Optimizing the surgical management of zygomaticomaxillary complex fractures

Intraoperative Computed Tomography in the Surgical Treatment of Zygomatic Complex Fracture: A Retrospective Cohort Study

This study aimed to assess the effectiveness of intraoperative computed tomography (ICT) in managing zygomatic complex (ZMC) fractures surgically. A total of 143 patients (84 men, 59 women; average age 37.13 y) undergoing surgical treatment for ZMC fractures participated in this retrospective cohort study, with 72 in the ICT group and 71 in the control group. There were no notable differences in gender, age, time from injury to surgery, and surgical duration between the two groups. The ICT group exhibited significantly fewer surgical approaches than the control group (1.39±0.519 vs. 2.07±0.617, P<0.001). Fixation points in the ICT group (1-point: 42, 2-point: 14, 3-point: 16) significantly differed from the control group (1-point: 15, 2-point: 17, 3-point: 39), P<0.001. Symmetry of reduction was assessed through immediate postoperative images, and stability was compared between immediate postoperative images and those taken at least 3 months later. Both assessments revealed no significant differences between the 2 groups. This study indicates that ICT facilitates prompt evaluation of ZMC reduction, minimizing the necessity for incisions and internal fixation, while achieving comparable reduction efficacy and long-term stability to conventional approaches.

Feasibility of 2-Point Fixation by Absorbable Plates Using the Transoral Approach in Management of the Zygomatic Complex Fractures

PURPOSE

The purpose of this study was to retrospectively evaluate the feasibility of 2-point fixation using absorbable plates by the transoral approach in the management of the zygomatic complex (ZMC) fractures.

METHODS

Twenty-five patients (15 male and 10 female, age range 16 y to 55 y) with Knight and North Group Ⅲ zygomatic fractures were included in this case series. Open reduction by intraoral approach was performed on these patients, and the fractures were fixed using absorbable plates placed at the zygomaticomaxillary buttress and infraorbital rim. Postoperatively, follow-up was undertaken to evaluate the fracture healing, mouth opening, facial asymmetry, diplopia, and paresthesia.

RESULTS

Postoperatively, all patients achieved uneventful healing; facial symmetry and wound healing were achieved, along with sensory recovery involving the infraorbital nerve. Complications such as sensory disturbances, infection, diplopia, malunion, and nonunion were not encountered in these patients.

CONCLUSIONS

Two-point fixation using absorbable plates by transoral approach can provide sufficient stabilization for Knight and North Group III zygomatic fractures.

Management of Ectropion Associated With a Malunited Zygomaticomaxillary Complex Fracture: A Case Report

We report the case of a 35-year-old male patient who presented with a right zygomaticomaxillary complex fracture, which was five months old. It was associated with ectropion over the right eye. Diagnosis was made by clinical examination and confirmed by computed tomography, which included a three-dimensional reconstruction view. The patient was concerned about a projecting deformity over the right side of his face and blurring of vision. Surgical rationale of treatment was to easily access the surgical site for the correction of deformity and to achieve the desired facial contour and ectropion correction with uneventful postoperative healing. Deformity at the right zygomatic arch was exposed by a hemicoronal incision. Ectropion over the lower eyelid was addressed by performing Z-plasty. Outcomes were esthetically pleasing with no loss of motor and sensory functions loss. The patient was followed up for six months.

Revisiting the U-Shaped Elevator for Zygomaticomaxillary Fracture: Study and Comparison of Elevators for Zygomaticomaxillary Fracture Reduction

The authors present the case of a 15-year-old male who sustained a unilateral zygomaticomaxillary complex fracture and underwent open reduction and rigid internal fixation, for which a U-shaped elevator was utilized. The authors discuss techniques in reduction and fixation of zygomaticomaxillary complex fractures, focusing on the use of various elevators during reduction, including straight-type and curved elevators. The U-shaped elevator is a handheld tool with bilateral symmetrically curved ends that is seldom used, despite its specific benefits including nonslip serrated tips, symmetrical nature that allows for direct loading needed for accurate reduction, visualization of the fracture site, and avoidance of tissue compression during elevation.

Direct or Indirect Surgical Approach of Zygomatic Complex Fracture: A Comparative Study

Zygoma is considered the main support of the midface. Zygoma is frequently fractured owing to its prominent site on the face. Treatment of zygomaticomaxillary complex fractures can be performed through either conservative or surgical measures (closed or open reduction). The study was a cross-sectional retrospective observational investigation done at 4 hospitals in Ramadi and Baghdad cities, Iraq. This investigation covered a duration of 6 years (2016-2021). We reviewed the medical records of patients with ZCFs. The participants were divided into 2 groups according to the approach used for their management (direct versus indirect approach). Data regarding the demographic and clinical characteristics were recorded for each subject. Of 265 patients with ZCFs, 209 (78.9%) were males. The highest age group affected was 18 to 40 years (51.7%). The majority of the ZCFs were caused by road traffic accidents (31.7%). Most of the cases belong to single fractures (72.1%). Cheek flattening (73.6%) was the commonest sign of the ZCFs. The majority of the fractures were treated by direct approach, 65.4% of the isolated fractures and 62.2% for multiple fractures. Excellent patient satisfaction was seen in the majority of the cases. There were no statistically significant differences between the 2 approaches regarding the abovementioned variables ( P -value > 0.05). The majority of the cases were with excellent patient satisfaction (n = 149) while only 7 patients with poor satisfaction. The age groups below 18 years and 18 to 40 years were associated with excellent patient satisfaction than good and poor satisfaction. All (n = 7) of the cases with poor satisfaction belong to the age group above 40 years. The majority of male (n = 113) and female (n = 36) patients were with excellent satisfaction, while all patients with poor results were males (n = 7). There were statistically significant differences between the results of the patient satisfaction and age group and complications ( P -value < 0.05). The ophthalmic complications were the most complications seen after ZCF surgical treatment (2.56%). Direct and indirect approaches can be used safely in the treatment of ZCFs owing to excellent patient satisfaction in the majority of the cases and a low complication rate. This study aims to evaluate the demographic and clinical characteristics and to compare different surgical procedures to treat patients with zygomaticomaxillary complex fractures in a country overwhelmed by violence.

