Operative Technique in Plastic Surgery – Kevin C.Chung

incised at the nasofrontal suture using Bovie needle-
tip electrocautery on the cut function to allow further
release of the scalp flap and improve exposure of the
fractures. The supraorbital bundles are visualized and
preserved. E. The fractures are stabilized using low-
profile miniplates. The plate is anchored to the stable
frontal bone. F. The scalp is closed with 3-0
absorbable suture in the deep dermis/galea and 4-0
absorbable suture in the skin. A Blake drain is placed
through a separate stab incision in the scalp.
■ Mark a curvilinear incision that extends from ear to ear. Clip the hair
adjacent to the incision (TECH FIG 2B,C).
■ Prep the scalp and face and within each nostril using Betadine. Inject local
anesthetic with epinephrine around the coronal incision, into the nasal septum
and circumferentially as a ring block around the nose.
■ Elevate the scalp flap in the subgaleal plane anteriorly. Lateral dissection
should proceed just superficial to the superficial layer of the temporalis
fascia.
■ The periosteum is incised approximately 2 cm superior to the supraorbital
rims, and the dissection continues to the supraorbital rims and the nasal bones
in the subperiosteal plane.
■ If the scalp flap will not sufficiently evert, then, laterally, incise the
superficial layer of temporalis fascia from the root of the temporomandibular
joint along a line running at a 45-degree angle toward the supraorbital
subperiosteal incision. This exposes the superficial temporal fat pad:
■ Continue the dissection using Metzenbaum scissors just deep to the
superficial layer of the temporalis fascia, until the zygomatic arch is
reached. Avoid dissection within the fat pad, as this may lead to unwanted
temporal hollowing.
■ Incise the periosteum along the superior aspect of the zygomatic arch. This
should allow sufficient eversion of the scalp flap for complete exposure of
the nasal fractures (and other facial fractures that require reduction).
■ Once the nasofrontal suture is exposed, longitudinal incision of the
periosteum in this region may allow further release of the flap for ease of

retraction. Preserve the supraorbital bundles (TECH FIG 2D).
■ Dissection may proceed along the dorsum to the nasal tip in the
subperiosteal and subperichondrial plane, using an elevator, if desired.
■ Address the fractures with fixation plates as needed (TECH FIG 2E).
■ Close the scalp incision with 3-0 absorbable suture in the deep dermis/galeal
layer and 4-0 absorbable suture for skin approximation (TECH FIG 2F):
■ Leave a Blake drain within the scalp wound.
■ Apply nasal splints.
“Open-Sky” or Glabellar Approach
■ Mark a transverse incision within a glabellar rhytid, connecting either to a
vertical incision within the nasal sidewall (open-sky) or to an upper and
lower eyelid incision (horizontal Y) (TECH FIG 3):
■ This approach is especially useful for providing direct visualization of
NOE fracture fragments needing open reduction and internal fixation.7
■ Skin incisions are made and the fractures addressed.
■ Close the glabellar incision with monofilament absorbable suture in the deep
dermis and a permanent monofilament suture in the skin (TECH FIG 4B).
Apply nasal splints.
TECH FIG 3 • A transverse incision is made within a
glabellar rhytid and may either be connected to a
curvilinear vertical incision within the nasal sidewall or

may bifurcate into an upper and lower eyelid incision.
The vertical incision is known as the “open-sky”
approach, while the upper and lower eyelid incisions
are known as the “horizontal Y” or extended glabellar
approach.
Open Rhinoplasty Approach
■ Transcolumellar incision is marked along with marginal incisions within
each nostril prior to injecting with local anesthetic (TECH FIG 5A).
■ Skin incisions are made and the nose degloved in the subperichondrial and
subperiosteal planes, as described in greater detail in “Rhinoplasty” chapters.
■ If needed, expose the septum by dissection through the interdomal ligaments
between the medial and middle crura of the lower lateral cartilages, using
tenotomy scissors. Incise the mucosa of the caudal septum using a no. 15
blade, and then elevate the mucoperichondrium bilaterally with a Cottle
elevator (TECH FIG 5B).
■ Insert a nasal speculum for wide exposure of the septum (TECH FIG 5C).
■ Address the fractures.
■ Close transcolumellar incision with fine nylon or polypropylene suture and
the marginal incisions using 5-0 absorbable suture.
■ Apply nasal splints (TECH FIG 5D,E).
TECH FIG 4 • A. The laceration is opened if previously

repaired. B. The laceration is closed with absorbable
suture in the deep dermis and permanent suture in the
skin.
TECH FIG 5 • A. A transcolumellar (inverted V or
stairstep) incision is marked along with marginal
incisions into each nostril, following the caudal border
of the lower lateral cartilages. B. The septum is
exposed through dissection of the interdomal
ligaments between the lower lateral cartilages.
Starting at the anterior septal angle,
mucoperichondrial flaps are elevated bilaterally using
a Cottle elevator. C. A nasal speculum is inserted to
provide wide exposure of the fractured or dislocated
septum. D,E. An Aquaplast splint and Doyle splints
are applied for stabilization of the nasal dorsum and
septum, respectively.

■ Dressings
■ For each approach, dressing application is similar.
■ Apply Mastisol and Steri-Strips to the dorsum of the nose in a triangular
fashion. Trim the Aquaplast splint to overly the Steri-Strips. Soak the splint
in a hot water bath until malleable. Place the Aquaplast splint on the Steri-
Strips, and gently conform the splint to the contour of the nose. Add
additional Steri-Strips to reinforce the splint as needed (TECH FIG 6A).
■ Trim Doyle splints as needed, and then place within each nostril after
lubricating them with Bacitracin ointment. Secure the internal splints to the
caudal septum with a 3-0 chromic suture (TECH FIG 6B).
TECH FIG 6 • A. A thermoplast splint (Aquaplast) is
placed for external stabilization. B. Internal (Doyle)
splints are covered with antibiotic ointment and then
secured to the caudal septum with absorbable
sutures.
PEARLS AND PITFALLS
Indications
■ The surgeon should have a clear understanding of patient history,
physical exam, imaging studies, and the pathology to be addressed.
Approach
■ For internal fixation of open fractures, use low-profile miniplates

(0.3-mm thickness) with 1.2 × 4-mm screws. Placement of a fixation
plate where glasses rest on the nose will lead to potential plate
exposure.2
Approach
■ Use the incisors as a midline reference when nasal bones are mobile
and displaced.2
Approach
■ Address septal deformities first.
Technique
■ The surgeon must assess and address persistent nasal deformities
(either cosmetic or functional) during the initial surgical procedure; if
these are not addressed, the patient will require repeat rhinoplasty.
POSTOPERATIVE CARE
■ Patients are discharged immediately after surgery with narcotic pain
medication.
■ Antibiotics are often prescribed while nasal packing is in place to minimize the
risk of infectious complications, such as toxic shock syndrome; however,
recent literature reviews indicate that routine antibiotic prophylaxis after
elective nasal surgery is likely not necessary if nasal packing is to be left in
place for less than 48 hours8,9 or for simple revision rhinoplasties.9
■ External and internal splints are removed at 1 week. If permanent suture was
used for skin closure, sutures are removed at this 1-week postoperative visit.
■ Elevate the head of the bed to prevent edema.
■ Apply cold compresses as tolerated for the first 24 hours to help with edema.
■ No nose blowing for 4 weeks.
■ Patients may use nasal saline irrigation, Afrin (oxymetazoline) or Sudafed
(pseudoephedrine), as needed for congestion.
OUTCOMES
■ Current management techniques for reduction of nasal fractures result in a
high incidence of persistent nasal deformity, with revision rates of 14% to 50%
reported in the literature.4
■ Patients with untreated or unrecognized septal deviation or injury are likely to
require a septorhinoplasty in the future, as the septum is the keystone of the
correction.2
■ Discrepancies remain throughout the literature regarding timing of nasal
reduction, the method of reduction, and postoperative management of these
patients.4

