Zy gomaticomaxil lar y

F r a c t u res
Christine M. Jones, MDa, Cecelia E. Schmalbach, MD, MScb,*

KEYWORDS
 Zygomaticomaxillary complex  Zygomatic arch  Orbitozygomatic fracture  Malar eminence
 Facial trauma  Facial fracture

KEY POINTS
 The zygomaticomaxillary complex (ZMC) is a tetrapod structure, with articulations at the zygoma-
ticofrontal buttress, zygomaticomaxillary buttress, infraorbital rim, zygomatic arch, and zygomati-
cosphenoid suture.
 Displaced zygomaticomaxillary fractures cause midfacial flattening and widening.
 The zygomatic arch is difficult to visualize directly, and ZMC fractures are often treated with open
reduction via minimal access incisions.
 The decision to perform one-, two-, three-, or four-point fixation of the zygomaticomaxillary com-
plex depends on individual fracture characteristics.
 Reduction of the zygomatic bone to the greater wing of the sphenoid should be checked in all but
single-point approaches, because it provides the most sensitive evaluation of three-dimensional
reduction of the ZMC with the skull base.

INTRODUCTION less common in pediatric patients than in adults,5

and are uncommon before development of the
Fractures of the zygomaticomaxillary complex globe pneumatization of the maxillary sinus is
(ZMC) are common injuries, representing up to complete, about age 7.8 The mechanism of injury,
25% of facial fractures.1 In athletes, ZMC fractures advances in protective equipment, and the age of
can result from low- or high-velocity midfacial typical athletes make ZMC fractures less common
trauma.2 Helmets have reduced the incidence of in athletes than in the general population, account-
injury, but ZMC fracture is still common in base- ing for 4% to 8% of facial fractures sustained in
ball, basketball, and sports with a predisposition sports.3,4,9
to falls from moderate heights, such as horseback
riding,3,4 among others.
The midface undergoes a substantial increase in ANATOMY
size and ossification during the adolescent growth The zygoma is a tetrapod cornerstone of the mid-
phase.5 Children have a greater cranial-to-facial face, representing the intersection of vertical, trans-
proportion, more flexible skeletal suture lines, verse, and sagittal facial buttresses (Fig. 2). The
unerupted dentition, and thicker overlying soft tis- ZMC can fracture at any of these five articulations.
sue, making midfacial fractures less common in Fracture of the ZMC requires less force than
young athletes than in late adolescents and adults most surrounding bones (Fig. 3).10 The zygoma
(Fig. 1).5–7 Fractures of the zygoma are about 70% tends to become impacted, medially rotated, and
facialplastic.theclinics.com

a
Division of Plastic and Reconstructive Surgery, Lewis Katz School of Medicine at Temple University, 3401
North Broad Street, 4th Floor Parkinson Pavilion, Philadelphia, PA 19140, USA; b David Myers, MD Professor
and Chair, Department of Otolaryngology – Head and Neck Surgery, Lewis Katz School of Medicine at Temple
University, 3440 North Broad Street, Kresge West # 309, Philadelphia, PA 19140, USA
* Corresponding author.
E-mail address: Cecelia.Schmalbach@tuhs.temple.edu
Twitter: @CMJones_MD (C.M.J.)

Facial Plast Surg Clin N Am 30 (2022) 47–61

https://doi.org/10.1016/j.fsc.2021.08.004
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48 Jones & Schmalbach

mandible. Depressed fractures of the zygomatic

arch or ZMC can cause trismus through impinge-
ment of the arch on the coronoid process of the
mandible, adhesions between the arch and coro-
noid process, or direct injury to the muscles of
mastication.12,13
The superomedial portion of the zygoma creates
the lateral 40% of the orbital floor. This portion of
the zygoma is thin and prone to buckling with an
anterior or lateral impact.14 For this reason, many
ZMC fractures are accompanied by fractures of
the orbital floor.