Management of zygomatico maxillary complex fractures

Zygomatic bone fractures should be effectively diagnosed and treated because they affect how the face is shaped for both aesthetically and functional reasons. It is possible to compare different surgical techniques and their comorbidities objectively through using outcome quantitative assessments, which call for a treatment programme and long-term follow-up. The purpose of this study was to compare the outcomes of two procedures and the effectiveness of the zygomatic bone following open reduction internal fixation (ORIF) employing two-point fixation and ORIF employing three-point fixation. Two groups of twenty patients each were randomly assigned to. Twenty patients in Group A had ORIF treatment using two-point miniplate fixation technique, and twenty patients in Group B received three-point miniplate fixation treatment. Differences between the two categories were ascertained after they had been evaluated in terms of their advantages and disadvantages. We discovered that the two-point fixation group had the fewest facial complications and neurological side effects. At 1 month follow up, Group B's average radiological evaluation score was 2.47± 0.30, and then at 6 months follow up, it was found out to be 1.87±0.47. A significant statistical distinction between the average radiological evaluations was observed in study participants of Group A at follow up done after one month and six months of procedure. Student's paired t- statistical test was utilized from this statistical analysis. (t = 6.54, P < 0.01). On carrying out follow up after one month of surgery, average neurological assessment score in study participants of group A was found out to be 0.22± 0.42, and then at 6 months follow up, it was 0.61±0.63. The average neurological evaluation score in study participants of Group A on carrying out follow up after one month of surgical procedure and and after six months of surgical procedure months showed a significant statistical distinction when utilizing Student's paired t- statistical test (t = 2.51, P = 0.021).It was determined that the best available rehabilitation for the treatment of zygomaticomaxillary complex fractures is open reduction and internal fixation employing two-point fixation by miniplates.

One-point versus two-point fixation in the management of zygoma complex fractures

Background

The treatment of zygoma complex fractures is of crucial importance in the field of plastic surgery. However, surgical methods to correct zygoma complex fractures, including the number of fixation sites, differ among operators. Although several studies have compared two-point and three-point fixation, no comparative research has yet been conducted on one-point versus two-point fixation using computed tomography scans of surgical results. Therefore, the present study aimed to address this gap in the literature by comparing surgical results between one-point and two-point fixation procedures.

Methods

In this study, we randomly selected patients to undergo surgery using one of two surgical methods. We analyzed patients with unilateral zygoma complex fractures unaccompanied by other fractures according to whether they underwent one-point fixation of the zygomaticomaxillary buttress or two-point fixation of the zygomaticomaxillary buttress and the zygomaticofrontal suture. We then made measurements at three points—the zygomaticofrontal suture, inferior orbital wall, and malar height—using 3-month postoperative computed tomography images and performed statistical analyses to compare the results of the two methods.

Results

All three measurements (zygomaticofrontal suture, inferior orbital wall, and malar height) showed significant differences (p<0.05) between one-point and two-point fixation. Highly significant differences were found for the zygomaticofrontal suture and malar height parameters. The difference in the inferior wall measurements was less meaningful, even though it also reached statistical significance.

Conclusion

Using three parameters in a statistical analysis of imaging findings, this study demonstrated significant differences in treatment outcomes according to the number of fixations. The results indicate that bone alignment and continuity can be achieved to a greater extent by two-point fixation instead of one-point fixation.

Assessment of the Wisconsin Criteria at a Level I Trauma Center

ABSTRACT

The Wisconsin Criteria was developed for physicians evaluating facial trauma to determine the likelihood of facial fractures. Subsequent studies have not consistently validated these criteria. This study seeks to validate the Wisconsin Criteria and determine its utility in predicting operative facial fractures.Retrospective chart review of the trauma database registry at a Level I Trauma Center was conducted from September 2011 to May 2019. Adult patients who had a complete facial examination by otolaryngology or plastic surgery as well as a head computed tomography scan completed, were included. Fisher exact test was utilized for statistical analysis (P < 0.05) and positive predictive value, and negative predictive value (NPV) were calculated with a 95% confidence interval.After screening, 546 patients met eligibility, 448 had at least 1 finding of the Wisconsin Criteria, and 472 patients had facial fractures. The sensitivity of the Wisconsin Criteria for determining the presence of a facial fracture was 86.23%, the specificity was 44.59%, and the NPV was 33.67% (P < .0001). Malocclusion was the criterion most specific in determining if a facial fracture was present (98.65%), and Glasgow Coma Score < 14 was the least specific (67.57%).The Wisconsin Criteria did aid in the identification of facial fractures in trauma patients with a comparable sensitivity, higher specificity, and much lower NPV than originally described. Further investigation should be done to validate the criteria in other large trauma centers.

