CRANIOFACIAL

Evaluation and Treatment of

Zygomatic Fractures
Patrick Kelley, M.D.
Richard Hopper, M.D.
Joseph Gruss, M.D.
Austin, Texas; and Seattle, Wash.

Summary: Orbitozygomatic fractures are some of the most common facial

fractures evaluated and treated by plastic surgeons. A considerable debate
remains surrounding the manner of evaluation and appropriate treatment
modalities. On the one hand, some would suggest that few fractures need formal
open reduction and internal fixation, whereas others would argue that the pull
of the strong masseter muscle ultimately leads to inferior and lateral rotation of
the zygoma, which justifies open reduction and internal fixation of most fractures excepting those fractures that are nondisplaced at all points of articulation.
The authors hope to shed some light on these issues by conveying their perspective on these fractures that has developed over several decades while servicing a single, major Level I trauma center. In general, the authors feel that
through a detailed evaluation including an accurate physical examination of the
face and orbit combined with detailed computed tomographic scanning of the
craniofacial skeleton and soft tissues, an appropriate treatment plan can be
generated. The common goal among all treatment plans should be the exact
three-dimensional restoration of the disturbed anatomy, that is, anatomical
reduction and the need for accurate restoration of orbital anatomy and volume
when necessary. (Plast. Reconstr. Surg. 120 (Suppl. 2): 5S, 2007.)

ractures involving the zygoma are among the

most common facial fractures seen in trauma
centers. Isolated fractures of the zygoma
have been variously termed zygomatic, tripod, or
orbitozygomatic fractures. We recommend the
term orbitozygomatic fracture because this term
refers to the two most important considerations in
treatment, which are accurate anatomical reduction of the zygoma and restoration of appropriate
orbital anatomy. Accurate anatomical reduction
in the primary setting, usually within 2 weeks of
injury, is imperative because this is the best opportunity to restore the patient to their preinjury
state. Secondary correction of deformities related to
the untreated or mistreated, malpositioned zygoma
is challenging and often less successful because of
bony malunion and soft-tissue contracture.17
From the Department of Craniofacial, Plastic, and Reconstructive Surgery, Dell Childrens Medical Center of Central
Texas; Division of Plastic Surgery, Department of Surgery,
University of Washington; and Division of Craniofacial,
Plastic, and Reconstructive Surgery, Childrens Hospital
and Regional Medical Center.
Received for publication May 4, 2006; accepted December 6,
2006.
Copyright 2007 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000260720.73370.d7

The diagnosis and management of orbitozygomatic injuries remains a controversial issue

among surgeons dealing with facial trauma. The
debate continues unabated as to which of these
common fractures can be treated with less invasive
methods and which ones need more extensive
open reduction and internal fixation to accomplish the desired repair. The essential elements of
the debate are centered on the degree of displacement and comminution that leads to secondary
deformities if left untreated or treated with less
comprehensive techniques. Other issues lacking
consensus are the most reliable sites of assessment
of anatomical deformity and displacement, the
appropriate sites of surgical exposure and stabilization, and the best methods of internal fixation.
It is generally agreed, however, that the standard
for comparison of other techniques of repair of
the orbitozygomatic structure is anatomical reduction after full anatomical exposure (assessment of

Disclosure: None of the authors has any commercial associations or financial disclosures that might
create a conflict of interest with information presented in this article.

www.PRSJournal.com

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Plastic and Reconstructive Surgery December Supplement 2, 2007

all articulations of the zygoma) and rigid fixation
of all possible points of fixations (buttresses).
Anything less than this is inherently a compromise
that may or may not be justified based on a logical
assessment of the degree of displacement, fracture
patterns, and comminution present.