EVALUATION
History
A complete medical history should be obtained,
focusing on mechanism of trauma, comorbidities,
and symptoms (Table 1). High-energy athletic in-
juries, loss of consciousness, or the presence of
Fig. 1. Comparison of fracture locations significantly
spinal pain or peripheral neurologic symptoms
more frequent in pediatric (left, nasal fractures
[red]) and adult (right, maxillary and zygomatic frac-
necessitate a full trauma work-up. In children,
tures [blue]) patients. Craniofacial skeletons are de- zygomatic and orbital fractures have a higher likeli-
picted at the same size to emphasize the small hood of accompanying cervical spine injury.15,16
facial-to-cranial proportions in pediatric patients. Baseline visual changes should be identified.
(From Fujisawa K, Suzuki A, Yamakawa T, Onishi F, Recent use of nonsteroidal anti-inflammatory
Minabe T. Pediatric-specific midfacial fracture pat- agents or anticoagulants may warrant discussion
terns and management: Pediatric vs adult patients. J of the risk of perioperative bleeding.17,18
Craniofac Surg. 2020;31:e312-e315; with permission)

Physical Examination
inferiorly displaced, which leads to widening and
A more accurate assessment is conducted after
flattening of the midface.11,12
edema subsides, about 5 to 7 days post-trauma.
Isolated fractures of the zygomatic arch should
Malar retrusion accompanies most operative frac-
be distinguished from those of the ZMC. The zygo-
tures.12 Step-offs may be palpable or visible along
matic arch typically bows inward, which may
the buttresses. Pseudoptosis, vertical dystopia,
create a palpable or visible depression under the
inferior displacement of the lateral canthus, or
thin skin of the lateral midface.
increased scleral show may be more subtle signs
The muscles of mastication pass from the tem-
of displacement.
poral fossa and zygomatic arch to insert onto the
Infraorbital hypoesthesia is often present,
extending onto the upper lip and dentate maxilla.
Trismus can represent an operative indication;
approximately 4.5 cm of interincisal opening is
necessary for full function. Subjective malocclu-
sion may occur secondary to altered sensation in
the region of the maxillary premolars and molars.
Signs of orbital trauma should be evaluated (see
Table 1). Subconjunctival hemorrhage is a sensi-
tive indicator of orbital fracture.12,19,20 With
concomitant orbital floor fractures, emergencies,
such as entrapment, superior orbital fissure syn-
drome, orbital apex syndrome, and retrobulbar he-
matoma, must be ruled out. Concomitant major
Fig. 2. Tetrapod structure of the ZMC. (From Strong ocular or blinding injuries may be present in about
EB, Gary C. Management of zygomaticomaxillary com- 10% of patients; thus, consideration should be
plex fractures. Fac Plast Surg Clin N Am. 2017;25:547– given for ophthalmologic evaluation in all ZMC
562; with permission) fractures.19,20

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 ZMC Fractures 49

(Fig. 4). The zygomaticosphenoid buttress pro-

vides sagittal and transverse support to the
zygoma and is a sensitive indicator of fracture
displacement.23,24 Retropositioning of the malar
eminence is assessed on axial and three-
dimensional imaging. Coronal and sagittal imaging
are best to examine fractures and displacement of
the zygomaticofrontal and zygomaticomaxillary
buttresses. The degree of comminution should
be noted, because this influences the number of
points of fixation needed.