The application of augmented reality in craniofacial bone fracture reduction: study protocol for a randomized controlled trial

Background

Augmented reality (AR) is a new technology that increases users’ perception of the real world. The purpose of this study is to evaluate the efficacy and safety of augmented reality navigation system in treatment with craniofacial fracture reduction.

Methods

This will be a single-center prospective randomized controlled trial. Twenty-two patients will be assigned to two groups of 11, and those with zygomaticomaxillary complex fractures will undergo preoperative three-dimensional CT modeling and have operational plans designed. The control team will use traditional optical navigation to perform the surgery, and the experimental team will use an AR navigation system. The primary outcome measures will be the accuracy of the key points of surgical area between the preoperational surgical plan and post-operation. The secondary outcome measures will be the blood loss, operation time, bone reduction time, hospital time, and complication rate. The findings obtained through this study are expected to evaluate efficacy and safety of the augmented reality navigation system in the treatment of zygomaticomaxillary complex fractures.

Discussion

This controlled trial of augmented reality navigation system in treatment with zygomaticomaxillary complex fracture reduction will clarify the efficacy and safety of this technology by measuring the accuracy of the key points of surgical area and blood loss, operation and bone reduction times, hospital stay duration, and complication rates. This is a single-center study, and the results are expected to promote the application of augmented reality in craniofacial fracture reduction to improve surgery accuracy and efficacy.

Trial registration

Chinese Clinical Trial Registry ChiCTR1900022626. Registered on April 19, 2019.

Comparing diagnosis of midfacial fractures by radiologists and plastic surgeons

BACKGROUND

Clinicians who manage facial fractures often rely on radiologist interpretations to help with assessment and management. Among treating physicians, facial fractures are categorized into clinically relevant patterns of injury. On the other hand, while radiologists are unsurpassed at identifying individual breaks in the bone, larger fracture patterns are not always conveyed in radiology reports.

PURPOSE

This study aims to assess the frequency with which the terminology describing midfacial fracture patterns is concordant among radiologists and treating clinicians.

METHODS

The authors identified patients with different patterns of midfacial injury including Le Fort I, Le Fort II, Le Fort III, naso-orbito-ethmoid (NOE), and zygomaticomaxillary complex (ZMC) fractures. Plastic surgery consult notes and radiological imaging reports were reviewed for concordance in documentation of injury patterns. Identification of individual fractures consistent with the diagnosed fracture pattern was also recorded.

RESULTS

Radiologists were noted to be highly successful in describing individual fractures of the facial bones, identifying at least two defining components of a fracture pattern in 96% of Le Fort, 88% of NOE, and 94% of ZMC injuries. However, when injury patterns were considered, only 32% of Le Fort, 28% of ZMC, and 6% of NOE fractures were explicitly identified in radiology reports.

CONCLUSIONS

Radiologists are highly skilled in discerning individual fractures in facial trauma cases. However, less reliability was seen in the identification of fracture patterns in midfacial injury, with particular weaknesses in descriptions of NOE and ZMC fractures. This data suggests that greater focus on patterns of midfacial injury would improve the clinical applicability of radiological reports.

Zygomaticomaxillary Fractures

Fractures of the zygomaticomaxillary complex and zygomatic arch are common athletic injuries. Fracture displacement can lead to midfacial retrusion and widening, causing noticeable deformity. Associated signs and symptoms include hypoesthesia of the infraorbital nerve distribution, trismus, and subjective malocclusion. Operative treatment is indicated in cases of significant displacement or functional disturbance. The approach and details of osteosynthesis are catered to the specific characteristics of the fracture. Technology, such as virtual surgical planning, intraoperative navigation, and intraoperative imaging, has the potential to improve accuracy of treating challenging fractures.

Postoperative Computed Tomography for Facial Fractures

In order for a radiologist to create reports that are meaningful to facial reconstructive surgeons, an understanding of the principles that guide surgical management and the hardware employed is imperative. This article is intended to promote efficient and salient reporting by illustrating surgical approaches and rationale. Hardware selection can be inferred and a defined set of potential complications anticipated when assessing the adequacy of surgical reconstruction on postoperative computed tomography for midface, internal orbital, and mandible fractures.

Evaluation of 3 and 2-point internal fixation in the management of zygomaticomaxillary complex fractures: Case report

Introduction

The ZMC has a prominent shape compared to other parts in the midfacial region, thus small injuries will generate fractures in the ZMC. The management of ZMC fracture depends on the fracture deformity and the surgeon's considerations. Various studies have revealed the success of ZMC reconstruction with one fixation point to 4 fixation points fitting to the tetrapod shape.

Case report

We report two cases of ZMC fractures which comparing the efficacy of 3- and 2-point internal fixations for improving clinical outcomes The first patient underwent ORIF which placed at 2 fixation points, the first point in the left ZF suture and the second point in the left ZMB. The second patient underwent ORIF reconstruction at 3 fixation points, the first point in the right inferior orbital rim, the second point in the right ZF suture, and the third point in the right ZMB.

Discussion

The most common surgical approach for ZMC fractures is through a gingivobuccal groin incision. This approach is for body exposure of the ZMB, which is the main buttress. The 3-point internal fixation improved the postoperative clinical outcome of fracture fragment stability compared to two-point fixation, but the mean malar height projection, vertical dystopia, and enophthalmos were not different between the two fixation methods.

Conclusion

Three-point internal fixation can improve the clinical outcome of fracture fragment stability compared to 2-point fixation; however, it has a mean operative duration 22.2 minutes longer than 2-point fixation, so its application must be considered during the COVID-19 pandemic.