ANATOMY
The zygomatic complex has been incorrectly
labeled in the past as a tripod and, in fact, should
be considered a quadripod. The lateral orbital wall
should be considered the base of the quadripod,
with the four legs being the lateral orbital rim,
the inferior orbital rim, the zygomaticomaxillary
buttress, and the zygomatic arch. Fractures of the
zygomatic complex involve all four legs in addition
to the fracture that extends through the lateral
orbital wall. These four legs and the lateral orbital
wall make up five potential points of assessment
for the degree of displacement. The legs of the
quadripod provide two attachments to the cranium and two to the maxilla and create a large
portion of the orbital floors and lateral orbital
walls. The zygomaticomaxillary complexes are
therefore surgically important in establishing orbital volume and serving as a reference for reduction of maxillary fractures to the cranium.
Fractures often, but not always, occur across
the three buttress-related sutures. The term tripod
fracture was derived out of reference to the three
related sutures, but reference to the associated
sutures is inconsequential because they do not
provide consistent and reliable information with
regard to anatomical alignment, nor do they have
any significance with regard to durable points of
fixation. In addition, the term tripod fails to recognize the posterior relationship of the zygoma
with the sphenoid bone of the skull base and its
extension inferiorly down the lateral wall of the
maxillary sinus.
The four legs represent two major buttresses
of the face which are the upper transverse maxillary (across the zygomaticomaxillary and zygomaticotemporal sutures) and the lateral vertical
maxillary (across the zygomaticomaxillary and the
frontozygomatic sutures). If the two buttresses of
the zygoma are reduced and fixated, it is still possible to have a rotational deformity of the zygoma
about the zygomaticosphenoid suture. The four
legs are composed of narrow, dense bone, which
is excellent for alignment and fixation. However,
because they are narrow structures, it is difficult to
determine the degree of rotation of the zygoma
from assessment of only one or two of these points
alone. The four legs of the quadripod and the

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lateral orbital wall in concert make up the five

most accurate points of assessment for the degree
of displacement, and only by assessing at least
three (more commonly all five) can accurate reduction be ensured (Fig. 1).
The anterior portion of the lateral orbital wall
is formed by the zygoma. The frontal bone and
greater wing of the sphenoid articulate with the
zygoma through a suture within the lateral orbital
wall, which starts as the zygomaticofrontal suture
on the upper portion of the lateral orbital rim and

Fig. 1. (Above) Orbitozygomatic fractures can be described as

quadripods, with the legs being the inferior orbital rim, the zygomaticomaxillary buttress, the lateral orbital rim, and the zygomatic arch. The base of the quadripod is the lateral orbital wall.
The most accurate means of determining anatomical reduction is
through assessment of all five of these points in concert. (Below)
The facial buttresses represent thickened regions of bone that
provide structure to the face and stabilize the position of the face
with the cranium; as such, they represent ideal points of fixation.
The illuminated skull illustrates that there is thickened bone at
the lateral orbital wall, the zygomatic arch, the inferior orbital rim,
and the lateral wall of the maxillary sinus, known as the zygomaticomaxillary buttress.

Volume 120, Number 7 Suppl. 2 Zygomatic Fractures

Fig. 2. (Left) The zygomatic complex articulates with the frontal bone and sphenoid through a suture within the lateral orbital wall.
Orbitozygomatic fractures often but not always extend directly through this suture line (arrows). The thickness of the lateral orbital
wall in relation to the other orbital walls often prevents comminution at this fracture site. The lack of comminution in addition to the
natural three-dimensional character of this concave wall makes it the single most reliable indicator of anatomical reduction. (Right)
One exception to this rule is the presence of an orbitozygomatic injury ipsilateral to an impacted sphenoid fracture, unless it is a large
fragment that can be anatomically reduced before reduction of the orbitozygomatic injury.

has a slight posteroinferior course within the orbit

to the anterior to mid portion of the inferior orbital fissure. The lateral orbital wall is the thickest
portion of the orbit and is rarely comminuted.
This portion of the orbit has a distinct shape and
is the longest interaction of the zygoma with the
rest of the facial bones with attributes in all three
dimensions. This makes the zygomaticosphenoid
fracture line the single most reliable indicator of
degree and direction of displacement and of anatomical alignment of the zygoma in all three dimensions (Fig. 2).
The zygomatic arch serves as the origin of the
masseter on its inferior margin and the attachment of the fascial layers of the face (superficial
musculoaponeurotic system) and the temporal region (temporoparietal fascia) superficially. The
origin of the masseter is the major deforming
force acting on the fractured zygoma, interfering
with mobilization and reduction and contributing
to relapse in the inadequately fixated fracture. An
oblique suture in the mid portion of the arch
represents the articulation of the contribution of
the zygoma and the contribution of the temporal
bone to the arch proper. The temporomandibular
joint abuts the posteromedial aspect of the arch,
with its anterior limit at the articular tubercle of
the zygomatic arch. The term arch is a misnomer,
because it is linear through most of its course (Fig.
3, above). It is gently curved in its posterior aspect
near the region of the articular tubercle of the

Fig. 3. (Above) The term zygomatic arch is a misnomer. As seen

in this inferior view of the skull, the arch is straight through most
of its course, with curvatures posteriorly and anteriorly. (Below)
Malreduction and fixation of the zygomatic arch as an arch
leads to disturbances in facial width and cheek projection.