COMPLICATIONS
■ Persistent deformity requiring repeat rhinoplasty, for both aesthetic concerns
and functional problems.
■ Infection: use antibiotics for intranasal packing and CSF rhinorrhea.
■ Open-sky incision may heal with scar contracture, causing medial canthal
webbing.
■ Septal hematoma: drain urgently to prevent the late complication of saddle
nose deformity, which results from fibrosis and distortion or complete necrosis
of the septum.4
■ Epistaxis: control with direct pressure and/or intranasal packing. If unusual
bleeding occurs, consider coagulation studies.
REFERENCES
1. Chan J, Most SP. Diagnosis and management of nasal fractures. Oper Tech
Otolaryngol. 2008;19:263-266.
2. Higuera S, Lee EI, Cole P, et al. Nasal trauma and the deviated nose. Plast
Reconstr Surg. 2007;120(suppl 2):64S-75S.
3. Mondin V, Rinaldo A, Ferlito A. Management of nasal bone fractures. Am J
Otolaryngol. 2005;26:181-185.
4. Rohrich RJ, Adams WP. Nasal fracture management: minimizing secondary
nasal deformities. Plast Reconstr Surg. 2000;106:266-273.
5. Hwang K, You SH, Kim SG, et al. Analysis of nasal bone fractures: a six-year
study of 503 patients. J Craniofac Surg. 2006;17:261-264.
6. Cafferty A, Becker DG. Open and closed rhinoplasty. Clin Plast Surg.
2016;43:17-27.
7. Converse JM, Hogan VM. Open-sky approach for reduction of naso-orbital
fractures. Plast Reconstr Surg. 1970;46:396-398.
8. Cohn B. Are prophylactic antibiotics necessary for anterior nasal packing in
epistaxis?. Ann Emerg Med. 2015;65:109-111.
9. Georgiou I, Farber N, Mendes D, et al. The role of antibiotics in rhinoplasty
and septoplasty: a literature review. Rhinology. 2008;46: 267-270.

61
CHAPTER
Section IX: NOE Fractures
Naso-Orbital-Ethmoid (NOE)
Fractures
Craig Birgfeld and Joseph Gruss
DEFINITION
■ Naso-orbital-ethmoid (NOE) fractures are fractures of the bones of the central
face between the orbits involving the nose, the orbits, and the ethmoid sinuses.
ANATOMY
■ The NOE region is comprised of the confluence of the nasal bones, the frontal
process of the maxilla, the internal angular process of the frontal bone, the
lamina papyracea of the ethmoid bone, and the lacrimal bone (FIG 1A).
■ The NOE framework defines the nasal dorsum, the volume of the orbits, the
shape of the medial orbits, and the support of the central face.
■ Fractures tend to extend across the nasofrontal junction, down the medial
orbital wall, across the inferior orbital rim, and across the medial buttress into
the pyriform aperture (FIG 1B).
■ NOE fractures include the complex anatomy of the medial canthal tendon
attachments and nasolacrimal apparatus (FIG 1C).
PATHOGENESIS
■ NOE fractures generally occur from blunt force trauma to the central face
between the eyes, such as hitting the steering wheel or dashboard during an
MVC.
■ They frequently occur from self-inflicted gunshot wounds across the temple
and orbits.
■ NOE fractures are often components of more complex fracture patterns such

as frontal sinus fractures and panfacial fractures.
NATURAL HISTORY
■ Without treatment, patients can suffer upper airway obstruction from
impaction of the pyriform aperture and/or loss of nasal support resulting in a
saddle nose deformity (FIG 2).
■ Impacted and comminuted NOE fractures can change orbital volume leading
to enophthalmos, dystopia, and diplopia.
■ Damage to the nasolacrimal apparatus can lead to epiphora.
■ Disruption of the nasofrontal outflow tract with an impacted NOE fracture can
lead to frontal sinus congestion and mucocele formation.
■ Untreated NOE fractures can significantly alter physical appearance.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients generally present with a history of blunt force trauma to the central
upper face between the orbits.
■ They may report airway obstruction, epiphora, diplopia, and alteration of
physical appearance.
■ Physical exam should focus first on vision, extraocular muscle involvement,
and globe position.
■ Patients may display telecanthus (an increased distance between the medial
canthal tendons that is greater than 35 mm in adults) and hence a shortened
palpebral fissure.
■ The loss of dorsal nasal support leads to a saddle nose deformity with loss of
nasal bridge, upturned nasal tip, and an increased nasolabial angle (normal =
90–100 degrees; FIG 3).
■ A speculum exam should be performed to assess impaction of the lateral nasal
sidewall and rule out septal fracture and/or hematoma.
IMAGING
■ Fine cut (0.3–0.5 mm) maxillofacial CT scans with, at a minimum, axial and
coronal views are necessary for accurate diagnosis (FIG 4A,B).
■ Three-dimensional reconstructions are helpful to delineate anatomy and plan
reduction maneuvers (FIG 4C).
■ Sagittal views can be helpful if orbital floor fractures are also present.
DIFFERENTIAL DIAGNOSIS

■ Isolated nasal bone fracture
■ Isolated medial orbital wall fractures
NONOPERATIVE MANAGEMENT
■ Nondisplaced NOE fractures can be managed conservatively with activity
precautions and protection of the nasal dorsum with a splint.
SURGICAL MANAGEMENT
■ Surgical intervention is reserved for displaced NOE fractures.
■ The complexity of the intervention is determined by the amount of
displacement and comminution of the segments.
FIG 1 • A. The Naso-orbital-ethmoid complex is formed
by the confluence of the nasal bones, the frontal

process of the maxilla, the internal angular process of
the frontal bone, the lamina papyracea of the ethmoid
bone, and the lacrimal bone. B. Typical fracture
locations of a noncomminuted bilateral NOE fracture. C.
NOE fractures involve the complex attachments of the
medial canthal tendon and the nasolacrimal apparatus.
■ The goal of surgical management is to restore facial harmony by focusing on
the following features:
■ Establish dorsal nasal support
■ Ensure airway patency
■ Restore normal orbital volume
■ Return the intercanthal distance to within normal range
FIG 2 • Loss of dorsal nasal support frequently occurs
with NOE fractures.
Preoperative Planning
■ Review of CT scans will allow planning of surgical approaches necessary to
restore normal anatomy, the maneuvers necessary for reduction, and the
amount and placement of rigid fixation needed for a stable framework.
■ Two classification systems aid in preoperative planning:

■ Manson (focus on central segment and canthal attachment):1
• Type 1: single segment (FIG 5A)
• Type 2: comminuted (FIG 5B)
• Type 3: comminuted into the canthal insertion (FIG 5C)
FIG 3 • Untreated NOE fractures can lead to a “saddle
nose” deformity.
FIG 4 • A,B. Axial and coronal CT scans demonstrate a
comminuted bilateral NOE fracture. C. NOE fractures
are often associated with other upper and midface
fractures such as demonstrated in this CT scan of a
panfacial fracture.
■ Gruss (with a focus on central face stability and associated fractures; FIG
6):2