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The incidence of ZMC fracture is reported to be 13%–40% of all facial fractures.

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Improper reduction of ZMC fracture can cause facial asymmetry and malposition.

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3-point internal fixation improved the postoperative fracture fragment stability.

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3-point internal fixation has a mean operative duration 22.2 minutes longer than the 2-point.

The Association of Zygomaticomaxillary Complex Fractures with Naso-Orbitoethmoid Fractures in Pediatric Populations

BACKGROUND

Naso-orbitoethmoid fractures associated with ipsilateral zygomaticomaxillary complex fractures are more challenging injuries than zygomaticomaxillary complex fractures alone. However, there is a paucity of information on this complex fracture pattern in the pediatric population. This study investigated the cause, treatment, and outcomes of combined zygomaticomaxillary complex and naso-orbitoethmoid fractures versus isolated zygomaticomaxillary complex fractures in pediatric patients.

METHODS

This was a 25-year retrospective cohort study of pediatric patients who presented to a single institution with zygomaticomaxillary complex fractures. Baseline patient demographics and clinical information, and concomitant injuries, treatment/operative management, and postoperative complications/deformities were recorded and compared between patients with combined zygomaticomaxillary complex and naso-orbitoethmoid fractures and patients with isolated zygomaticomaxillary complex fractures.

RESULTS

Forty-nine patients were identified to have had zygomaticomaxillary complex fractures in the authors' 25-year study period, of whom 46 had adequate clinical documentation and follow-up. Seventeen patients had combined zygomaticomaxillary complex-naso-orbitoethmoid fractures, of whom six had panfacial fractures. Both patient groups (zygomaticomaxillary complex only and combined zygomaticomaxillary complex-naso-orbitoethmoid fractures) were similar in terms of demographics. However, a significantly greater proportion of combined fracture patients experienced postoperative complications compared to isolated zygomaticomaxillary complex fracture patients, even after excluding those with panfacial fractures (87.5 percent versus 35.3 percent; p < 0.001). Enophthalmos (37.5 percent) and midface growth restriction (37.5 percent) were the two most common complications/deformities in all combined fracture patients.

CONCLUSIONS

High-impact trauma can lead to zygomaticomaxillary complex fractures with associated naso-orbitoethmoid fractures in children. This injury pattern was found to cause significantly greater postoperative morbidity than isolated zygomaticomaxillary complex fractures alone. Thus, pediatric patients presenting with this complex facial fracture pattern should be closely monitored.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Etiology, Modalities of Zygomaticomaxillary Complex Fracture, open reduction and fixation

Background

Zygomatic complex fracture is second most common mid face fracture and frequent amongst the maxillofacial trauma. Fracture pattern ranges from simple to comminuted and from minimally displaced to severely displaced depending on various factors.

Material and Methods

98 patients with zygomaticomaxillary complex fracture reporting during December 2017 to January 2020 were included in the study. On the basis of radiographic evaluation and computerized tomography scan (CT scan) with 3D reconstruction severity of fracture was assessed and different treatment options were selected.

Results

Road traffic accident accounted as the leading cause of fracture (57.1%) followed by self-fall (16.3%), interpersonal violence (12.3%). Reduction and semi rigid fixation was done in (83.7%), in which 1-point fixation in (22.9%), 2-point fixation in (42.4%) and 3-point fixation in (18.4%). Rest 16.3 % of the cases were managed conservatively since they had minimal displacement.

Conclusions

Road traffic incident was the main etiology in our study and younger age group patients were more involved. Occipitomental radiograph and computerized tomography scan (CT scan) were used to confirm the diagnosis and to determine the severity of displacement of zygomatic fracture on the basis of which treatment options were decided.

Key words:Incidence, etiology and management zygomaticomaxillary complex fracture

Blowout Fracture Complex Type

Functional problems and appearance may emerge if careful therapy is not applied in orbital fracture caused by maxillofacial trauma. Recently, the focus of fracture management on fragment fixation most possibly uses anatomy approach. The management of blowout fracture should be overcome by involving several departments. First, identification was carried out in emergency room and then it is consulted to occuloplasty and maxillofacial trauma surgeon. Multidisciplinary management will provide better outcome to retrieve face structural function and improve the appearance. We reported two cases of blowout fracture complex in Dr. Soetomo Hospital, Surabaya, Indonesia, done by Plastic Reconstruction Division of ORL-HNS Department in collaboration with Plastic Reconstruction Division of Ophthalmology Department. In the first case, a 64-year-old female was consulted by Plastic Reconstruction Division of Ophthalmology Department with diagnosis of right orbital adnexal injury, open eye globe injury, scleral laceration, and blowout fracture. In the second case, a 37-year-old male came to Plastic Reconstruction Division of ORL HNS Department, consulted by Plastic Reconstruction of Ophthalmology Department with diagnosis of left cornea and scleral laceration,  left full thickness laceration palpebral at 1/3 nasal inferior, rupture of lacrimal canal, and  blowout fracture. These cases of blowout fracture with rim orbita fracture complex type were managed well by Plastic Reconstruction Division of ORL-HNS and Plastic Reconstruction Division of Ophthalmology Department. It is apparent that multidisciplinary management was required for optimum outcome.

