,with manipulation

21356 Open treatment of depressed zygomatic arch fracture (eg, Gillies approach)21360 Open treatment of depressed malar fracture, including zygomatic arch and malar tripod21365 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina)

fracture(s) of malar area, including zygomatic arch and malar tripod; with internal fixation andmultiple surgical approaches

21366 Open treatment of complicated (eg, comminuted or involving cranial nerve foramina)fracture(s) of malar area, including zygomatic arch and malar tripod; with bone grafting(includes obtaining graft)

21385 Open treatment of orbital floor blowout fracture; transantral approach (Caldwell-Luc typeoperation)

21386 Open treatment of orbital floor blowout fracture; periorbital appoach21387 Open treatment of orbital floor blowout fracture; combined approach21390 Open treatment of orbital floor blowout fracture; periorbital approach, with alloplastic or

other implant21395 Open treatment of orbital floor blowout fracture; periorbital approach with bone graft

(included obtaining graft)

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or comminuted fragments require open reduction.36

Thus, multiple approaches allow us to achieve the bestresults individualized for each of our patients.

Gregory R. D. Evans, M.DAesthetic and Plastic Surgery Institute

200 South Manchester, Suite 650Orange, Calif. 92868

gevans@uci.edu

REFERENCES1. Manson, P. Facial fractures. In J. Smith and S. Aston (Eds.),

Plastic Surgery. Boston: Little, Brown, 1991. Pp. 347–396.2. Wittwer, G., Adeyemo, W. L., Yerit, K., et al. Complications

after zygoma fracture fixation: Is there a difference betweenbiodegradable materials and how do they compare with ti-tanium osteosynthesis? Oral Surg. Oral Med. Oral Pathol. OralRadiol. Endod. 101: 419, 2006.

3. Crighton, L. A., and Koppel, D. A. The value of postoperativeradiographs in the management of zygomatic fractures: Pro-spective study. Br. J. Oral Maxillofac. Surg. 45: 51, 2006.

4. Nitsch, A., Bruns, A., Gruber, R. M., Wiese, K. G., and Merten,H. A. Evaluation of the postoperative clinical results of re-positioning isolated zygomatic fractures. Schweiz. Monatsschr.Zahnmed. 116: 43, 2006.

5. Czerwinski, M., and Lee, C. The rationale and technique ofendoscopic approach to the zygomatic arch in facial trauma.Facial Plast. Surg. Clin. North Am. 14: 37, 2006.

6. Gomes, P. P., Passeri, L. A., and Barbosa, J. R. A 5 yearretrospective study of zygomatico-orbital complex and zygo-matic arch fractures in Sao Paulo State, Brazil. J. Oral Max-illofac. Surg. 64: 63, 2006.

7. Langsdon, P. R., Knipe, T. A., Whatley, W. S., and Costello,T. H. Transconjunctival approach to the zygomatico-frontallimb of orbitozygomatic complex fractures. Facial Plast. Surg.21: 171, 2005.

8. Pribitkin, E. A., Cognetti, D. M., Marshall, S. N., and Bilyk,J. Lag screw fixation in midface fractures. Facial Plast. Surg.21: 165, 2005.

9. Dziadek, H., and Cieslik, T. Treatment of zygomatico-orbitaland zygomatico-maxillo-orbital fractures by open reductionand rigid internal fixation (in Polish). Wiad. Lek. 58: 270, 2005.

10. Mavili, M. E., and Tuncbilek, G. Treatment of noncommi-nuted zygoma fractures with percutaneous reduction andrigid external devices. J. Craniofac. Surg. 16: 829, 2005.

11. Dziadek, H., and Cieslik, T. Causes and effects of zygomatico-orbital and zygomatico-maxillo-orbital fractures managed byopen reduction and rigid internal fixation. Ann. Univ. MariaeCurie Sklodowska 59: 44, 2004.

12. Obuekwe, O., Owotade, F., and Osaiyuwu, O. Etiology andpattern of zygomatic complex fractures: A retrospectivestudy. J. Natl. Med. Assoc. 97: 992, 2005.

13. Pedemonte, C., and Basili, A. Predictive factors in infraor-bital sensitivity disturbances following zygomaticomaxillaryfactures. Int. J. Oral Maxillofac. Surg. 34: 503, 2005.

14. Czerwinski, M., Martin, M., and Lee, C. Quantitative com-parison of open reduction and internal fixation versus theGillies method in the treatment of orbitozygomatic complexfractures. Plast. Reconstr. Surg. 115: 1848, 2005.

15. Chang, E. L., Hatton, M. P., Bernardion, C. R., and Rubin,P. A. Simplified repair of zygomatic fractures through atransconjunctival approach. Ophthalmology 112: 1302, 2005.

16. Yonehara, Y., Hirabayashi, S., Tachi, M., and Ishii, H. Treat-ment of zygomatic fractures without inferior orbital rim fix-ation. J. Craniofac. Surg. 16: 481, 2005.