• Type 1: isolated to the bony NOE region

FIG 5 • The Manson Classification of NOE fractures
demonstrates progressive comminution of the bony
segment containing the medial canthal attachment. (A.
Type I. Single Segment. B. Type 2. Comminuted. C.
Type 3. Communited into the canthal insertion.)
• Type 2a: bony NOE and central maxilla with loss of nasal support
• Type 2b: bony NOE and one lateral maxilla
• Type 2c: bony NOE and bilateral lateral maxilla
• Type 3a: frontobasilar injury (frontal sinus involvement)
• Type 3b: Le Fort II and Le Fort III fractures
• Type 4a: NOE with ocular/orbital displacement
• Type 4b: NOE with ocular/orbital displacement including orbital roof
• Type 5: NOE fractures with loss of the bone
■ The use of these classification systems also allows planning for primary bone
grafting and the need for transnasal wiring and medial canthoplasty. Upon
induction of anesthesia, the surgeon should place traction on the medial canthal
tendon with forceps to assess its stability and determine whether wiring is
required.
Positioning
■ Patients are placed supine on a gel donut for a limited approach and on a
Mayfield headrest for a coronal approach.
■ An oral airway secured with a wire can be used for isolated NOE fractures.
■ If maxillary fractures (Gruss type 3, 4, or 5) or mandibular fractures requiring
intermaxillary fixation are present, a nasal airway should be avoided, and either
a submental airway or tracheostomy is preferred.
Approaches
■ Increasingly complex NOE fractures require greater exposure.
■ Central segment (type 1) fractures impacted only at the pyriform aperture can
be approached through a single gingivobuccal sulcus incision.3
■ If the inferior orbital rim is also displaced; then a lower eyelid incision can be
added.
■ If there is also displacement at the nasofrontal junction, a Lynch incision

(semicurved incision placed in the superomedial eyelid near the glabella) can
be added, or a serendipitous laceration can be utilized.
■ For increasingly comminuted fractures (type 2 and above) and those requiring
immediate bone grafting, a coronal incision is generally preferred.
■ Though the gull-wing or open sky approach has been described, it should
generally be avoided.
FIG 6 • Gruss types 1, 2, and 4 NOE fractures.
T E C H N I Q U E S

■ Open Reduction Internal Fixation of NOE
Fractures
Exposure
■ Begin with exposure of all fracture sites starting with the lower eyelid
approach.
■ Incise sharply through the skin and orbicularis oculi muscle; then dissect
bluntly in the submuscular, supraseptal plane down to the orbital rim. Incise
through the arcus marginalis, and use a periosteal elevator to expose the
fractured inferior orbital rim.
■ Perform the coronal incision using a zigzag technique beginning within the
hairline of the temple 1 cm superior and 1 cm posterior to the root of the
helix. The use of microtip cautery can avoid the use of Rainey clips and
subsequent alopecia. Dissect in the subgaleal plane until approximately 1 cm
cephalad to the superior orbital rim; then transition to the subperiosteal plane
to approach the nasofrontal junction. Carefully dissect down and around the
insertion point of the medial canthal tendon attachment to join the previous
lower eyelid dissection.
■ Perform the gingivobuccal sulcus incision leaving a 1 cm cuff of mucosa
attached to the gingiva to aid in closure. Dissect along the medial buttress to
meet the lower eyelid dissection.
Fixation and Completion
■ Once the fractures are exposed, place a Dingman elevator or Ash forceps
into the nose, and disimpact the NOE segment to restore airway patency.
■ With type 1 NOE fractures, place a miniplate along the cephalad margin of
the NOE segment via the coronal incision (TECH FIG 1A).
■ Apply cephalad traction to the plate to reduce the fracture at the
nasofrontal junction (video); then fixate the fracture.
■ The segment can then be rocked laterally with the intranasal Dingman
elevator until the fractures are reduced at the orbital rim and medial
buttress.
■ These are then fixated with a thin (0.5 mm) plate at the orbital rim and a
thicker plate at the medial buttress (0.7–0.8 mm).
■ With comminuted type 2 and type 3 NOE fractures, multiple bony fragments
require reduction and fixation.
■ It is paramount to include the fragment that holds the medial canthal

attachment to restore normal intercanthal distance.
■ A carefully bent 0.5-mm daisy chain plate mimicking the normal contour
of the medial orbit can be used to reduce and fixate the comminuted
fragments (TECH FIG 1B).
■ If the tendon is avulsed or the bony fragment is too small to allow plate
fixation, then either transnasal wiring (TECH FIG 1C) or a medial canthal
barb can be used to re-establish normal canthal position. Overcorrection is
the rule.4
■ Next perform a nasal speculum exam to ensure patency of the airway and to
assess septal integrity. If there remains inadequate dorsal nasal and tip
support, then a cantilevered bone graft is placed through the coronal incision
and an external rhinoplasty incision; centralize the lower lateral cartilages
over top of the cantilever bone graft.
■ Before closure, inspect the medial orbital wall. If there remains significant
displacement of the orbital contents into the ethmoid sinuses or loss of the
ethmoid contour bulge, then the medial orbital wall should be reconstructed
with autograft or alloplast to prevent enophthalmos.
■ After soft tissue closure, splints are applied. If the septum has been fractured,
Doyle splints are placed intranasally. External compression splints are then
placed along the lateral nasal sidewalls in the region of the medial canthal
attachment to prevent edema and to redrape the soft tissue, recreating the
normal concavity (TECH FIG 1D).5

TECH FIG 1 • A. In situ placement of fixation plate
allows caudal traction on the displaced NOE segment
and reduction of the fracture at the nasofrontal
junction. B. A periorbital spanning plate allows fixation
of the NOE fracture at the inferior orbital rim and the
nasofrontal junction while maintaining medial
reduction of the NOE segment, thus correcting
telecanthus. C. Transnasal wiring technique. D.
Placement of external splints to promote redraping of
pericanthal soft tissue after narrowing of the
underlying NOE segments.
PEARLS AND PITFALLS
Indications

■ It can be helpful to compare current appearance to a preinjury
photo.
■ An ophthalmology consult should be obtained to rule out
concomitant injury to the globe.6
■ Edema early after injury can mask the severity of enophthalmos
and saddle nose deformity.
Approach
■ If a Lynch incision is used, carefully dissect around and preserve
the supratrochlear neurovascular bundle.
Concomitant
frontal sinus
injury
■ If a concomitant frontal sinus injury requires either obliteration or
cranialization, the NOE segment should be reduced and rigidly
fixed first. Disimpacting the NOE fracture can reopen the
frontonasal outflow tract, which needs to be obliterated.
Telecanthus
■ For type 1 NOE fractures, ensure the segment is not rotated
outward before fixation.
■ For type 2 NOE fractures, be sure to capture the canthal bearing
bony segment with the fixation plate. The surgeon can manually
bend the plate medially to restore normal width.
■ For type 3 NOE fractures, transnasal wires or canthoplasty barb
may be used to fixate the medial canthal position.
■ Overcorrection is key as the tendon tends to drift laterally.
Medial
canthal
webbing
■ Place external compression splints to redrape the soft tissue after
fracture reduction and fixation.
Persistent
enophthalmos
■ Be sure to recreate the ethmoid bulge when reconstructing the
medial orbital wall fracture with either autograft or alloplast.
Nasolacrimal
injury
■ Routine probing of the canalicular system is not recommended.
However, if an obvious laceration involves the ducts, then they
should be repaired over a Crawford tube.
POSTOPERATIVE CARE
■ Tobacco avoidance and soft diet are recommended until the intraoral incisions
have healed.
■ Patients should avoid strenuous activity and nose blowing for 2 weeks
postoperatively to prevent periorbital hematoma.
■ Patients should avoid contact sports for 3 months postoperatively to ensure
stable bony healing.
■ The patient should be seen within 2 weeks after surgery to ensure normal