Two-point versus three-point fixation in the management of zygomaticomaxillary complex fractures: A comparative study

Introduction:

The zygoma plays an important role in the facial contour for both cosmetic and functional reasons; therefore, zygomatic bone injuries should be properly diagnosed and adequately treated. Comparison of various surgical approaches and their complications can only be done objectively using outcome measurements that require a protocol for management and long-term follow-up. The objectives of this study were to compare the efficacy of zygomatic bone after treatment with open reduction internal fixation (ORIF) using two-point fixation and ORIF using three-point fixation and compare the outcome of two procedures.

Materials and Methods:

Twenty patients were randomly divided equally into two groups. In Group A, ten patients were treated by ORIF using two-point fixation by miniplates and in Group B, ten patients were treated by ORIF using three-point fixation by miniplates. They were evaluated with their advantages and disadvantages and the difference between the two groups was observed.

Results:

We found that postoperative facial and neurological complications are minimum in two-point fixation group. Based on this study, open reduction and internal fixation using two-point fixation by miniplates is sufficient and the best available treatment of choice for the management of zygomaticomaxillary complex fractures.

Discussion:

Alignment of the fracture at three points and fixation at two stable points provide the most accurate and satisfactory postoperative results. Two-point interosseous fixation at the “buttress” fracture and the frontozygomatic (FZ) fracture is suitable for routine surgery. The results of these studies confirm with the present study that two-point fixation provided better stability in patients with clinical and radiological evidence of fracture in FZ and zygomaticomaxillary buttress area.

Interrelation between facial soft tissue lessions, underlying fracture patterns and treatment of zygomatic bone trauma: a 10 year retrospective study

Background

The pattern of zygomatic bone fractures varies in the literature, their features being frequently masked by the presence of associated soft tissue lesions. In this context the clinical diagnosis and the therapeutic indications can be difficult. The aim of this study was to evaluate the clinical features of zygomatic bone fractures and their interrelation with concomitant overlying soft tissue injuries, as well as to assess the type of treatment methods applied depending on the fracture pattern and the results achieved depending on the incidence rate of postoperative complications. We will use these results in order to improve the diagnosis and the establishment of correct treatment of this pathology.

Methods

A 10-year retrospective evaluation of midface fractures was performed in patients diagnosed and treated in a tertiary Clinic of Oral and Maxillofacial Surgery. Statistical analysis was performed with the MedCalc Statistical Software version 19.2 (MedCalc Software bvba, Ostend, Belgium; 53 https://www.medcalc.org; 2020). Nominal data were expressed as frequency and percentage. The comparisons of the frequencies of a nominal variable among the categories of another nominal variable were made using the chi-square test. Multivariate logistic regressions were used in order to establish the independent association between variables and lacerations/excoriations. After using the Bonferroni correction for multiple comparisons, a value of p < 0.025 was considered statistically significant.

Results

The study included 242 patients with zygomatic bone fractures. The majority of the fractures were displaced n = 179 (73.9%), closed n = 179 (73.9%) and complete n = 219 (90.5%). Hematoma was the most frequent associated soft tissue lesion n = 102 (42.1%) regardless of the fracture pattern (p = 1.000). Complete zygomatic fracture (OR – 2.68; p = 0.035) and fractures with displacement (OR – 3.66; p = 0.012) were independently associated with the presence of laceration. Fractures with displacement (OR – 7.1; p = 0.003) were independently associated with the presence of excoriation. The most frequent type of treatment applied was Gillies reduction (61.9%), followed by ORIF (30.9%). The most frequent postoperative complication was malunion secondary to Gillies treatment (4,6%).

Conclusions

Patients presenting lacerations and excoriations on clinical soft tissue examination will most frequently have an underlying complete, displaced or comminuted zygomatic fracture. In the case of displaced, open or comminuted fractures we achieved the best results secondary to ORIF treatment method, while in the case of non-displaced and closed fractures, the best results achieved were secondary to conservative treatment.

Surgical management of isolated orbital floor and zygomaticomaxillary complex fractures with focus on surgical approaches and complications

Zygomaticomaxillary complex (ZMC) and orbital blow out fractures are commonly encountered midfacial fractures that may result in aesthetic and functional impairment. This retrospective study reports on the surgical treatment and associated postoperative complications in our patient collective. We evaluated 100 patients who underwent open reduction and internal fixation of midfacial fractures between 2010 and 2015. Preoperative clinical features, surgical technique and postoperative complications were analyzed. Surgery was performed with a mean latency of 7 days after trauma. We used titanium mesh and polydioxanone sheets to reconstruct the orbital floor. Most ZMC fractures were stabilized with two point fixation with titanium plates. Preoperative symptoms were present in 70 patients (70%). Infraorbital hypesthesia occurred in 49 patients, diplopia in 41 patients and ocular motility impairment in 24 patients. Postoperative symptoms persisted during a mean follow-up time of 4.5 months in 47 patients (47%) showing infraorbital hypesthesia in 24%, diplopia in 17%, ectropion in 7% and ocular motility impairment in 4%. Complications requiring revision were retrobulbar hematoma 3% (n = 3), ectropion 3% (n = 3), diplopia 1% (n = 1), exophthalmos 1% (n = 1), implant dislocation 1% (n = 1), implant discomfort 2% (n = 2), persisting fracture dislocation 1% (n = 1). All patients recovered without significant impairment. Surgery is required in the majority of the patients with midfacial fractures. Among others ectropion is challenging due to its aesthetic and functional impact on patients. To prevent ectropion, additional canthopexy or the transconjunctival surgical approach are reasonable options in selected cases. Level of Evidence: Level V, descriptive study. AbbreviationsCTcomputed tomographyOForbital floorPDSpolydioxanoneORIFopen reduction and internal fixationZMCzygomaticomaxillary complex.