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Plastic and Reconstructive Surgery December Supplement 2, 2007

Fig. 4. Most orbitozygomatic injuries present with ipsilateral proptosis secondary to orbital swelling even in cases of orbital blow-out
(orbital expansion). When a patient presents with acute enophthalmos, it is indicative of severe orbital expansion, as indicated in the
associated floor fracture of this patient with an otherwise simple orbitozygomatic fracture.

temporomandibular joint. It then maintains a linear projection with a slight medial angulation until it sharply curves at its most anterior aspect to
meet the maxilla. The zygomaticomaxillary suture
line lies at approximately the mid portion of this
anterior curvature; thus, both the zygoma and
maxilla contribute to the anterior curvature. The
anatomy of the arch is critical because it is the arch
that forms the outer facial frame, determining the
width and the anterior projection of the midface.
Without proper restoration of the position of the
arch, facial width and midface projection will be
incorrect (Fig. 3, below).

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DIAGNOSIS
Displacement of the zygoma leads to cheek depression and, depending on the condition of the
arch, disturbance of facial width. Physical signs and
symptoms of zygoma fractures include (1) subconjunctival hemorrhage and periorbital ecchymosis;
(2) disturbance of sensation in the region of infraorbital nerve; (3) palpable step-offs in the upper lateral
orbital rim, inferior orbital rim, and upper buccal
sulcus; (4) emphysema within the orbit or overlying
soft tissues of the cheek; (5) trismus; and (6) malposition of the globe and/or diplopia.

Volume 120, Number 7 Suppl. 2 Zygomatic Fractures

Facial swelling is usually substantial by the time
the patient presents to the plastic surgeon, and it
tends to minimize the degree of deformity by
masking globe and cheek malposition. The swelling has usually resolved sufficiently by approximately 2 weeks after injury that the underlying
deformity can be appreciated. It is important for
the patient to understand this dynamic because
treatment should be carried out within the first 2
weeks after injury, still within the timeframe where
it is difficult for the patient to appreciate the true
deformity.
The position of the globe is affected by the
integrity of the periorbital fascial support, the direction and degree of displacement of the zygoma,
and the degree of concomitant swelling. Fractures
that cause an increase in orbital volume (blow-out
fracture) will predispose to enophthalmos, but
during the acute period, swelling within the orbit
may cause some degree of proptosis despite the
expansion of the orbit. As swelling resolves, the
globe progressively sinks back, revealing the underlying orbital expansion. Zygomatic fractures
that present with acute enophthalmos indicate severe displacement and orbital expansion (Fig. 4).
Zygomatic fractures that impinge into the domain
of the orbit (blow-in fracture) reduce the orbital
volume and present with acute proptosis, which
will improve only slightly as swelling resolves.
Some degree of trismus is common with zygomatic fractures secondary to direct injury to the
masseter and its origin on the zygomatic arch.
When the arch is severely collapsed or impacted,
it can cause a trismus secondary to mechanical
impedance of the coronoid process as it slides
upward, preventing closure of the mouth, but this
is less common than trismus secondary to direct
muscle injury.
Secondary deformities related to untreated or
mistreated fractures of the zygoma are not uncommon. These deformities are especially common in the patient with associated panfacial injuries. The patient with a malpositioned zygoma
typically presents with an underprojected cheek
and a wide face, but overprojection is also possible.
Failure to evaluate and treat the concomitant orbital deformity usually results in globe malposition
if the fascial support of the eyeball has been disrupted. Enophthalmos is the usual result, but occasionally exophthalmos can occur if the orbital
volume is decreased by a blow-in type fracture.
Secondary deformities can also result from iatrogenic malposition of the overlying soft tissues.
Even with accurate reduction of the bone anatomy, soft-tissue deformities can result from inad-

equate suspension after extensive surgical exposure. Cheek ptosis, inferior displacement of the
lateral canthus, temporal hollowing, and lower lid
ectropion are among the most common findings.