incisional healing.
■ The external nasal splints and Doyle splints are removed at this clinic visit.
■ It is common for patients to report transient diplopia for the first few weeks
after surgery due to edema.
■ It is also common for patients to exhibit epiphora after surgery due to edema
that collapses the nasolacrimal apparatus.7
■ If diplopia persists for 3 to 6 months, then referral to ophthalmology should be
considered.8
■ If epiphora persists greater than 6 months, then probing of the canalicular
system and possible dacryocystorhinostomy (DCR) should be considered.
OUTCOMES
■ Lack of treatment or inadequate treatment can leave permanent deformities
such as telecanthus, shortened palpebral fissure, and saddle nose deformities,
which are difficult, if not impossible, to correct secondarily.
■ Herford et al. presented ten consecutive patients with Manson type 3 NOE
fractures treated with ORIF. Of these, two patients were found to have
asymmetry between the medial canthi and two had overprojection of the
nasofrontal region.9
■ Gruss et al. presented 46 consecutive patients with severe NOE fractures, 8 of
whom had persistent nasolacrimal duct dysfunction and epiphora requiring
DCR.7
COMPLICATIONS
■ Complications can result from inadequate reduction of fracture segments and
include:
■ Persistent telecanthus
■ Enophthalmos
■ Persistent epiphora
■ Airway obstruction
■ Saddle nose deformity
■ Complications can result from surgical intervention:
■ Lower eyelid malposition
■ Scar alopecia
■ Visible scarring
REFERENCES

1. Markowitz BL. et al. Management of the medial canthal tendon in
nasoethmoid orbital fractures: the importance of the central fragment in
classification and treatment. Plast Reconstr Surg. 1991;87:843-853.
2. Gruss JS. Naso-ethmoid-orbital fractures: classification and role of primary
bone grafting. Plast Reconstr Surg. 1985;75:303-317.
3. Evans GR, Clark N, Manson PN. Identification and management of minimally
displaced nasoethmoidal orbital fractures. Ann Plast Surg. 1995;35:469-473.
4. Ellis E 3rd. Sequencing treatment for naso-orbito-ethmoid fractures. J Oral
Maxillofac Surg. 1993;51:543-558.
5. Sargent LA. Nasoethmoid orbital fractures: diagnosis and treatment. Plast
Reconstr Surg. 2007;120:16S-31S, doi:10.1097/01.prs.0000260731.01178.18.
6. Holt GR, Holt JE. Incidence of eye injuries in facial fractures: an analysis of
727 cases. Otolaryngol Head Neck Surg. 1983;91:276-279.
7. Gruss JS, Hurwitz JJ, Nik NA, Kassel EE. The pattern and incidence of
nasolacrimal injury in naso-orbital-ethmoid fractures: the role of delayed
assessment and dacryocystorhinostomy. Br J Plast Surg. 1985;38:116-121.
8. Ali MJ, Gupta H, Honavar SG, Naik MN. Acquired nasolacrimal duct
obstructions secondary to naso-orbito-ethmoidal fractures: patterns and
outcomes. Ophthal Plast Reconstr Surg. 2012;28:242-245.
doi:10.1097/IOP.0b013e31823f3266.
9. Herford AS, Ying T, Brown B. Outcomes of severely comminuted (type III)
nasoorbitoethmoid fractures. J Oral Maxillofac Surg. 2005;63:1266-1277.
doi:10.1016/j.joms.2005.05.297.

62
CHAPTER
Section X: Maxillary
Trauma
Closed Reduction of
Zygomatic Arch Fractures
Oluwaseun A. Adetayo
DEFINITION
■ The zygoma bone has four skeletal articulations—the maxilla, frontal,
temporal, and sphenoid bones.
■ The zygomatic arch plays a prominent role in facial skeletal profile by
establishing malar projection (“cheek bones”).
■ Fractures of the zygomatic arch can occur in isolation. In such cases, the
tetrapod articulations are usually not violated and the remainder of the complex
is stable.
■ This chapter focuses on closed reduction and treatment options for isolated
zygomatic arch fractures.
ANATOMY
■ The zygomatic arch is a part of the zygomaticomaxillary complex (ZMC). The
bone and its articulations are shown in (FIG 1A).
■ Although the term “arch” is used to describe the bone, it is more anatomically
flat in configuration for the majority of its length and is curved posteriorly.
■ The zygoma is also an important landmark for the muscles of mastication.
■ The zygomatic arch furnishes attachments for portions of the superficial
muscular aponeurotic system (SMAS), the temporoparietal fascia (TPF), and
origins for some of the muscles of facial expression and mastication.
■ The highly powered masseter muscle has superficial and deep components that

take their origin from the zygomatic arch and insert into the buccal surface of
the mandibular angle, ramus, and body. Portions of the deep fibers of the
muscle also radiate to the anterior capsule and the articular disk of the
temporomandibular joint (TMJ), thus helping to stabilize the capsule of the
TMJ.
■ Fractures of the zygomatic arch may disrupt the origin of the masseter and
potentially affect elevation and protrusion of the mandible, resulting in pain,
trismus, and occlusal problems.
■ The temporalis muscle is located deep to the zygomatic arch as it inserts onto
the coronoid process. Depression of an isolated arch fracture can contribute to
trismus or malocclusion, via an indirect impingement on the temporalis.
■ The relationship of the masseter and temporalis muscles to the zygomatic arch
are depicted in FIG 1B.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ All trauma patients should undergo appropriate evaluation to rule out any
concomitant facial fractures or other life-threatening injuries.
■ Physical findings in patients with zygomatic arch fractures may include facial
asymmetry, loss of malar projection, trismus, pain, and decreased maximum
incisal opening (MIO).
■ Trismus and decreased MIO can occur due to direct pull of the masseter on the
arch, impingement of a displaced arch on the temporalis muscle as it inserts
into the coronoid, or more directly via its compressive effect on other muscles
of mastication.
FIG 1 • A. The zygoma bone and its articulations. B.

The relationship of the masseter and temporalis
muscles to the zygomatic arch.
■ Facial asymmetry may result because of actual displacement of the arch or
disruption of the origin of the zygomaticus muscles, which contribute to facial
expression.
IMAGING
■ Various modalities including x-rays, ultrasounds, and computed tomography
(CT) scans have been described for evaluation of zygoma fractures.1–3
■ CT scans are the most commonly utilized diagnostic tools in patients with
facial fractures and provide excellent detail for the evaluation of zygomatic
fractures.
■ CT scan using fine cuts with axial, coronal, and 3D reconstruction are
particularly helpful to evaluate the degree of displacement, impingement,
malrotation, and associated fractures.
NONOPERATIVE MANAGEMENT
■ Nonoperative management of isolated zygomatic arch fractures is the
treatment choice in patients with the following:
■ Nondisplaced or noncomminuted arch fractures
■ Lack of trismus
■ Lack of facial or malar asymmetry
■ Normal MIO
■ Preservation of facial width and projection
SURGICAL MANAGEMENT
■ Operative intervention should be considered in patients who are medically
stable with sequelae of arch fractures such as trismus, malar flattening, facial
asymmetry, difficulty with mouth opening, and presence of concomitant
fractures.
■ The goals of treatment are:
■ Anatomic restoration of three-dimensional anatomy of the zygoma with
articulation and muscular complexes
■ Restoration of facial width and malar projection
■ Resolution of symptoms due to fracture
■ Restoration of orbital volume and anatomy in cases of orbitozygomatic