Reconstruction of Complex Cranial and Orbit Fractures with Associated Hemorrhages: Case Report and Review of the Literature

We present our experience following a unique case of coincident intracranial hemorrhage and comminuted fractures of both the squamous temporal bone and zygomaticofrontal orbit. Surgical techniques and outcome for this presentation have yet to be sufficiently described. A 55-year-old male presented following trauma with Glasgow Coma Scale score of 7. Radiographic evaluation revealed comminuted fractures of the squamous temporal bone with extension into the lateral orbit, along with zygomatic process fracture extending 2.5 cm medially into the orbital roof. Zygomaticofrontal orbital roof fragments reached superiorly into the middle cranial fossa and inferiorly into the orbit. Surgical intervention was deemed necessary to address underlying epidural hematoma, subarachnoid hemorrhage, correction of cranial bone defects, and decompression of the optic nerve and other intraorbital nerves. A frontotemporal approach was employed. Repair of temporal and orbital fractures was accomplished using a combination of wire mesh screws and titanium miniplates. Postoperative imaging demonstrated bony approximation and successful evacuation of traumatic hemorrhage. The patient remains functionally and neurologically intact apart from a sluggishly responsive left eye presumed to result from a left optic nerve or ciliary ganglion lesion. Although rapid reconstruction of complex cranial-orbital trauma and hematoma evacuation can permit acceptable gross functional neurological outcome following massive trauma, orbital fracture and subsequent hemorrhagic processes may be the nidus of neurological sequelae in this complex traumatic constellation. Thus, alterations in surgical approach and reconstruction are appropriate in order to maximize neurological function while supporting restoration of cosmetic space.

Single-Point Fixation for Noncomminuted Zygomaticomaxillary Complex Fractures-A 20-Year Experience

PURPOSE

Zygomaticomaxillary complex (ZMC) fractures occur often. However, no clinical consensus has been reached regarding the number of fixation points required when performing open reduction and internal fixation (ORIF). The objective of the present study was to explore the utility of single-point fixation in the management of noncomminuted ZMC fractures.

PATIENTS AND METHODS

We analyzed the data from a retrospective case series of 211 patients treated during a 20-year period.

RESULTS

The mean length of follow-up was 3.4 months. Of the 211 patients, 162 with noncomminuted ZMC fractures had been treated with single-point fixation of the zygomaticomaxillary buttress. During the follow-up period, 1 patient experienced tooth loss because of a root present in the fracture line, 7 experienced intraoral plate exposure, with 2 subsequently undergoing plate exchange, and 8 developed a wound infection. No patients required orthognathic surgery or cheek implants for malar asymmetry. No patient developed hypoglobus or enophthalmos, and none required revision ORIF of their ZMC fracture.

CONCLUSIONS

To the best of our knowledge, the present study represents the largest series in the literature reporting the surgical results and outcomes of patients with noncomminuted ZMC fractures treated with single-point fixation. In experienced hands, we believe this is a viable surgical option if appropriate surgical considerations are made.

A study protocol for a randomised controlled trial evaluating the effects of intraoperative computed tomography on the outcomes of zygomatic fractures

Background

Zygomaticomaxillary complex (ZMC) and zygomatic arch (ZA) fractures are common injuries resulting from facial trauma and frequently require surgical management (Huang et al., Craniomaxillofac Trauma Reconstr 8(4):271-6, 2015). A substantial number of post-operative functional and cosmetic complications can arise from the surgical management of these fractures. These include scarring, inadequate facial profile restoration, facial asymmetries and diplopia (Ellis et al. J Oral Maxillofac Surg 54(4):386-400, 1996; Yang et al. Oral Maxillofac Surg Clin North Am 23(1):31-45, 2011; Kloss et al. Int J Oral Maxillofac Surg 40(1):33-7, 2011). Intuitively, most of these aforementioned complications arise as a result of inadequate fracture reduction; however, current standard practice is to assess reduction post-operatively through plain radiographs or computed tomography (CT) scans. The role of intra-operative CT scanning to assess the reduction of ZMC/ZA fractures and the potential impact on complications, has thus far not been established.

Methods

This is a prospective randomised controlled trial currently being undertaken at the Royal Brisbane and Women’s Hospital. All patients who require operative management of their ZMC or ZA fractures are offered enrollment in the trial. The patients are randomised into two groups: interventional (intra-operative CT) and control (no intra-operative CT). All patients in each group will have post-operative radiographs taken. From these radiographs, the reduction of the ZMC and/or ZA fracture is graded by a blinded assessor. Patients will be reviewed in clinic at 1 week and 6 weeks post-surgery. During these consultations, all patients will be assessed for scarring, diplopia, facial profile restoration and need for revision surgery.

Discussion

Many complications associated with surgical management of ZMC and ZA fractures involve poor aesthetic results as a direct consequence of inadequate fracture reduction. Inadequate fracture reduction is predictable given that small incisions are used and only limited visualisation of the fractures is possible during the procedure. This is due to a desire to limit scarring and reduce the risk of damage to vital structures in an aesthetically sensitive region of the body. It follows that an intraoperative adjunctive tool such as a CT scan, which can assist in visualisation of the fractures and the subsequent reduction, could potentially improve reduction and reduce complications.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12616000693426. Registered on 26 May 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3625-8) contains supplementary material, which is available to authorized users.

Magnetic resonance imaging for three-dimensional printing of the bony orbit: is clinical use imminent?