OPERATIVE MANAGEMENT
Virtual Surgical Planning
Preoperative virtual surgical planning (VSP) allows
identification and reduction of individual fracture
segments. Reduction is based on a mirror image
of the uninjured contralateral side. In bilateral in-
juries or baseline deformity, a representative
normative scan matched to the age and gender
of the patient is used. Stereolithographic models
are three-dimensional printed, modeling the frac-
tured skeleton for better conceptualization, or
Fig. 3. Forces needed to fracture the facial bones. simulating the reduced ZMC to prebend osteosyn-
(From Viozzi CF. Maxillofacial and mandibular frac- thesis plates.25 Custom implants are fabricated to
tures in sports. Clin Sports Med. 2017;36:355–368; guide the proper skeletal reduction. VSP session
used with permission of Mayo Foundation for Medical data are combined with intraoperative navigation
Education and Research, all rights reserved) to compare the preoperative plan with operative
execution.1,26,27
Timing and expense are barriers to widespread
Radiographic Evaluation
adoption. Commercial fabrication of custom-
Maxillofacial computed tomography (CT) with thin printed osteosynthesis plates currently takes
cuts (0.625–1.0 mm) is the gold standard in evalu- approximately 2 weeks from the time of CT data
ating for zygomaticomaxillary fractures.21,22 In submission. For acute trauma, timing is often not
children, low-dose radiation protocols can limit prompt enough to make VSP application practical,
exposure to ionizing radiation. Fracture lines and particularly for all but the most complex zygomati-
displacement are evaluated. On axial imaging, comaxillary cases. With technologic advances and
alignment of the zygomaticosphenoid buttress, institutional sourcing, VSP may be more
infraorbital rim, and zygomatic arch is assessed commonly used in the future.

Fig. 4. Right ZMC fracture with displacement at infraorbital rim (A), zygomatic arch (B), and zygomaticosphenoid
suture (C).

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 50
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Table 1
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Possible clinical signs and symptoms accompanying ZMC fractures.

Jones & Schmalbach

Ocular/ophthalmic
Skeletal detormities symptoms Sensory impairment Oral symptoms Nasal symptoms
 Asymmetry of the  Periorbital edema or he- Sensory deficit  Ecchymosis of the gingi-  Ipsilateral epistaxis
midface matoma (“monocle (hypoesthesia, vobuccal maxillary sulcus  Ipsilateral hematosinus
 Depression/flattening of hematoma”) anesthesia) in the  Subjective occlusal disor-
the malar prominence  Pseudoptosis distribution of the der due to altered sensa-
 Flattening, hollowing  Increased scleral show following nerves: tion of the maxillary
(bony indentation) or  Downward slant of  Infraorbital nerve: premolars/molars and
broadening over the palpebral fissure or hori-  lower eyelid gingiva, no objective
zygomatic arch zontal lid axis  upper lip malocclusion
 Palpable step offs or gap respectively  ala and lateral sidewall  Palpable contour distur-
deformities (infraorbital/  Malposition of the of the nose bance of zygomatico-
lateral) lateral canthus  Zygomatiofacial nerve: maxillaiy buttress
 Vertical shortening of  malar eminence  Restriction of mandib-
the lower eyelid  cheek ular opening (trismus) or
(ectropion)  Zygomatiofacial nerve: closing—blockage of
 Subconjunctival ecchy-  lower lateral orbital temporal muscle or co-
mosis (temporal/medial) rim ronoid process either by
 Chemosis  anterior temporal/ impacted zygomatic arch
 Pupillary or globe level lateral/frontal region or retrodis-placed
disparity (hypoglobus) zygoma
 Proptosis bulbi
 Enophthalmos (outward
displacement of zygoma)
 Exophthalmos (inward
displacement of zygoma)
 Subcutaneous periorbital
air emphysema (skin
crepitation)
  Pneumoexophthalmos
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 Diplopia (neurogenic
ocular motility disorder
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— III, IV, VI; enophthal-

mos; entrapment, re-
vealed by forced duction
test)
 Amaurosis
 Superior orbital fissure
syndrome
From Cornelius CP. Zygomaticomaxillary complex fractures, zygomatic arch fractures. In: Principles of Internal Fixation of the Craniomaxillofacial Skeleton – Trauma and Orthognathic
Surgery. Thieme;2012:205–221; with permission. Copyright AO Foundation, Switzerland.

ZMC Fractures
51
52 Jones & Schmalbach

Fig. 5. The Carroll-Gerard screw is a threaded tool (A) that is placed through the lower eyelid incision or percu-
taneously (B) to assist with reduction or stabilize the ZMC during osteosynthesis.