fractures
Preoperative Planning
■ A complete history and physical examination should be performed on every
patient and all concomitant injuries identified.
■ Obtain imaging of choice. Most commonly used are craniomaxillofacial CT
scans with fine cuts (range of 0.625- to 1.25-mm cuts at most institutions) and
includes axial, sagittal, coronal, and 3D imagings as needed.
■ Isolated arch fractures have been estimated to occur in 5% to 10.4% of patients
with zygoma fractures, of which 59.3% are displaced or comminuted.2,4
Positioning
■ The patient is positioned supine on the operating table with exposure of the
head and neck to facilitate access. CT scan images are displayed
intraoperatively.
Approach
■ The following approaches have been described for treatment of isolated
zygomatic arch fractures:
■ Percutaneous approach
■ Gilles approach
■ Keen approach
■ Others
T E C H N I Q U E S
■ Percutaneous Approach
■ A 0.5- to 1-cm cutaneous incision is made directly overlying the zygoma,
and a reduction instrument such as a bone hook or a Carroll-Girard T-bar
screw is inserted into the body of the zygoma.5
■ Lateral traction is placed on the isolated zygomatic arch fragment and
external manual palpation is performed to guide the reduction, which is
denoted by the sound of the fragment clicking back into place.
■ The contralateral hand is placed at the maxilla-zygomatic arch interface on

the face and used to guide the fragment during reduction into the appropriate
axial projection and skeletal relationship.
■ Advantages include the minimal access incision.
■ Disadvantages include presence of a facial scar and the possibility of
inadequate reduction or loss of reduction.
■ Gilles Approach
■ This approach was described in 1927 by Gilles, and it involves the use of a
scalp incision to access the zygomatic arch fracture.
■ A 2-cm incision is made in the temporal hairline 4 cm superior to the helix
and extended to the superficial temporal fascia (STF), which is incised.
■ This exposes the deep temporal fascia (DTF), which has two layers—the
superficial layer and the deep layer—that enclose the temporalis muscle.
■ Next, the superficial layer of the DTF is incised, and the surgeon gains entry
into the plane between this superficial layer and the temporalis muscle.
■ Dissection is performed between these layers, staying below the superficial
layer of the DTF and above the temporalis muscle, thus leading to the
zygomatic arch.
■ The frontal branch of the facial nerve, which crosses the zygomatic arch and
is enclosed within the STF, is protected.6,7

TECH FIG 1 • A. Relationships of the frontal branch of
the facial nerve, superficial temporal fascia, deep
temporal fascia, and the zygoma. B. Gilles approach.
■ Above the zygomatic arch at the fascial transition zone, the frontal branches
of the facial nerve course on the undersurface of the STF before terminating
in the frontalis and orbicularis oculi muscles. The fascial transition zone runs
1.5 to 3 cm above the superior aspect of the zygomatic arch.6,8 TECH FIG
1A illustrates the anatomic relationship in this region.
■ A reduction forcep, such as a Rowe zygomatic elevator or a periosteal
elevator, is placed beneath the zygoma, and lateral traction is performed to

reduce the fracture, while the contralateral hand can be used to guide
reduction of the zygoma to re-establish malar projection (TECH FIG 1B).
■ The adjunct use of fluoroscopy may be employed to guide reduction,
although this practice is not routinely necessary or widespread. Fluoroscopy
may aid in proper fracture reduction with closed reduction.9
■ Reduction is usually completed by a palpable reduction into anatomic
position and/or sound of the fragment clicking into position.
■ Hemostasis is achieved and the incision is closed with reapproximation of all
anatomic layers.
■ Advantages include a camouflaged scar within the hair without facial
scarring.
■ Disadvantages include risk of alopecia, possibility of injury to the frontal
branch of the facial nerve and the temporal fat pad, and inadequate or
unstable reduction.
■ Keen Approach
■ This approach was described by Keen in 1909 and utilizes an intraoral
approach.
■ The upper gingivobuccal sulcus of the affected side is infiltrated with local
anesthetic of choice, and a 2- to 3-cm gingivobuccal sulcus incision is made
running from the lateral incisor to the mesial aspect of the first molar.
■ Subperiosteal dissection is performed over the maxilla to expose the zygoma
and the zygomaticomaxillary buttress.
■ A reduction forcep, such as a Boise or zygoma elevator, is placed deep to the
zygomatic arch while palpating the malar eminence with the contralateral
hand. This allows for elevation and reduction of the depressed arch with the
application of a steady reduction force (TECH FIG 2).
■ Completion of reduction is usually heralded by a palpable reduction into
anatomic position and/or sound of the fragment clicking into position.
■ Following reduction, the area is irrigated and the incision is closed.
■ Advantages include a camouflaged scar in the oral cavity, and prevention of
a temporal scar, alopecia, or facial scar.
■ Disadvantages include the risk of inadequate or unstable reduction.

TECH FIG 2 • Keen approach.
■ Other
■ Additional approaches for access to the fractured zygomatic arch have been
described, including endoscopic approaches to assist visualization,
hemicoronal incision for more direct access, fluoroscopic guidance,
intraoperative ultrasonography to aid reduction, etc.1,3,4,7,9–12
■ The exact details of these additional techniques or adjuncts are beyond the
scope of this chapter, and the reader is referred to the literature for additional
information.
PEARLS AND PITFALLS
Indications
■ Evaluate for concomitant fractures.

■ Comminuted, malrotated, impinged, and unstable fractures may
require open reduction and internal fixation.
Surgical
technique
■ Respect the anatomic layers to avoid injury to the frontal branch of
the facial nerve or atrophy of the temporal fat pad.
■ Avoid extensive stripping of the soft tissues to prevent premature
midface descent secondary to soft tissue ptosis.
■ If any of the surgical techniques fail to achieve or maintain a
stable reduction, then open reduction and internal fixation of the
zygoma should be performed.
Failure of
treatment
■ Patients whose fractures remain unstable after the various
approaches described above should undergo open reduction and
internal fixation of the fractures to restore normal anatomy and
function.
Postoperative
care
■ It is critical to identify or mark the site postoperatively.
■ A tape, sticker, or note serves as a good external reminder.
■ Monitor the patients to ensure compliance and that the reduction is
stable. If any of the techniques fail, then proceed with open
reduction and internal fixation with or without osteotomies.
POSTOPERATIVE CARE
■ It is the author’s practice to inscribe “No pressure” on a piece of wide tape,
which is then gently secured to the patient’s operated side over the malar
eminence prior to extubation. This serves as a visual reminder to the patient,
surgeon, anesthesiologist, and nursing staff caring for the patient
postoperatively.
■ Patient should be monitored to avoid pressure during sleep or activity on the
operated side of the face while recovering from anesthesia.
■ Nursing staff, treating personnel, and the patient should be educated on
positioning and activity restrictions.
■ Place the patient on a soft diet to avoid significant loading of the masticatory
muscles during bony healing. Practices vary anywhere from 2 to 6 weeks
depending on surgeon preferences, patient factors, degree of comminution,
symptoms, etc.
■ Maintaining good oral hygiene is key.
■ There are no standardized recommendations regarding antibiotic use.
OUTCOMES
■ Patients with successfully reduced zygomatic arch fractures have excellent