IMAGING
Advancement of computed tomographic
scanning technology has resulted in vast improvements in the quality of images, the ability
to develop three-dimensional models (digital
and stereolithographic), increased speed of scanning, and reduced radiation exposure. This has
established computed tomography as the modality
of choice for the evaluation of facial fractures.
Patients with suspected facial trauma on initial
evaluation are evaluated with a complete craniofacial computed tomographic scan. Our protocol
includes a full facial analysis from the top of the head
through the mandible with 1.5-mm axial cuts. Coronal reformatting can then be constructed from
this data set without additional scanning. Although sagittal reformat and three-dimensional
representation of the data are not part of our usual
protocol, they each have their role in specific situations. Sagittal reformat is particularly useful in
assessing the effect of a complex orbital fracture
on the inferomedial bulge of the orbital floor. In
a busy Level I trauma center, where many patients
present with neurologic compromise (head injury
or intoxication) and cannot comply with a complete physical examination, it is prudent to obtain
a complete scan at the time that the head computed tomographic scan is obtained; doing so
takes only a few seconds.

PRINCIPLES OF SURGICAL PLANNING

AND REPAIR
The zygoma has five articulations that can be
used to guide anatomical reduction: (1) the lateral
orbital rim, (2) the inferior orbital rim, (3) the
zygomaticomaxillary buttress, (4) the zygomatic
arch, and (5) the lateral orbital wall. Rigid internal
fixation can be achieved at four of these articulations through limited access incisions. Fixation of
fractures through the lateral orbital wall requires
extensive exposure by means of a coronal incision,
with elevation of the temporalis muscle out of the
sphenopalatine fossa. This exposure is reserved
for rare cases with severe comminution and displacement of the zygomatic arch and lateral orbital wall. In theory, reduction and fixation of
three of the four potential points of fixation (buttresses) will correct both translation and rotation
of the zygoma in three-dimensional space. When
one or more of the buttresses is comminuted,

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Plastic and Reconstructive Surgery December Supplement 2, 2007

exposure and reduction of all four buttresses becomes increasingly important. The use of established craniofacial techniques to achieve wide exposure and mobilization of the entire zygoma is of
paramount importance to accurate anatomical reduction of the severely displaced and comminuted
zygoma.
With a careful assessment of a fine-cut computed tomographic scan of the facial skeleton,
examining both the axial and coronal cuts, the
surgeon should be able to accurately diagnose the
exact fracture pattern and search for any degree
of separation or comminution at the multiple fracture sites. All five points of assessment listed above
should be evaluated carefully on the computed
tomographic scan for the degree of displacement
and comminution. Simple elevation of the fracture by means of a Gillies or intraoral approach is
usually reserved for minimal displacement at all
fives buttresses with no comminution. In these
cases, the periosteal hinge is still present at the
majority of the fracture sites, and the zygoma
should be stable in reduction. If there is a significant degree of displacement at any of the five
sites, particularly if there is associated comminution, the pull of the masseter muscle will cause a
collapse at the area of comminution, particularly
if it is at the zygomaticomaxillary buttress. Our
preferred method for mobilizing the displaced
zygoma, whether it requires extensive exposure or
limited exposure, is to place a mayo scissors posterior to the body of the zygoma by means of the
upper buccal sulcus incision. This affords an excellent purchase on the body of the zygoma and
mobilization is usually associated with an audible
clunk. A Carroll-Jerrard screw can be used to
achieve the same effect.
If significant displacement or comminution is
present at any of the five sites, an open reduction
and internal fixation is indicated. The surgeon
then decides how many of the five points of fracturing need to be exposed and assessed intraoperatively. The condition of the zygomatic arch is a
key element in the decision tree as to which incisions are required. The arch establishes the outer
facial frame (facial width and midface projection).
A careful analysis of patients who present with
secondary midface depression and increased facial width reveals that all had untreated deformity
of the zygomatic arch. Segmentation, lateral displacement, telescoping, and comminution of the
arch are indications for exposure, reduction, and
fixation (Fig. 5).
The safest approach to the zygomatic arch is by
means of a coronal incision with protection of the