Timing maxillary approach is common, with or without a

superolateral approach. For isolated zygomatic
Allowing time for facial edema to subside improves
arch fractures, the Gilles or Keen approach
the precision of evaluating operative indications,
(described later) provides access for open reduc-
while facilitating access through concealed inci-
tion without fixation. For complex, highly commi-
sions. However, by 2 to 3 weeks postinjury, frac-
nuted, or panfacial fractures, or fractures in
tures begin to heal, particularly in younger
which osteosynthesis is required along the zygo-
athletes, making accurate reduction more chal-
matic arch, a coronal approach is necessary.
lenging. Most surgeons prefer to operate at 1 to
2 weeks postinjury.23
Minimally Invasive Incisions
Closed Reduction Isolated zygomatic arch fractures are treated with
open reduction via a limited access approach us-
Closed reduction has limited indications because
ing the Gilles or Keen incisions. The Gilles
of the difficulty of accessing the deep aspect of
approach is achieved by making a 2-cm incision
the midface in the absence of incisions. For iso-
within the temporal scalp, 2.5 cm superior and
lated zygomatic arch fractures, a bone hook is
anterior to the helical root (Fig. 6A). Use of electric
placed percutaneously over the arch, and a later-
cautery should be minimized to avoid alopecia.
ally directed force applied to achieve reduction.
Careful palpation prevents incising over the course
Similarly, a bone hook, threaded reduction tool
of the superficial temporal artery. The scalp and
(Fig. 5A), or screw is applied to the body of the
subcutaneous tissue are incised. The subcutane-
zygoma, and reducing forces applied percutane-
ous tissue is bluntly divided until the temporalis
ously using these tools to reduce ZMC fractures.
fascia is seen (see Fig. 6B). The temporalis fascia
Many fractures demonstrate inadequate stability
is incised, exposing the temporalis muscle (see
or too significant a degree of displacement to be
Fig. 6C). At this point, an elevator is placed deep
appropriate for these methods. The presence of
to the temporalis fascia, and a sweeping motion
a fracture along the zygomaticofrontal buttress is
allows the elevator to pass caudally, until the tip
predictive of failure of closed reduction, and
is deep to the zygomatic arch (see Fig. 6D).
displacement at this location is an indication for
Applying a laterally directed force while palpating
open reduction with internal fixation. Because of
along the arch, the depressed segment is
the risk of concomitant orbital fracture, forced
reduced.
duction should be completed after closed ZMC
In the Keen incision, a 2-cm incision is made in
reduction to assess for entrapment caused by
the upper buccal sulcus in the region of the zygo-
fracture reduction.
maticomaxillary buttress (Fig. 7A–B). An elevator
is directed just medial to the arch (see Fig. 7C).
Open Reduction
Laterally directed force with manual palpation
The number and location of incisions depends on guides the completion of reduction.
the anticipated sites of fixation. For ZMC fractures, The stability of the reduced zygomatic arch de-
a combination of a lower eyelid and inferior pends on the fracture location, pattern, and

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 ZMC Fractures 53

Fig. 6. (A-D) The Gilles approach. (From Haug RH, Buchbinder D. Incisions for access to craniomaxillofacial frac-
tures. Atlas Oral Maxillofac Surg Clin North Am. 1993;1:1–29; with permission)

Fig. 7. (A-C) The Keen approach. (From Haug RH, Buchbinder D. Incisions for access to craniomaxillofacial frac-
tures. Atlas Oral Maxillofac Surg Clin North Am. 1993;1:1–29; with permission)