outcomes with the various techniques described above with minimal sequelae.
■ Patients in whom reduction cannot be achieved or maintained should be
considered for open reduction and internal fixation.
COMPLICATIONS
■ Complications associated with each technique are described in the
accompanying sections.
■ General complications include:
■ Scar
■ Inability to achieve reduction
■ Inability to maintain reduction
■ Alopecia
■ Persistence of occlusal problems and facial asymmetry13
REFERENCES
1. Akizuki H, Yoshida H, Michi K. Ultrasonographic evaluation during reduction
of zygomatic arch fractures. J Craniomaxillofac Surg. 1990; 18:263-266.
2. Covington DS, Wainwright DJ, Teichgraeber JF, Parks DH. Changing patterns
in the epidemiology and treatment of zygoma fractures: 10-year review. J
Trauma. 1994;37(2):243-248.
3. Gilles HD, Kilner TP, Stone D. Fractures of the malar-zygomatic compound,
with a description of a new X-ray position. Br J Surg. 1927;14:651.
4. Kiwanuka E, Smith SE, Frates MC, Caterson EJ. Use of high-frequency
ultrasound guidance for intraoperative zygomatic arch fracture reduction. J
Craniofac Surg. 2013 Nov;24(6):2036-2038.
5. Baek JE, Chung CM, Hong IP. Reduction of Zygomatic Fractures Using the
Carroll-Girard T-bar Screw. Arch Plast Surg. 2012;39(5): 556-560.
6. 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;85(6):878-890.
7. Werner JA, Frenkler JE, Lippert BM, Folz BJ. Isolated zygomatic arch
fracture: report on a modified surgical technique. Plast Reconstr Surg.
2002;109(3):1085-1089.
8. Agarwal CA, Mendenhall SD III, Foreman KB, Owsley JQ. The course of the
frontal branch of the facial nerve in relation to fascial planes: an anatomic
study. Plast Reconstr Surg. 2010;125(2):532-537.

9. Chen RF, Chen CT, Hao Chen C, Liao HT, et al. Optimizing closed reduction
of nasal and zygomatic arch fractures with a mobile fluoroscan. Plast Reconstr
Surg. 2010;126(2):554-563.
10. Czerwinski M. C-arm assisted zygoma fracture repair: a critical analysis of
the first 20 cases. J Oral Maxillofac Surg. 2015;73(4):692.e1-692.e8.
11. Gülicher D, Krimmel M, Reinert S. The role of intraoperative
ultrasonography in zygomatic complex fracture repair. Int J Oral Maxillofac
Surg. 2006;35:224-230.
12. Xie L, Shao Y, Hu Y, et al. Modification of surgical technique in isolated
zygomatic arch fracture repair: seven case studies. Int J Oral Maxillofac Surg.
2009;38(10):1096-1100.
13. Kelley P, Hopper R, Gruss J. Evaluation and treatment of zygomatic
fractures. Plast Reconstr Surg. 2007;120(7 suppl 2):5S-15S.

63
CHAPTER
Open Correction of
Zygomatic Fractures
Warren Schubert and Yeshaswini Thelekkat
DEFINITION
■ Zygomatic fractures are fractures of the zygomatic bone together with any one
or all of its four processes—maxillary, frontal, orbital, and temporal (FIG 1).
■ When the fracture involves only the temporal process, it is referred to as an
isolated zygomatic arch fracture.
■ More often, fractures involve the adjacent bones through the other processes,
and the term zygomatic complex or zygomaticomaxillary complex (ZMC)
fracture is more appropriate.
■ ZMC fractures are also referred to as fractures of the zygoma, malar complex,
quadripod, quadramalar, tetrapod, trimalar fractures, and orbitozygomatic
fractures.
ANATOMY
■ The zygoma maintains points of articulation with the maxilla at the
zygomaticomaxillary buttress (ZMB or lateral column of the midface) and at
the inferior orbital rim (IOR), the frontal bone at the zygomaticofrontal (ZF)
suture, the greater wing of the sphenoid at the zygomaticosphenoid (ZS) suture,
and the temporal bone at the zygomaticotemporal (ZT) suture.
■ The ZS component makes up the lateral component of the orbital wall.

FIG 1 • ZMC showing fracture of four processes of the
zygoma—
maxillary, frontal, orbital and temporal.
■ The zygoma also forms a major component of the maxillary sinus,
contributing partially to the roof and to the posterolateral wall of the sinus.
■ The zygoma serves as an attachment for a major portion of the masseter along
the body and the zygomatic arch. The arch also serves as an attachment for
both the superficial and deep portion of the deep temporal fascia along the
zygomatic arch and posterolateral edge of the temporal process. The masseter
muscle has a significant role in causing intrinsic deformations of the body and
arch1 (FIG 2A).
■ The zygoma also provides attachment to the muscles of facial animation.
These main muscles include the levator labii superioris along the infraorbital
rim and the zygomaticus major and minor muscles along the malar eminence.1
■ The Whitnall tubercle lies on the medial aspect of the zygomatic bone, about 9
mm inferior to the ZF suture and 4 mm posterior to the lateral orbital rim (FIG

2B).2,3 This tubercle provides attachments to the lateral palpebral ligaments
and the suspensory ligament of Lockwood, which forms the inferior hammock
of the globe.
■ This may cause a downward slant of the eyelids when there is an inferior
displacement of the zygoma following trauma.3,4
■ A key to a successful reduction of the ZMC fracture is the alignment of the
zygomaticosphenoidal suture in the lateral wall of the orbit, as this area is least
likely to be comminuted.5
■ Though it is referred to as the zygomatic “arch,” this structure is anatomically
closer to being a relatively straight structure in the AP direction, rather than a
curvilinear arch.
■ A fracture of the ZMC is indeed complex as the zygoma helps to define the
degree of midface projection and width, as well as contribute to the anatomy
defining orbital volume, including the lateral orbital wall and part of the orbital
floor (OF).
■ Malposition of the ZMC can have a significant impact on the function of the
eye as well as sensation to the infraorbital nerve.
■ The various techniques that are described depend on how many points of
fixation the surgeon feels are necessary for adequate reduction and fixation.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The clinical presentation of the patient is dependent on the direction and
strength of the force striking the midface. The patient often presents with a
blunting of the malar eminence, which is commonly displaced posteriorly.

FIG 2 • A. Muscles that attach to the zygoma. B.
Position of the Whitnall tubercle relative to the
zygomaticofrontal suture with the lateral canthal
ligament attached.
■ Unless the fracture is a pure fracture of the zygomatic arch, all zygomatic
complex fractures also result in orbital fractures, commonly of the OF and
lateral orbital wall. As the orbit is involved, a complete orbital exam is required
to confirm that the patient’s globe and vision have not been compromised.
■ The surgeon should confirm that the extraocular muscles are functioning,
without evidence of entrapment of the extraocular muscles or other periorbital
soft tissue.
■ Diplopia may be due to entrapment or due to other malfunctions of the
extraocular muscles or nerves to those muscles.
■ A forced duction test may be needed to discern the difference between
entrapment and malfunction of the extraocular muscles.
■ Many have claimed to be able to perform a forced duction test adequately
under topical anesthesia. We have generally found it necessary to have the
patient completely relaxed and sedated to rule out entrapment in the acute
phase of facial trauma.
■ Trapdoor orbital fractures are more common in the pediatric and very young
adult skeleton owing to the increased elasticity of the bone. In response to an
acute periorbital impact following trauma, the floor fractures, and temporarily

bends, resulting in a linear crack. On the release of the force, the floor snaps
back into its original position. There may be entrapment of the extraocular
muscles and periorbita restricting the movements of the eyeball. There may be
minimal signs of edema or ecchymosis externally, and CT imaging may be
unremarkable when the volume of tissue entrapped is minimal. These fractures
were referred to as “white-eyed blowout fracture” by Jordan et al.6
■ The patients often present with severe pain on attempted eye movement
associated with nausea and vomiting due to an unresolving oculocardiac
reflex, which may be misinterpreted as being a primary intracranial injury.
■ This form of entrapment requires emergent intervention, both for the comfort
of the patient and to prevent prolonged muscle ischemia, which can result in
a persistent diplopia.
■ ZMC fractures and the associated OF fractures are commonly associated with
impingement on the infraorbital nerve and numbness in that distribution of the
midface.
■ This should be recorded prior to any intervention to avoid postoperative
concerns of an iatrogenic injury.
■ A depression of the zygomatic arch medially may be associated with
impingement of the coronoid process, thereby interfering with the movements
of the mandible.
■ This limits the patient’s ability to open or close his mouth, depending on the
position of the patient’s mouth at the time of the impact and fracture of the
arch and the degree of medial displacement of the arch.
■ Contact of the arch with the coronoid process may also limit the excursion of
the mandible from side to side (FIG 3).