The aim of this study was to examine the accuracy of three dimensionally (3D) printed models of the bony orbit derived from magnetic resonance imaging (MRI) for the purpose of preoperative plate bending in the setting of orbital blowout fracture. Retrospective computed tomography (CT) and MRI data from patients with suspected orbital fractures were used. Virtual models were manually generated and analysed for spatial accuracy of the fracture margins. 3D-printed models were produced and orbital fan plates bent by a single operator. The plates were then digitized and analysed for spatial discrepancy using reverse engineering software. Seven orbital blowout fractures were evident in six orbits. Analysis of the virtual models revealed high congruence between blowout fracture margins on CT and MRI (n=7, average deviation 0.85mm). Three zygomaticomaxillary complex fractures were seen, for which MRI did not demonstrate the same accuracy. For plates bent to the 3D-printed models of blowout fractures (n=6), no significant difference was found between those bent to CT versus those bent to MRI when compared for average surface and average border deviation (Wilcoxon signed rank test). Orbital blowout fractures can be defined on MRI with clinically acceptable accuracy. 3D printing of orbital biomodels from MRI for bending reconstructive plates is an acceptable and accurate technique.

Defining the Zygomaticosphenoidal Angle as a Guide to Anatomic Zygomaticomaxillary Complex Fracture Reduction

BACKGROUND

Alignment of the zygomaticosphenoid suture is fundamental to reduction of zygomaticomaxillary complex fractures. To prevent a rotational deformity, the correct angle of the zygoma relative to the cranial base must be restored. Clinically, this can be a challenge, especially when there is comminution of the zygomaticosphenoid suture. Defining a zygomaticosphenoidal angle would provide a reference for use with stereotactic navigation to achieve anatomic reduction.

METHODS

A single-center retrospective analysis of 100 patients was designed to determine normative zygomaticosphenoidal angle values. An angle subtended by the midline and a best-fit line through the zygomaticosphenoid suture on axial computed tomography was measured bilaterally in patients with isolated mandibular or nasal fractures. The mean of this measurement for 3 vertically adjacent cuts was calculated with position of central cut determined by the equator of the globe and trigone of the sphenoid. Multivariate regression was completed to identify changes in zygomaticosphenoidal angle with age, sex, and race.

RESULTS

The mean zygomaticosphenoidal angle was 47° (range 39°-55°). 97% of angles were within 2 standard deviations (8°) of mean. Regression analysis demonstrated no significant change in angle with age (P = 0.74) or sex (P = 0.89). For each angle, the variation across the 3 sample cuts was ≤4.5°. Patients demonstrated high fidelity in zygomaticosphenoidal angle bilaterally with mean difference of 3°.

CONCLUSION

The zygomaticosphenoidal angle is a useful reference, in conjunction with stereotactic navigation, for reduction of zygomaticomaxillary complex fractures. Contralaterally obtained patient-specific data may be used to guide unilateral repair. Normative values may serve as reference in bilateral injury.

Endoscopic-Assisted Zygomatic Arch Fracture Repair With a Preauricular Approach

Introduction

Because of numerous negative sequelae with open techniques, endoscopic techniques are beginning to be widely used for maxillofacial fractures. Many endoscopic approaches for this area have been described according to several dissection plans and incisions. The aim of the present study was to report a new surgical incision and dissection method for zygomatic arch fracture that aims at reducing the complication rate of previously defined techniques.

Material and Methods

The authors operated on 8 patients with a new endoscopic-assisted surgical technique. This study focused on evaluating the complication rate and surgical comfort of these patients.

Results

Of the 8 patients, the plate was palpable in the zygomatic arch in one. No complications occurred due to this technique during the 1-year follow-up. Symmetrical facial contour and inconspicuous scars were obtained in all patients. Average operative time was 3 hours; hospitalization time was 1.6 days.

Conclusion

This study demonstrates that an endoscopic-assisted surgical approach with a preauricular mini-incision can be safely performed in isolated multifragment zygomatic arch fractures. Using individually designed plates improved our results. This technique is easy to apply, its cosmetic results are good, and its complication rate is low.

Do orbital floor plates adequately protect against serious secondary injury?

Reconstruction of the orbital floor is common in cases of trauma and a variety of alloplastic materials, including titanium, can be used. However, we know of no reports about what happens to these materials if there is a second injury to the surgical site. This pilot study on six human cadavers (12 orbits) was therefore designed to investigate the possible outcomes should this occur. A "blowout fracture" was created in each orbit, which was then repaired using a preformed titanium implant. In two orbits, two implants were placed without fixation. The remaining implants were secured to the anterior orbital floor with a single screw, which was placed laterally or medially. A second impact sufficient to fracture the zygomaticomaxillary complex was then applied and its effect on the implants noted.

Aesthetic Outcome of a Case of Orbital Floor Fracture Treated Using a Retroseptal Transconjunctival Approach

The orbital floor is a bone structure frequently involved in orbital fractures. Various methods have been documented to approach the orbital floor and infraorbital rim. Traditionally, transcutaneous approaches like infraorbital, subciliary, and subtarsal have been employed to access the orbital floor and infraorbital rim. A significant amount of complications including a visible, prominent scar, eyelid abnormalities like ectropion, lower lid retraction, and increased scleral show result from these transcutaneous approaches. To overcome these complications, the transconjunctival approach has been preferred recently. However, the transconjunctival approach has been associated with rare complications like entropion, synechia, or trichiasis. In the present article, we report a case of orbital floor fracture treated using a retroseptal transconjunctival approach. We intend to evaluate the aesthetic outcome of a case of orbital floor fracture treated using a retroseptal transconjunctival approach.