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frontal branch. If the zygomatic arch has a greenstick fracture with minimal displacement or is medially displaced, it is not necessary to expose the
zygomatic arch, and the entire open reduction can
be performed from an anterior approach without
the need for a coronal incision (Fig. 6). An anterior approach in our center involves three incisions, including an upper buccal sulcus, a mideyelid (subtarsal) or transconjunctival, and the
lateral part of an upper blepharoplasty incision.
The zygomaticosphenoid alignment at the lateral orbital wall is recognized as a fundamental key
to the proper reduction of orbitozygomatic injuries. Displacement at this surface indicates a residual rotational deformity. As mentioned earlier,
the thick lateral orbital wall is rarely comminuted.
Accurate reduction of the lateral orbital wall in
combination with inspection of the other three or
four sites as necessary will allow the surgeon to
achieve a very accurate reduction of the fracture
before the application of rigid fixation. Subperiosteal dissection at the exposed buttresses is limited to the minimum required to assess reduction
and achieve fixation but always adequate to allow
full assessment of the fracture character.
The pull of the masseter can often frustrate
adequate mobilization of the fracture fragment.
This can be overcome by either chemical paralysis
or partial or complete release of the anterior portion of the masseter from the zygoma by means of
the intraoral or coronal incision. The correct reduction is best accomplished by placing a temporary interosseous wire at the frontozygomatic suture on the lateral orbital rim to set the vertical
height of the zygoma, followed by rotation of the
entire complex into correct position. Failure to
accurately reduce the fractures will result in the
zygomatic complex being stabilized in an unreduced position otherwise known as an open internal fixation without reduction.
Rigid fixation with plates and screws is the
accepted standard of fixation of reduced fractures
of the zygoma. There is no consensus, however, on
the strength of plates required at each fracture site
that will provide sufficient rigidity to resist the
regional deforming forces (Fig. 7). All currently
available internal fixation systems have a large selection of plates of various thicknesses, sizes, and
strengths. The benefit of a smaller plate is less
dissection required to place it and potentially less
palpability. These benefits must always be weighed
against the fundamental goal of rigid fixation to
retain reduction and promote osseous union.
Thus, it is always safer to err on a slightly larger and
stronger plate than a smaller plate that will not be

Volume 120, Number 7 Suppl. 2 Zygomatic Fractures

Fig. 5. Segmentation, lateral displacement, telescoping, and comminution of the arch are indications for exposure, reduction, and
fixation.

strong enough to withstand the forces acting at

that specific fracture site. The best site for rigid
fixation is the zygomaticomaxillary buttress, because this is the direct antagonist to the pull of the
masseter muscle. In addition, this site of fixation
is deep, and plates are rarely felt in this area. Thus,
a longer and stronger fixation plate (2.0 mm)
should usually be used at this site. Likewise, it is
very important to primarily bone graft any sites of
bone loss, especially the zygomaticomaxillary buttress, because of its antagonistic effect on the pull

of the masseter. The infraorbital rim is an important site for fracture reduction but is the least
important site for fracture fixation, and either an
interosseous wire or a small plate can be used in
this site quite safely.
The frontozygomatic suture line represents
very thick bone that is ideal for rigid fixation.
Unfortunately, plates in this area are readily palpable, and therefore it is usually advisable to use
smaller plates at this location, provided that the
fracture is not too unstable. It is very important to

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Plastic and Reconstructive Surgery December Supplement 2, 2007

Fig. 7. Plating guidelines for fixation of orbitozygomatic fractures. A 2.0-mm plate is indicated at the zygomaticomaxillary
buttress because this strong buttress directly opposes the deforming forces of the masseter muscle. A 2.0-mm plate is easily
concealed in the region of the arch and provides further stability
to this structure. Plates placed on the lateral orbital rim and the
inferior orbital rim tend to be more palpable; therefore, smaller
plates or wires can be used in these regions because these areas
bear less weight. A 1.7- or 2.0-mm plate is recommended on the
inferior orbital rim in the presence of an ipsilateral naso-orbitoethmoid fracture to further stabilize the adjacent fractures in the
correct position.