FIG 3 • Impingement of zygomatic arch on coronoid
process.
IMAGING
■ The appropriate radiologic workup requires fine-cut CT.
■ The ideal workup includes axial cuts, reformatted coronal cuts, and sagittal
cuts through the orbit.
■ For our sagittal reformatting, we prefer oblique parasagittal cuts through the
orbit that follow the axial line of the optic nerve.
■ In special cases of complex or comminuted fractures, a 3D reformatting may
also be very useful.
NONOPERATIVE MANAGEMENT
■ If the zygoma is fractured, but not displaced, surgical intervention is usually
not needed.
■ In isolated arch fractures, if there is no coronoid impingement or significant
cosmetic deformity in the form of a depression on the cheek posterior to the
malar eminence, no intervention is usually required.
SURGICAL MANAGEMENT
■ Steps involved in an appropriate open reduction and internal fixation (ORIF)
of a complex zygoma fracture are variable, depending on the clinical findings,

CT findings, degree of comminution, and instability of the zygoma.
■ The technique first described for fixation of a ZMC fracture is that of a
standard three-point fixation of the zygoma.
■ The number of points of fixation needed depends on the degree of instability
of the zygoma following fracture reduction.
Preoperative Planning
■ An exam documenting the patient’s visual acuity, movements of the globe in
all directions, presence or absence of diplopia, and infraorbital nerve
anesthesia/paresthesia should be included in the preoperative exam.
■ Adequate preoperative axial fine cuts and coronal and oblique parasagittal
reformatted CT of the midface fractures should be part of the routine
preoperative workup.
■ Oblique parasagittal reconstructions in the plane of the optic nerve offer the
best single global view of the degree of displacement of the OF (and roof) and
can present the surgeon an estimate of the length of material needed if an OF
reconstruction is required.
Positioning
■ Positioning should be supine.
■ A decision should be made preoperatively as to whether it is necessary to
perform a coronal approach, as this will affect the position of the endotracheal
tube. For a pure ZMC fracture, a coronal approach is seldom needed.
■ Availability of intraoperative imaging or navigation also affects patient
positioning on the table and the position of the operating table relative to
anesthesia providers.
■ We usually prefer to have the operative table at 90 or 180 degrees from the
anesthesia source.
Approach
■ Fractures of the ZMC can be accessed using various transcutaneous,
transconjunctival, transoral, and coronal approaches.
■ The ZF suture is commonly approached transcutaneously using an upper
eyelid/lateral blepharoplasty incision.
■ Although a lateral brow incision is popular with surgeons in other parts of the
world, the access attained is not superior to the lateral brow and results in scar
alopecia in the hair of the eyebrow, which can often be quite apparent. The

lateral blepharoplasty incision is a more direct approach to the ZF fracture and
leaves a scar that is barely perceptible.
■ The ZF can also be accessed with a transconjunctival lateral canthotomy
incision, but requires considerable traction of the soft tissues in the cephalad
direction, and may result in considerable postop edema.
■ The infraorbital rim (IOR) and the OF can be accessed transcutaneously using
a subcilliary or subtarsal (midlid) incision.
■ Alternatively, the transconjunctival incision with or without a lateral
canthotomy and a transcaruncular or retrocaruncular incision (for medial
orbital wall fractures and medial floor fractures) will provide excellent
aesthetic exposure to the IOR and medial and lateral OF.
■ The ZMB can be accessed transorally using a maxillary vestibular incision.
■ The zygomatic complex and the arch can be indirectly reduced using a
transoral vestibular incision (Keen approach) or an extraoral, temporal incision
(Gillies approach).
■ For extensive fractures, a coronal approach can be contemplated through
which the lateral and medial orbital walls and supraorbital rim can be accessed
in one incision. The coronal incision provides direct exposure of the zygomatic
arch for reduction and plating.
■ Visualization of the arch can offer an additional landmark for achieving the
proper AP projection of the malar eminence, particularly in cases where other
key landmarks have been destroyed, such as when the lateral wall of the orbit
is comminuted.
■ The coronal incision will have to be combined with other incisions of choice
to access the IOR and ZMB.
■ The specific indication for each approach is discussed in the techniques
section.
T E C H N I Q U E S
■ Three-Point Fixation of a ZMC Fracture
Approach
■ In a severely displaced zygoma, the patient will require a lateral
blepharoplasty incision (upper eyelid) and periorbital approach (subcilliary,

midlid, or conjunctival incision).
■ If there is significant displacement of the zygoma, especially with
comminution of the lateral wall of the orbit, some surgeons advocate using a
coronal incision to expose and plate the zygomatic arch to obtain the proper
AP position of the zygomatic complex.
■ It is the authors’ opinion that the coronal approach often creates worse
cosmetic results than the deformity it is meant to correct, including scalp scar
alopecia, temporal hollowing, and the risk of injury to the frontal branch of
the facial nerve.
■ We would seldom advocate including the coronal incision to address the
arch unless there are additional reasons a coronal incision has to be made,
such as a frontal sinus fracture or extremely comminuted landmarks of the
other key reference points addressed below.
■ Exposure of the ZF suture can be achieved by performing a lateral
canthotomy/conjunctival incision without a blepharoplasty incision.
■ The degree of extreme pull on the soft tissues in the cephalad direction
results in both a struggle of retraction intraoperatively and more
postoperative periorbital edema than including an additional lateral
blepharoplasty incision and heals with a minimal scar when done properly
and is well concealed.
■ The authors do not recommend the use of the lateral brow incision, which
does not provide any better exposure to the ZF suture than a blepharoplasty
incision and commonly results in an obvious permanent alopecia and what
appears as a part in the hair of the eyebrow that can be noted from across the
waiting room.

TECH FIG 1 • A. Poor technique, with screw first
placed in the frontal bone. B. Preferred technique, in
which the first screw is placed in the zygoma so that
the gap in the ZF suture can be further reduced by
pulling the plate and fractured segment in the
cephalad direction before placing the second screw in
the frontal process.
■ A ZMC fracture where there is separation of the ZF suture and comminution
of the orbital rim is approached using a blepharoplasty and periorbital
incision at the minimum.
First Plate
■ We recommend first to plate the ZF fracture, initially with a single screw
placed on each side of the fracture.
■ The ZF fracture is the poorest landmark of the various sites that will be
plated to confirm the three-dimensional reduction of the zygoma.
■ By using only one screw on each side of the fracture, the zygoma is still
mobile and later can be swiveled into position for alignment of the orbital rim
and lateral column of the midface in the area of the ZMB.
■ The screw holes that are recommended to be used first should be the plate
holes that are the nearest to the ZF fracture site (TECH FIG 1).

Reduction
■ Once the initial stabilization of the ZF fracture has been done with just one
screw on each side of the fracture, the zygoma is reduced.
■ The authors prefer the Keen or intraoral approach. With this Keen approach,
a significant force can be used to elevate the ZMC into its proper position
using an appropriate zygoma elevator.
■ The landmarks of the lateral orbital wall, the orbital rim, and the
zygomaticomaxillary suture are used to confirm the proper alignment and
reduction of the zygoma (TECH FIG 2).
■ Some surgeons prefer the Gillies approach for elevating and repositioning
the zygomatic complex.
■ This approach requires an additional incision in the scalp, resulting in scar
alopecia, and provides a far more indirect approach to the zygomatic arch,
with several opportunities to end up in the wrong plane of dissection.