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54 Jones & Schmalbach

Open Reduction with Internal Fixation

Depending on fracture comminution and concom-
itant injuries, anterior or posterior approaches may
be selected (Fig. 8). Anterior approaches allow
regional access, and multiple incisions are typi-
cally performed depending on the ease of assess-
ing reduction and the number of sites planned for
osteosynthesis. The anterior approaches include
the lateral brow incisions, upper blepharoplasty
or lower eyelid incisions, and upper buccal sulcus
incisions. The primary posterior approach is the
coronal incision.
The lateral brow incision is a small incision made
inferior to the lateral portion of the eyebrow
(Fig. 9), providing local access to the zygomatico-
frontal suture. The incision is made outside the
hair-bearing skin to avoid alopecia. The upper
blepharoplasty incision is drawn in a supratarsal
Fig. 8. Selected incisions for periorbital and midface crease along the lateral portion of the upper eyelid.
skeletal access include the coronal (a), Wright (b), up- A skin-muscle flap is elevated, leaving the orbital
per lid crease (c), transconjunctival (d), lateral can- septum intact, and blunt dissection proceeds in a
thotomy (e), subcilliary (f), subtarsal/mid-lid (g), supraperiosteal plane until the lateral orbital rim
infraorbital (h), Lynch (i), and upper buccal sulcus (j). is reached. This incision provides access to the
(From Jones CM, van Aalst JA. Facial fractures and
lateral orbital wall and zygomaticofrontal suture.
soft tissue injuries. In: Chung K, ed. Grabb & Smith’s
Plastic Surgery. 8th Ed. Wolters Kluwer;2020:1237–
The upper blepharoplasty incision is generally
1285; with permission) preferred over the lateral brow incision.
Lower eyelid incisions include transconjunctival
preseptal, transconjunctival postseptal, subcilli-
ary, or infraorbital approaches (Fig. 10). These ap-
proaches are discussed in detail by Flynn and
degree of comminution. Only fractures with a high colleagues in this issue. At the infraorbital rim, sub-
level of stability should be selected. More commi- periosteal dissection proceeds caudally onto the
nuted and unstable zygomatic arch fractures, zygoma and medially and laterally along the infe-
particularly those causing significant aesthetic de- rior and lateral orbital rims to expose fracture lines.
formities, may be better suited to open reduction The upper buccal sulcus incision is made from
with internal fixation via coronal approach, or later the lateral incisor to the first molar, 3 to 4 mm
camouflage with bone graft, fat graft, or alloplastic above the mucogingival line to facilitate closure.
material. The position of the parotid duct orifice is checked

Fig. 9. (A-B) The lateral brow incision. (From Haug RH, Buchbinder D. Incisions for access to craniomaxillofacial
fractures. Atlas Oral Maxillofac Surg Clin North Am. 1993;1:1–29; with permission)

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 ZMC Fractures 55

along the nasomaxillary and posterior maxillary

buttresses, just medial and lateral to the infraorbi-
tal nerve, respectively.
The coronal approach has the advantage of
wide exposure of the frontal bone, orbit, malar
eminence, and zygomatic arch, and is used to
treat a variety of complex facial fractures. Howev-
er, potential disadvantages include a long scar, al-
opecia, temporal hollowing, or injury to the frontal
branch of the facial nerve. The scar is made less
conspicuous by a curving zig-zag pattern, which
allows the hair follicles to lie at an angle to the
scar. The incision is extended anterior to the heli-
cal root in the preauricular crease. A hemicoronal
Fig. 10. Cross-sectional view of lower eyelid ap- incision is used to access a unilateral zygomatico-
proaches. (From Jones CM, van Aalst JA. Facial frac- maxillary fracture.
tures and soft tissue injuries. In: Chung K, ed. Grabb The coronal incision is made sharply through the
& Smith’s Plastic Surgery. 8th Ed. Wolters skin, subcutaneous tissue, and galea aponeuro-
Kluwer;2020:1237–1285; with permission) tica. Working in small sections, needle-point elec-
trocautery is used to cauterize small vessels while
to avoid injury. After incising the mucosa sharply or protecting the hair follicles. Avoiding compressive
with electrocautery, dissection is carried directly hemostatic clips can minimize alopecia. A subga-
down to and through the periosteum. Dissection leal or supraperiosteal dissection is completed to
then switches to a blunt subperiosteal elevation the supraorbital rims and the superior temporal
line. At the superior temporal line, dissection pro-
ceeds toward the zygomatic arch along the super-
ficial aspect of the temporalis fascia. Caudally, the
yellow outline of the superficial temporal fat pad is
seen; at this point, the temporalis fascia splits into
the superficial and deep layers of the deep tempo-
ral fascia. The superficial layer of the deep tempo-
ral fascia is incised, and dissection continues
along the deep aspect of this layer, just superficial
to the temporal fat pad, using minimal electrocau-
tery to preserve the temporal fat pad. Once the
arch is reached, the periosteum is incised,
providing access for exposure in the subperiosteal
plane. This manner of dissection protects the fron-
tal branch of the facial nerve, which runs superfi-
cial to the deep temporal fascia over the
zygomatic arch (Fig. 11).