17. Benoliel, R., Birenboim, R., Regev, E., and Eliav, E. Neuro-sensory changes in the infraorbital nerve following zygomaticfractures. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.99: 657, 2005.

18. Enislidis, G., Yerit, K., Wittwer, G., Kohnke, R., Schragl, S.,and Ewers, R. Self-reinforced biodegradable plates andscrews for fixation of zygomatic fractures. J. Craniomaxillofac.Surg. 33: 95, 2005.

19. Hanemann, M., Simmons, O., Jain, S., Baratta, R., Guerra,A. B., and Metzinger, S. E. A comparison of combinations oftitanium and resorbable plating systems for repair of isolatedzygomatic fractures in the adult: A quantitative biomechani-cal study. Ann. Plast. Surg. 54: 402, 2005.

20. Czerwinski, M., and Lee, C. Traumatic arch injury: Indica-tions and an endoscopic method of repair. Facial Plast. Surg.20: 231, 2004.

21. Chang, E. L., and Bernardino, C. R. Update on orbitaltrauma. Curr. Opin. Ophthalmol. 15: 411, 2004.

22. Honig, J. F., and Merten, H. A. Classification system andtreatment of zygomatic arch fractures in the clinical setting.J. Craniofac. Surg. 15: 986, 2004.

23. Ferreira, P., Marques, M., Pinho, C., Rodrigues, J., Reis, J., andAmarante, J. Midfacial fractures in children and adolescents: Areview of 492 cases. Br. J. Oral Maxillofac. Surg. 42: 501, 2004.

24. Top, H., Aygit, C., Sarikaya, A., Karaman, D., and Firat, M. F.Evaluation of maxillary sinus after treatment of midfacialfractures. J. Oral Maxillofac. Surg. 62: 1229, 2004.

25. Holzle, F., Swaid, S., Schiwy, T., Wolfelschneider, P., Nolte,D., and Wolff, K. D. Management of zygomatic fractures viaa transconjunctival approach with lateral canthotomy whilepreserving the lateral ligament. Mund. Kiefer. Gesichtschir. 8:296, 2004.

26. Zhong, L. P., and Chen, G. F. Subciliary incision and lateralcantholysis in rigid internal fixation of zygomatic complexfractures. Chin. J. Traumatol. 7: 170, 2004.

27. Cheema, S. A. Zygomatic bone fracture. J. Coll. PhysiciansSurg. Pak. 14: 337, 2004.

28. Deveci, M., Eski, M., Gurses, S., Yucesoy, C. A., Selmanpa-koglu, N., and Akkas, N. Biomechanical analysis of the rigidfixation of zygoma fractures: An experimental study.J. Craniofac. Surg. 15: 595, 2004.

29. He, D. M., Zhang, Y., and Zhang, Z. K. A study on theclassification and treatment of zygomatic complex fractures.Zhonghau Kou Qiang Yi Xue Za Zhi 39: 211, 2004.

30. Fogaca, W. C., Fereirra, M. C., and Dellon, A. L. Infraorbitalnerve injury associated with zygomatic fractures: Documenta-tion with neurosensory testing. Plast. Reconstr. Surg. 113: 834,2004.

31. Nkenke, E., Maier, T., Benz, M., et al. Hertel exophthal-mometry versus computed tomography and optical 3D im-aging for the determination of the globe position in zygo-matic fractures. Int. J. Oral Maxillofac. Surg. 33: 125, 2004.

32. Folkestad, L., and Granstrom, G. A prospective study of or-bital fracture sequelae after change of surgical routines.J. Oral Maxillofac. Surg. 61: 1038, 2003.

33. Hollier, L. H., Thornton, J., Pazmino, P., and Stal, S. Themanagement of orbitozygomatic fractures. Plast. Reconstr.Surg. 111: 2386, 2003.

34. Rohrich, R. J., Janis, J. E., and Adams, W. P. Subciliary versussubtarsal approaches to orbitozygomatic fractures. Plast. Re-constr. Surg. 111: 1708, 2003.

35. Yokoo, S., Tahara, S., Sakurai, A., et al. Replantation of anavulsed zygomatic bone as a freeze-preserved autologousgraft: A case report. J. Craniomaxillofac. Surg. 31: 115, 2003.

36. Tadj, A., and Kimble, F. W. Fractured zygomas. Aust.N. Z. J. Surg. 73: 49, 2003.

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37. Motamedi, M. H. An assessment of maxillofacial fractures: A 5year study of 237 patients. J. Oral Maxillofac. Surg. 61: 61, 2003.

38. Manolidis, S., Weeks, B. H., Kirby, M., Scarlett, M., and Hol-lier, L. Classification and surgical management of orbitalfractures: Experience with 111 orbital reconstructions.J. Craniofac. Surg. 13: 726, 2002.