Fig. 6. If the zygomatic arch has a greenstick fracture with minimal displacement or is medially displaced, it is not necessary to
expose the zygomatic arch, and the entire open reduction can be
performed from an anterior approach without the need for a
coronal incision.

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realize that the frontozygomatic suture line is the

least important site with which to determine the
degree of rotation of the fracture, because many
significantly displaced fractures will have very little
separation at the frontozygomatic suture line.
Thus, it is essential to look at the frontozygomatic
suture line in combination with exposure at the
other sites to assess the correct degree of reduction of the fracture. The zygomatic arch, if necessary, is a very important site of fixation, and
stronger plates usually should be used in this area.
It is very important not to stabilize and reconstruct
the arch as a true arch but to ensure that the
central portion is flattened and compressed medially to ensure restoration of facial width and
correct projection of the zygomatic body. A frequently missed zygomaticomaxillary complex fracture is at the temporal bone portion of the upper
transverse maxillary buttress. When the arch is

Volume 120, Number 7 Suppl. 2 Zygomatic Fractures

Fig. 8. Accurate reduction and fixation of the base of the zygomatic arch is important for reestablishing the correct facial width and
projection. Care must be taken when fixating fractures at the base of the zygomatic arch to avoid penetration of screws into the
glenoid fossa. Correct position of hardware is demonstrated in this coronal image.

fractured posteriorly from the zygomatic process

of the temporal bone, care must be taken not to
place screws into the adjacent glenoid fossa and
mandibular condyle (Fig. 8).
Once the entire orbitozygomatic complex has
been reduced and rigidly fixed in its correct alignment, the orbit then needs to be carefully evaluated
for possible bony loss and needs to be anatomically
reconstructed to accurately restore the correct orbital volume. We generally use a thin sheet of Medpor (Porex Surgical, Inc., Newnan, Ga.) to reconstruct simple disruptions of a single orbital wall.
More extensive fractures of the orbit involving large
bone loss or multiple walls are more commonly reconstructed with cranial bone graft harvested from
the outer cranial cortex. Achieving the correct orbital volume in complex fractures is more challenging and is more commonly associated with the need
for secondary procedures to fine tune the position
of the globe. Secondary surgery in a primarily bone
grafted orbit is much easier to perform because a
perfect dissection plane develops between the bone
graft and periorbita.
Finally, the midfacial soft tissue needs to be
repositioned in relation to the bony reconstruction and skeleton framework by the insertion of
multiple drill holes in the inferior and lateral orbital rims to enable suspension of the muscular
periosteal envelope to these drill holes. We use at
least four 2-0 resorbable sutures that attach to
independent drill holes starting in the region of
the mid inferior orbital rim and extending to the
lower lateral orbital rim below the lateral canthal
attachment. The lateral canthal tendon is reat-

tached in a slightly overcorrected position when it

has been detached in the dissection.

APPROACH TO THE ARCH

Safe exposure of the entire zygomatic arch
and assessment of its exact relationship to the
remaining craniofacial skeleton can be accomplished only through an extended coronal incision. The scalp flap must be dissected meticulously to prevent postoperative morbidity
relating to the following:
1. Weakness or permanent paralysis of the
frontal branch of the facial nerve
2. Temporal depression related to atrophy of
the temporal fat pad
3. Displacement of the lateral canthal ligament
resulting in an antimongoloid slant of the
palpebral fissure
4. Inferior descent of the lateral cheek tissues
secondary to failure to reconstruct the incision in the temporal fat pad
5. Preauricular scar and injury to the superficial temporal vessels
Our approach to the zygomatic arch based
primarily on the location of the frontal branch of
the facial nerve (deep to the superficial musculoaponeurotic system, below the arch; superficial
to the temporoparietal fascial, above the arch) has
been previously described. It is based on dissection
one plane deeper than the nerve, entering the
subperiosteal plane 2 cm above the orbital rims
and entering the plane deep to the superficial
layer of the deep temporal fascia 1 cm above the