Osteosynthesis
Points of fixation
One-, two-, three-, or four-point fixation is selected
depending on fracture displacement and commi-
nution.1,24,28 Titanium plates demonstrate a low
complication profile and excellent biomechanical
stability and are favored over bioabsorbable plates
in most fractures.2,29,30
Fig. 11. Anatomy of the temporal region as related to
approaches to the zygomatic arch. SMAS, superficial For stable fractures with mild displacement,
musculoaponeurotic system. (From Agarwal CA, Men- including minimal to no displacement at the zygo-
denhall SD, Foreman KB, Owsley JQ. The course of the maticofrontal suture, single-point fixation is per-
frontal branch of the facial nerve in relation to fascial formed at the posterior maxillary buttress via
planes: An anatomic study. Plast Reconstr Surg. upper buccal sulcus approach. After elevation of
2010;125:532–537; with permission) the fracture, an L-shaped plate is placed along

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56 Jones & Schmalbach

Fig. 12. Osteosynthesis with (A) 1-point fixation, (B) 2-point fixation, (C) 3-point fixation, (D) 4-point fixation, and
(E) 4-point fixation with repair of orbital floor.

the zygomaticomaxillary buttress (Fig. 12A). The dimensional fracture reduction. The infraorbital rim
plate is adapted to the three-dimensional skeletal is accessed through a lower eyelid incision. The
contour by curving the cephalad portion out-of- zygomaticofrontal buttress is accessed through a
plane and opening in-plane to a more obtuse lateral blepharoplasty, lateral brow, or coronal
angle. The vertical and horizontal limbs of the plate approach. In both locations, a low-profile, curvi-
are secured to thick, stable bone of the posterior linear miniplate is typically selected for fixation. Ad-
maxillary buttress and the alveolar bone superior equacy of reduction should be sequentially
to the tooth roots. Inadequate plate adaptation checked at each buttress. A plate is adapted at
places screws into the thin bone of the maxillary si- one fracture first, typically the zygomaticofrontal
nus. Fracture comminution along the posterior buttress, using a single screw on either side of the
maxillary buttress is common, and is overcome fracture, until adequate reduction and stabilization
by selecting an L-plate of a longer length. Plate are achieved at the other visualized sites.
profiles vary. The posterior maxillary buttress con- Reduction of the zygomatic bone to the
tains thick bone that adds significant stability and greater wing of the sphenoid should be checked
has the thick overlying buccal fat pad. For this in all but single-point approaches, because it
reason, a thicker plate is advocated in this provides the most sensitive evaluation of the ad-
region.22,24 equacy of three-dimensional reduction of the
A second or third point of fixation is added along ZMC with the skull base.24 This is accomplished
the infraorbital rim and/or zygomaticofrontal suture through the lower eyelid or upper blepharoplasty
for fractures demonstrating more displacement and incision via subperiosteal dissection along the
less stability (see Fig. 12B–C). Plate location is lateral orbital wall. Comminution along the lateral
selected by palpating for bony step-offs, evaluating orbital wall makes assessment of the zygomati-
displacement on imaging, and surgeon preference. cosphenoid reduction more difficult, and more
The skin and soft tissue in both locations is thin, emphasis is then placed on evaluating other ar-
which can make displaced fracture edges or an ticulations. Completing osteosynthesis at the
implanted plate more easily perceptible. In addition zygomaticosphenoid buttress is uncommon
to allowing another site of osteosynthesis, a second because of difficulty obtaining an appropriate
access can provide better assessment of three- angle for fixation.