39. Rohner, D., Tay, A., Meng, C. S., Hutmacher, D. W., andHammer, B. The sphenozygomatic suture as a key site forosteosynthesis of the orbitozygomatic complex in panfacialfractures: A biomechanical study in human cadavers basedon clinical practice. Plast. Reconstr. Surg. 110: 1463, 2002.

40. Baumann, A., Burggasser, G., Gauss, N., and Ewers, R. Or-bital floor reconstruction with an alloplastic resorbable poly-dioxanone sheet. Int. J. Oral Maxillofac. Surg. 31: 367, 2002.

41. Becelli, R., Carboni, A., Cerulli, G., Perugini, M., and Ian-netti, G. Delayed and inadequately treated malar fractures:Evolution in the treatment, presentation of 77 cases andreview of the literature. Aesthetic Plast. Surg. 26: 134, 2002.

42. Carlin, C. B., Ruff, G., Mansfeld, C. P., and Clinton, M. S.Facial fractures and related injuries: A ten year retrospectiveanalysis. J. Craniomaxillofac. Trauma 4: 44, 1998.

43. Peled, M., Ardekian, L., Abu-el-Naaj, I., Rahmiel, A., andLaufer, D. Complications of miniplate osteosynthesis in thetreatment of mandibular fractures. J. Craniomaxillofac.Trauma 3: 14, 1997.

44. Triana, R. J., and Shockley, W. W. Pediatric zygomatico-orbital complex fractures: The use of resorbable plattingsystems. A case report. J. Craniomaxillofac. Trauma 4: 32, 1998.

45. Yaremchuk, M. J. Orbital deformity after craniofacial frac-ture repair: Avoidance and treatment. J. Craniomaxillofac.Trauma 5: 7, 1999.

46. Kokoska, M. S., and Citardi, M. J. Computer-aided surgicalreduction of facial fractures. Facial Plast. Surg. 16: 169, 2000.

47. McRae, M., and Frodel, J. Midface fractures. Facial Plast. Surg.16: 107, 2000.

48. Chen, C. T., and Chen, Y. R. Endoscopically assisted repairof orbital floor fractures. Plast. Reconstr. Surg. 108: 2011, 2001.

49. Kovacs, A. F., and Ghahremani, M. Minimization of zygo-matic complex fracture treatment. Int. J. Oral Maxillofac. Surg.30: 380, 2001.

50. Becelli, R., Renzi, G., Perugini, M., and Iannetti, G. Cranio-facial traumas: Immediate and delayed treatment. J. Cranio-fac. Surg. 11: 265, 2000.

51. Iatrou, I., Theologie-Lygidakis, N., and Angelopoulos, A. Useof membrane and bone grafts in the reconstruction of orbitalfractures. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod.91: 281, 2001.

52. McGimpsey, J. G., Vaidya, A., Biagioni, P. A., and Lamey, P.J. Role of thermography in the assessment of infraorbitalnerve injury after malar fractures. Br. J. Oral Maxillofac. Surg.38: 581, 2000.

53. Roccia, F., Servadio, F., and Gerbino, G. Maxillofacial frac-tures following airbag deployment. J. Craniomaxillofac. Surg.27: 335, 1999.

54. Hwang, K., and Lee, S. I. Reduction of zygomatic arch frac-tures using a towel clip. J. Craniofac. Surg. 10: 439, 1999.

55. Courtney, D. J. Upper buccal sulcus approach to manage-ment of fractures of the zygomatic complex: A retrospectivestudy of 50 cases. Br. J. Oral Maxillofac. Surg. 37: 464, 1999.

56. Strong, E. B., and Sykes, J. M. Zygoma complex fractures.Facial Plast. Surg. 14: 105, 1998.

57. Patel, B. C., and Hoffman, J. Management of complex orbitalfractures. Facial Plast. Surg. 14: 83, 1998.

58. Shumrick, K. A., and Campbell, A. C. Management of theorbital rim and floor in zygoma and midface fractures: Cri-teria for selective exploration. Facial Plast. Surg. 14: 77, 1998.

59. Gassner, R., Hackl, W., Tuli, T., and Emshoff, R. Facial in-juries in skiing: A retrospective study of 549 cases. Sports Med.27: 127, 1999.

60. Martin, R. J., Greenman, D. N., and Jackman, D. S. A customsplint for zygomatic fractures. Plast. Reconstr. Surg. 103: 1254,1999.

61. Zachariades, N., Mezitis, M., and Anagnostopoulos, D.Changing trends in the treatment of zygomaticomaxillarycomplex fractures: A 12 year evaluation of methods used.J. Oral Maxillofac. Surg. 56: 1152, 1998.

62. Longaker, M. T., and Kawamoto, H. K. Evolving thoughts oncorrecting posttraumatic enophthalmos. Plast. Reconstr. Surg.101: 899, 1998.

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65. Celikoz, B., Duman, H., and Selmanpakoglu, N. Reconstruc-tion of the orbital floor with lyophilized tensor fascia lata.J. Oral Maxillofac. Surg. 55: 240, 1997.

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