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Plastic and Reconstructive Surgery December Supplement 2, 2007

zygomatic arch. Damage to the temporal fat pad
can be avoided by approaching the arch above the
fat pad, just deep to the first fascial layer of the
thick deep temporal fascia. We almost never require a preauricular extension of the incision to
gain additional exposure. Equally adequate exposure can be achieved by extending the incision
posterior to the ear and raising the soft tissues
subperiosteally to the level of the external auditory
canal.
Full exposure of the arch requires division and
dissection of many important suspensory ligaments in the region. It is imperative to reestablish
the integrity of these structures to prevent the
premature descent of these structures. Specifically, the lateral canthal tendon must be taken
down to gain exposure of the arch. The appropriate repositioning of this tendon to the internal
surface of the lateral orbital wall is necessary to
prevent postsurgical deformity. Resuspension of
the deep temporal fascia at the point of division
just above the zygomatic arch reestablishes the soft
tissues over the reconstructed arch to prevent the
arch from becoming displaced into the subcutaneous plane. Care must be taken when placing
these sutures to prevent inadvertent damage to
the frontal branch of the facial nerve. In addition,
extension of the incision behind the ear mobilizes
the superior aspect of the ear and requires resuspension to prevent malpositioning of the ear and
collapse of the external auditory canal.

ZYGOMATIC FRACTURES ASSOCIATED

WITH IPSILATERAL
NASOETHMOIDAL FRACTURES
One of the important sites of zygomatic reduction is the inferior orbital rim. Because this site
is so readily visible through direct exposure, there
is a tendency for surgeons to rely heavily on this
site. One of the pitfalls of the inferior orbital rim
is that it is often displaced by the presence of an
ipsilateral naso-orbito-ethmoid fracture. When reviewing our results and results of patients referred
to our center for secondary correction of displaced zygomatic fractures, there is often a missed
ipsilateral naso-orbito-ethmoid fracture.
The naso-orbito-ethmoid fracture involves fractures through the nasofrontal junction, medial orbital wall (ethmoids), frontal process of the maxilla
at the pyriform (medial nasomaxillary buttress), and
the inferior orbital rim. Although severe naso-orbito-ethmoid fractures associated with comminution and displacement are fairly easy to diagnose
by the presence of telecanthus and nasal distortion, less comminuted and displaced fractures can

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Fig. 9. The presence of an ipsilateral naso-orbito-ethmoid

fracture can be misleading as to the correct position of the
zygoma. Failure to appreciate an ipsilateral naso-orbito-ethmoid will lead to malreduction of the fracture and postoperative deformities related to malposition of the zygoma and the
naso-orbito-ethmoid.

be much more subtle and easily missed. The nasofrontal junction in these less severe naso-orbitoethmoid injuries is often greensticked, with posterior, inferior displacement of the medial
buttress and inferior orbital rim (Fig. 9).
If an ipsilateral naso-orbito-ethmoid is not appreciated, reduction of the zygoma to the malpositioned medial portion of the inferior orbital rim
will lead to fixation of the zygoma in an incorrect
position. The clinical consequence to using this
displaced anatomy as a guide to reduction of the
orbitozygomatic complex is usually malar flattening, hemifacial widening caused by lateral displacement of the zygomatic arch, enophthalmos,
ocular dystopia, a depressed inferior orbital rim,
and telecanthus.
The best way to evaluate for the presence of an
ipsilateral naso-orbito-ethmoid in the absence of
overt clinical signs is through careful evaluation of
a fine cut, craniofacial computed tomographic
scan. Findings consistent with naso-orbito-ethmoid injury on axial views include lateral, inferior,
and posterior displacement of the nasomaxillary
buttress (often seen as a discrepancy in the position of nasolacrimal ducts), opacification and
comminution of the ethmoids air cells, ipsilateral
depression and displacement of the nasal bone,
displaced fractures of the medial orbital wall, and
significant periorbital emphysema. Coronal views
may demonstrate medial and inferior displacement of the nasomaxillary buttress or fracture of
the inferior orbital rim with posterior displacement.