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 ZMC Fractures 57

A fourth point of fixation is added along the reduces its stability by releasing periosteal attach-
zygomatic arch in the most complex, comminuted, ments of small bone fragments, increasing the
or unstable fractures, particularly those causing likelihood that fractures need to be treated.
deformity along the arch (see Fig. 12D–E).2 A cor- Through imaging before exploration, a more accu-
onal approach is needed to access the arch rate assessment of the fracture pattern and size is
directly. A long miniplate can stabilize multiple achieved to tailor treatment to the individual
fracture segments. This technique has the advan- defect.33,34
tage of excellent visualization of all zygomatic ar-
ticulations, allowing reduction to be checked Intraoperative Navigation
sequentially. In general, the zygomaticofrontal Technology widely used in neurosurgery and
buttress provides an initial point of stability, endoscopic sinus surgery is now being adapted
creating a superiorly based hinge, while the other for treatment of craniomaxillofacial trauma.28
articulations are assessed and stabilized. Begin- Intraoperative navigation combines preoperative
ning with articulations that are least comminuted facial scans with intraoperative positioning de-
helps simplify the fracture. vices to allow more accurate assessment of
With unstable or highly impacted ZMC fractures, reduction. If VSP is conducted preoperatively,
a threaded reduction tool can help reduce the the simulated reduction can be uploaded to the
zygoma and add stability while osteosynthesis is navigation system for real-time assessment of
completed (see Fig. 5A–B).1 This tool is applied plan execution.
to the body of the zygoma through the lower eyelid Inserting positioning screws onto the maxilla
incision or directly via percutaneous approach before preoperative CT acquisition provides stable
(Fig. 13A–D). intraoperative reference points (Fig. 14A). Preop-
Traditionally, the orbital floor was routinely erative virtual reduction is done via VSP, and the
explored after reduction of the ZMC to ensure unreduced and reduced scans uploaded to the
that it did not need repair. More recently, it has system (see Fig. 14B). Intraoperatively, the patient
become apparent that this is usually unnecessary is fitted with a digital reference frame fixed to the
and the need to repair is accurately predicted skull with a titanium screw (see Fig. 14C). Refer-
based on the preoperative CT imaging. Alterna- ence points are marked using an instrument with
tively, intraoperative imaging after ZMC reduction light-reflecting balls, which reflect infrared rays
can determine whether orbital floor exploration is emitted by cameras (see Fig. 14D). By registering
indicated.25 the positioning screws, navigation accuracy is
In pediatric athletes who have not yet completed checked to less than 1 mm (see Fig. 14E).27,28
growth, consideration should be given to using Combining VSP, intraoperative navigation, and
absorbable plates and screws when internal fixa- intraoperative imaging provides an accurate pro-
tion is necessary.5,8,24 Titanium plates can migrate cess of planning, execution, and verification of
with growth and require secondary removal. In the desired operative result.1
young athletes, fracture at the zygomaticomaxil-
lary buttress is most common, with incomplete
POSTOPERATIVE CARE
greenstick fracture at the zygomaticofrontal
Routine Care
buttress. These cases may be treated with intrao-
ral reduction and a single plate placed along the Patients should elevate the head to reduce edema
zygomaticomaxillary buttress.8 and pain. If orbital exploration was undertaken, vi-
sual acuity should be examined postoperatively. A
temporary suture tarsorrhaphy (Frost suture) is
Intraoperative Imaging
commonly used with lower eyelid approaches to
Long used in neurosurgical and orthopedic appli- manage early chemosis. In this technique, a
cations, intraoperative CT is becoming more monofilament suture, such as 4–0 Prolene, is
commonly applied to treatment of facial fractures. passed through the gray line of the lower tarsal
Properly executed, the scan adds little time to the plate and taped to the forehead. The suture is
operation and has been shown to reduce the rate removed once the risk of severe chemosis has
of reoperation by prompting necessary revisions subsided, commonly on the first postoperative
intraoperatively.31,32 Intraoperative imaging can day, before discharge. Dry eye is managed with
assess whether an additional approach is needed artificial tears during the day and lubricating oint-
after single- or two-point fixation of the ZMC.33 ment at night. Nose-blowing is avoided for about
The use of intraoperative imaging has the ability 10 days to avoid orbital emphysema and propaga-
to change treatment algorithms of concomitant tion of sinus bacteria into the orbital soft tissue.35
orbital floor fractures. Exploring the orbital floor Oral hygiene with regular brushing of teeth and