TECH FIG 2 • Intraoral (Keen) approach, with an
instrument placed deep to the zygomatic arch to
mobilize the ZMC.
■ With a fractured zygomatic arch using a Keen approach, the surgeon can
often insert a digit to actually palpate through the incision to confirm if the
reduction has been achieved. This direct digital confirmation is not possible
with the Gillies approach.
■ Other methods of elevating the zygoma have been popularized, including
using a hook under the zygomatic arch, a screw in the malar prominence to
pull on, and a Carroll-Girard instrument.
Second Plate
■ If three plates are required, the authors recommend plating the IOR next,
after plating the ZF suture. The goal is to have the orbit and orbital rim as
perfect as possible.
■ A small deformity of the lateral column of the midface is more forgivable
than not having the orbit perfectly aligned (both the lateral wall and the
orbital rim).
■ After plating the ZF fracture and before placing a plate on the orbital rim
or the lateral column of the midface, it is key to examine the lateral wall of
the orbit to confirm an adequate reduction (TECH FIG 3A).
■ The lateral wall of the orbit commonly fractures in the area of the junction
between the zygoma and the greater wing of the sphenoid. We have found
that in 60% of cases, this is not comminuted, and the ZS suture is an
excellent landmark for confirmation of the proper reduction of the zygoma.5
■ After various landmarks have confirmed the proper reduction of the
zygoma, the orbital rim is plated using the surgeon’s preferred periorbital
approach. There are great differences in comfort and experience level using
various periorbital approaches.
■ We recommend using the kind of approach with which the surgeon has the
most experience (TECH FIG 3B).
Third Plate
■ The last plate commonly used in the three-plate technique is an L-plate on
the lateral column of the midface.

■ The plates used at the ZF suture and the orbital rim are generally smaller
(1.3 mm or smaller plates) so that the patient will not be able to palpate and
complain of the plate’s prominence. The L-plate is a much larger plate and
offers significant stability.
TECH FIG 3 • A. Initially, the ZF plate is placed with
only one screw on each side of the fracture. It is
important to align the fracture along the lateral wall of
the orbit, which commonly occurs at the junction of the
greater wing of the sphenoid and the zygoma, prior to
the placement of additional plates. B. Inferior orbital
rim plate is placed after the ZF plate and after
confirmation of the proper reduction of the ZMC,
including visualization of the lateral orbital wall.
■ As there is commonly significant comminution of the lateral column of the
midface with these patients, we prefer a 2-mm L-plate that offers many

hole options to capture comminuted segments in variable locations (TECH
FIG 4).
■ Only after all of the other plates are placed are the final two holes of the
plate at the ZF suture filled.
Other Concerns
■ If reconstruction of the OF is required, this should be addressed after
reduction and plating of the ZMC are complete.
■ Every effort should be taken to protect the eye during the case.
■ Corneal protectors are useful.
■ A forced duction test should be performed at the end of the case to confirm
that there has not been any entrapment, even in cases where a ZMC
repositioning is performed without a reconstruction of the OF.
■ Numbness in the infraorbital distribution is common both pre- and
postoperatively. If the fracture segments appear to be impinging the nerve at
the infraorbital foramen, it may be worth considering disimpacting the
foramen.
TECH FIG 4 • The last plate to be placed in the three-

plate technique is the L-plate. After the placement of
this plate, the final two (or more) remaining holes in
the ZF plate are placed.
■ Alternative Treatments
■ Various forms of intraoperative imaging are having a dramatic impact on
previous traditional methods of treatment.
■ Many once thought that zygomatic arch fractures were unstable and if
reduced would not hold their reduced position without plating.
■ We found that with intraoperative confirmation of a proper reduction of
pure arch fractures, nine of nine consecutive fractures maintained their
reduction after using the Keen approach.7
■ In the past, it was often routine to explore the OF and reconstruct it as part of
the reduction of a complex zygomatic fracture where the floor was involved
or the malar eminence was telescoped posteriorly.
■ With the advent of intraoperative imaging, Wilde et al.8 have found that
81% of their patients did not need further surgery of the OF, the lateral
wall, or the arch after a proper reduction of the zygoma, without
exploration of these structures, having intraoperative visualization of an
adequate reduction of the orbital walls.
■ The key is being able to visualize with radiographic imagining
intraoperatively what has happened to all of the parts following the
reduction of the zygoma. Once the zygoma is reduced to its proper three-
dimensional projections, if the periorbita (specifically the periosteum of the
orbit) has not been violated and explored, the floor will often resume its
proper alignment in repositioning the ZMC due to ligamentotaxis.
■ Navigation may be used intraoperatively in a similar way that intraoperative
imaging is used if this technology is available to the surgeon.
■ With navigation, obtaining a preoperative CT with a fiducial guide may be
necessary. With this technique, the surgeon is able to perform a virtual
correction of the proper placement of the ZMC on the injured side by
mirroring the proper position of the ZMC from the contralateral uninjured
side.9
■ At the time of the surgery, the malpositioned ZMC is moved into its proper
position as visualized in the virtual image.

■ Rarely, a ZMC fracture will snap into reduction and be perfectly stable.
There is no reason to use any plates or screws in these cases.
■ If on the preoperative CT there is a fracture, but no displacement of the ZF
suture, this portion of the fracture is often attached to the periosteum and
hinged in a way that the surgeon may begin by only making an intraoral
incision.
■ The dissection can often be carried up to the orbital rim through this
intraoral incision.
■ If all of the key landmarks can be aligned and there is no (or little)
comminution, a single 2-mm L-plate may be sufficient for stabilization of
the ZMC facture at the buttress.
■ Every zygomatic fracture is unique. Good judgment should be used to
determine how many surgical approaches are required and how many areas
need to be plated. Though the authors originally supported the policy of
exposing all fractures before plating, it is possible that with intraoperative
imaging, fewer exposures and fewer plates and screws may be required.
TECH FIG 5 • The maximum number of plates (four-

point fixation) that might be used for a ZMC fracture.
The authors would seldom find it necessary to plate
the zygomatic arch, as a coronal incision would be
needed. If a coronal incision is required, the plate on
the arch would commonly be the second plate placed
after the plate on the ZF fracture. If the arch is not
plated, the orbital rim plate would commonly be the
second plate placed. If there is a significant orbital
floor defect, the floor would be the last part of the
reconstruction after all of the other plates have been
placed. Following placement of the orbital floor plate,
a forced duction of the globe would be performed to
confirm that the reduction of the zygoma or
reconstruction of the orbital floor did not result in
entrapment of the extraocular muscles or other soft
tissues of the periorbita.
■ In the same way that a few fractures may attain stability without any
fixation, some fractures may attain adequate stability (especially if there is no
gap at the ZF fracture) with simpler one- or two-point fixation. In these
noncomminuted fractures, one- or two-point fixation of the lateral wall of the
midface with the possible addition of an IOR plate may be a consideration.
■ In many cases in which the preoperative CT confirms a simple fracture of
the IOR, this area may be adequately visualized using the intraoral
approach only, without needing a periorbital incision.
■ In cases of severe comminution of the multiple landmarks with significant
displacement of the ZMC and a comminution of the lateral wall of the orbit,
four-point fixation with exposure and fixation of the arch may be considered
using a coronal incision, combined with other incisions (TECH FIG 5).
PEARLS AND PITFALLS