As I mentioned earlier this week, as a Los Angeles based diplomate of the American Board of Plastic Surgery, I find it important to stay abreast of new and updated information that will allow me to better care for my patients. The following is part two of a summary of an update that was recently published regarding the management of patients with facial fractures (i.e. nasal fractures, orbital fractures, zygoma fractures). In this particular article, studies on the management of zygoma fractures are reviewed. (Plastic and Reconstructive Surgery, Vol 127 No 2 Feb 2011 p891-7):
The prominent position of the cheek bone (zygoma) make it very susceptible to traumatic injury. The zygomatic bone is connected to the four surrounding facial bones through anatomic connections called sutures. The term suture, when used in this capacity, had nothing to do with surgical needle and thread. Bone sutures are simply areas where two facial bones have surface to surface contact and fusion. The zygoma (cheek bone) forms the bottom and outer surfaces of the eye socket (orbit). Therefore, when a traumatic force is severe enough to cause a fracture of the zygoma, there is usually also a concurrent injury to the thin floor bone of the eye socket
When it comes to repairing cheek bone fractures, the primary goal is to provide adequate reduction and stabilization of the bones. This usually requires placement of titanium plates and screws that hold the broken bone segments into normal anatomic alignment. There are multiple surgical approaches (incisions)that can be used when doing this. The most common incisions that I use include some combination of the following:
1) Transconjunctival incision: This incision is on the inside surface of the eyelid and will not leave a visible scar after surgery. This is the same incision that I use for cosmetic blepharoplasty (eyelid tuck surgery). This incision provides excellent access to the facial bones, orbital rim and orbital floor. This incision is also less traumatic to the anterior eyelid structures and therefore confers a lower risk of eyelid malposition or ectropion.
2) Lateral canthal extension incision: For extensive fractures of the zygoma and orbital floor, this incision allows a great deal more exposure with very little additional risk. This incision releases the lateral canthus, which is the small tendon that supports the outside of the eyelid. Doing so provides significant laxity to the eyelid which facilitates easy repair of the underlying fractures. The canthal extension incision is placed in the outside corner of the eyelid and is usually about 1-2 cm long at most. After the internal surgical work is complete, the tendon is reattached to reconstitute the normal eyelid anatomy and position. Once healed, this scar is barely visible as it is always placed in the natural eye crease wrinkle of the “crow’s feet.” Occasionally some patients with complex zygomatic arch fractures require fixation with plates and screws, but do not want to be subjected to a large and visible coronal scalp incision. The canthal extension incision is also very useful for placing plates and screws in these patients using a percutaneous approach.
3) Gingivobuccal sulcus incision: This incision is made on the inside of the mouth, just above the gum line. By exposing the facial fractures from this approach, the mid-facial bones can be easily reduced and secured with plates and screws. Once healed, this incision is not visible.
4) Temporal scalp incision: A small four centimeter incision in the hair-bearing portion of the scalp is sometimes required as well. This approach is usually reserved for treatment of zygomatic arch fractures using the Gilles procedure. By using this access incision, I am able to place a surgical instrument underneath a depressed bone segment and elevate it back to its anatomic position. This incision heals and is barely visible under the scalp hair, for patients who do not have hairline recession.