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58 Jones & Schmalbach

Fig. 13. Comminuted, depressed, unstable right ZMC fracture (A, B) was treated with 3-point fixation (C, D). This
is the same patient demonstrated in Figs. 4 and 5B.

use of chlorhexidine mouthwash is prescribed for may require reoperation. Late-presenting patients
at least 2 weeks. Following a soft diet for the first with history of ZMC malunion may benefit from
2 to 4 weeks reduces pain related to exertion of osteotomies or skeletal camouflage with bone graft,
the muscles of mastication. alloplastic malar implants, and/or fat grafting. The
widening of the midface characteristic of ZMC frac-
Complications ture is more difficult to camouflage and may require
Inadequate reduction of zygomaticomaxillary frac- osteotomies for proper reduction.
tures can lead to continued deformity or trismus.36 Infraorbital hypoesthesia is accentuated by
This is prevented through the use of intraoperative traction injury during the operative approach.
imaging or detected early with postoperative CT Dysesthesia is persistent in up to 50% of
before discharge. Significant residual displacement patients.33,36

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 ZMC Fractures 59

Fig. 14. (A-E) Intraoperative navigation. (From Yu H, Shen G, Wang Z, Zhang S. Navigation-guided reduction and
orbital floor reconstruction in the treatment of zygomatic-orbital-maxillary complex fractures. J Oral Maxillofac
Surg. 2010;68:28–34; with permission)

Intraoral incisional dehiscence can lead to hard- CLINICS CARE POINTS

ware exposure at the zygomaticomaxillary
buttress. The oral cavity often remucosalizes; re-
exploration and closure may be undertaken if
dehiscence occurs in the early postoperative
 Displacement of the ZMC or zygomatic arch
period. Ectropion can occur from lower eyelid ap-
can cause functional and aesthetic concerns,
proaches, with the subcilliary approach demon- and is the primary indication for operative
strating the highest incidence. Mild ectropion management.
often resolves with massage; more severe cases
 The choice of the number of access incisions
may require operative intervention.
and points of fixation seeks to balance
Redraping of the soft tissues is critical to prevent morbidity of the exposures with stability of
midfacial descent. In the lower eyelid approach, osteosynthesis. Only the exposures that are
the midfacial periosteum is resuspended to the necessary for a given fracture are performed.
infraorbital rim or hardware.37 Failure to
 Excessive traction on the infraorbital nerve
adequately resuspend the soft tissue can lead to should be avoided to reduce long-term hypo-
ectropion, premature aging, corneal exposure, esthesia.
and epiphora.24 In the coronal approach, the tem-
poroparietal fascia is reapproximated to prevent
temporal hollowing.1
Failure to recognize or adequately treat a
concomitant orbital floor fracture can lead to DISCLOSURE STATEMENT
enophthalmos, reduction in the palpebral fissure C. Schmalbach: Teaching honorarium for AO
with pseudoptosis, and diplopia.2 Operative treat- North America CMF, nonprofit teaching
ment of the orbital fracture is required to resolve consortium.
these complaints. C. Jones: None.
The hardware placed along the alveolar ridge at
the zygomaticomaxillary buttress should be posi- REFERENCES
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uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2023. Elsevier Inc. Todos los derechos reservados.
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