Volume 120, Number 7 Suppl. 2 Zygomatic Fractures

Although the inferomedial orbit is often involved in
orbitozygomatic fractures, the medial orbital wall is
not a component of pure orbitozygomatic injuries.
Fractures involving the medial orbit should alert the
examiner to the possible presence of an ipsilateral
naso-orbito-ethmoid fracture.
The displaced naso-orbito-ethmoid should be
addressed before final reduction of the zygoma. If
the fracture at the nasofrontal junction is a greenstick fracture, no additional fixation of this site is
required because the nasomaxillary buttress can
be used as a guide to assist with proper positioning
of the naso-orbito-ethmoid fragment. A strong
plate on the nasomaxillary buttress will stabilize
the naso-orbito-ethmoid segment once it is correctly reduced. The plate on the inferior orbital
rim will further stabilize the naso-orbito-ethmoid
segment in proper reduction because there are
minimal muscular deforming forces acting on the
naso-orbito-ethmoid complex. However, if the
naso-orbito-ethmoid component is displaced and
unstable at the nasofrontal suture, additional fixation at this site will be required, usually through
a coronal incision.
It is extremely important to preserve the attachment of the medial canthal ligament to the
lacrimal bone during dissection. The medial canthus is rarely avulsed from its bony attachment at
the time of the actual injury; rather, it is usually
stripped from its insertion during exposure of the
fracture. Preservation of its insertion to the bony
fragments facilitates proper positioning of the medial canthus, preventing traumatic telecanthus.

DISCUSSION
Poorly treated orbitozygomatic injury is undoubtedly the most common posttraumatic problem seen by most craniofacial surgeons today. The
advent of rigid fixation using plates and screws has
given many surgeons a false sense of security in the
management of these fractures. The use of plates
and screws is probably the least important part of
the entire treatment protocol in these patients. All
the plates and screws represent are the most sophisticated and best form of fixation of the fractures after they have been reduced. The most important aspect of the treatment of these fractures,
and all other facial fractures, is the careful expo-

sure of all fractures and the accurate reduction of

these fractures in a three-dimensional fashion. Facial symmetry is achieved by restoring the threedimensional position of the malar prominence,
and orbital volume is restored by alignment of the
zygoma with the sphenoid. If this is not done, the
fractures will merely be rigidly plated in an unreduced position. All craniofacial surgeons today
dealing with a significant volume of facial fractures
have noticed that there is a rapidly increasing epidemic of patients seen with fractures plated rigidly in the wrong position. The complications we
are now seeing with fractures plated in the unreduced position are much more disastrous for the
patient than those that used to be seen with simple
elevation or when fixation using interosseus wires
was used. It is essential for the surgeon treating
these very common injuries to thoroughly understand that there is no substitute for accurate exposure and reduction of the fractures. Only once
this is done will rigid fixation with plates and
screws accomplish its planned objective.
Joseph Gruss, M.D.
Childrens Hospital CH-78
4800 Sandpoint Way N.E.
Mail Stop G-0035
Seattle, Wash. 98115
joseph.gruss@seattlechildrens.org

REFERENCES
1. Gruss, J. S., Van Wyck, L., Phillips, J. H., and Antonyshyn, O.
The importance of the zygomatic arch in complex midfacial
fracture repair and correction of posttraumatic orbitozygomatic deformities. Plast. Reconstr. Surg. 85: 878, 1990.
2. Gruss, J. S., Antonyshyn, O., and Phillips, J. H. Early definitive
bone and soft-tissue reconstruction of major gunshot wounds
of the face. Plast. Reconstr. Surg. 87: 436, 1991.
3. Gruss, J. S. Advances in craniofacial fracture repair. Scand. J.
Plast. Reconstr. Surg. Hand. Surg. Suppl. 27: 67, 1995.
4. Gruss, J. S., Whelan, M. F., Rand, R. P., and Ellenbogen, R. G.
Lessons learnt from the management of 1500 complex facial
fractures. Ann. Acad. Med. Singapore 28: 677, 1999.
5. OHara, D. E., DelVecchio, D. A., Bartlett, S. P., and Whitaker,
L. A. The role of microfixation in malar fractures: A quantitative biophysical study. Plast. Reconstr. Surg. 97: 345, 1996.
6. Phillips, J. H., Gruss, J. S., Wells, M. D., and Chollet, A. Periosteal suspension of the lower eyelid and cheek following
subciliary exposure of facial fractures. Plast. Reconstr. Surg. 88:
145, 1991.
7. Yaremchuk, M. J., Gruss, J. S., and Manson, P. N. (Eds.). Rigid
Fixation of the Craniomaxillofacial Skeleton. Stoneham, Mass.:
Butterworth-Heinemann, 1992.

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