A Case Report of Scarless Direct Access to the Infraorbital Rim Using a Retroseptal Transconjuctival Approach

A variety of approaches have been documented in the literature for accessing the infraorbital rim and orbital floor in cases of fractures involving orbitozygomatic maxillary complex fractures. Various transcutaneous approaches like infraorbital, subtarsal, and subciliary approaches have been employed traditionally to access these regions. However, significant postoperative complications are associated with these approaches. The transconjunctival approach to access the infraorbital rim and orbital floor has recently been re-evaluated. We present a case of a patient with a zygomaticomaxillary complex fracture in which the infraorbital rim was fixed using a transconjunctival retroseptal approach.

Multidetector CT of Midfacial Fractures: Classification Systems, Principles of Reduction, and Common Complications

The advent of titanium hardware, which provides firm three-dimensional positional control, and the exquisite bone detail afforded by multidetector computed tomography (CT) have spurred the evolution of subunit-specific midfacial fracture management principles. The structural, diagnostic, and therapeutic complexity of the individual midfacial subunits, including the nose, the naso-orbito-ethmoidal region, the internal orbits, the zygomaticomaxillary complex, and the maxillary occlusion-bearing segment, are not adequately reflected in the Le Fort classification system, which provides only a general framework and has become less relevant in contemporary practice. The purpose of this article is to facilitate the involvement of radiologists in the delivery of individualized multidisciplinary care to adults who have sustained blunt trauma and have midfacial fractures by providing a clinically relevant review of the role of multidetector CT in the management of each midfacial subunit. Surgically relevant anatomic structures, search patterns, critical CT findings and their management implications, contemporary classification systems, and common posttraumatic and postoperative complications are emphasized. ^©RSNA, 2018.

Diagnostic reliability of low dose multidetector CT and cone beam CT in maxillofacial trauma-an experimental blinded and randomized study

OBJECTIVES

To assess the diagnostic reliability of low dose multidetector CT (MDCT) and cone beam CT (CBCT) for zygomaticomaxillary fracture diagnosis.

METHODS

Unilateral zygomaticomaxillary fractures were inflicted on four out of six fresh frozen human cadaver head specimens. All specimens were scanned using four MDCT and two CBCT imaging protocols of which the radiation exposure was systematically reduced. A blinded diagnostic routine was simulated at which 16 radiologists and 8 oral and maxillofacial (OMF) surgeons performed randomized image assessments. We considered the findings during an open operative approach of the zygomatic region as the gold standard.

RESULTS

Zygomaticomaxillary fractures were correctly diagnosed in 90.3% (n = 130) of the image assessments. The zygomatic arch was most often correctly diagnosed (91.0%). The zygomatic alveolar crest showed the lowest degree of correct diagnosis (65.3%). Dose reduction did not significantly affect the objective visualization of fractures of the zygomaticomaxillary complex. The sensitivity and specificity also remained consistent among the low dose scan protocols. Dose reduction did not decrease the ability to assess dislocation, comminution, orbital volume, volume rendering and soft tissues. OMF surgeons considered the low dose protocols sufficient for treatment planning.

CONCLUSIONS

Dose reduction did not decrease the diagnostic reliability of MDCT and CBCT for the diagnosis of zygomaticomaxillary fractures.

Facial Nerve Paralysis-A Rare Complication of Open Reduction of Zygomaticomaxillary Complex Fractures

Facial nerve paralysis is an unusual formidable complication that can manifest after various maxillofacial surgeries, including open reduction of facial trauma. The branches more predisposed to such injury are the zygomatic and marginal mandibular branches. Zygomaticomaxillary complex (ZMC) fractures are frequently encountered in maxillofacial trauma. The facial nerve has not been described as endangered during ZMC surgery. Paralysis of the buccal branch after ZMC repair with delayed onset has been reported only once. This report describes a patient with immediate facial nerve paralysis after open reduction and internal fixation of an isolated ZMC fracture through an intraoral approach. This is a previously unreported rare complication after ZMC fracture repair that should be discussed as a possibility when obtaining preoperative consent.

Malar Relocation with Reverse-L Osteotomy and Autogenous Bone Graft

The zygomaticomaxillary complex (ZMC) functions as a buttress for the face and is the cornerstone to a person's aesthetic appearance, by both setting the midfacial width and providing prominence to the cheek. Malar deficiency is often acquired by blunt injury incurred in a traumatic accident, resulting in ZMC fracture. A 48-year-old male patient presented a right ZMC fracture after contusion injury by a baseball. He only received conservative management and later he suffered discomfort during mouth opening at the moment of mastication, due to trismus involving the temporomandibular joint. In the current case, we describe a surgical technique, by which the malar body is shifted anteriorly and laterally after combined oblique-vertical osteotomy. The technique presented, eventually restored the former aesthetic position of the malar complex and symmetry, and, moreover, improved mastication function.

Zygomaticomaxillary complex fractures: diagnosis and treatment

PURPOSE OF REVIEW

To provide an overview of zygomaticomaxillary complex (ZMC) fractures and their treatment. Aspects of anatomy, diagnosis, and treatment objectives of these common fractures will be reviewed including recent literature.

RECENT FINDINGS

Advances in technology such as guided surgery have allowed for better outcomes and a reduction in surgeon variability with regard to postoperative results. The use of titanium and bioresorbable mini screws and plates have expanded the ability to achieve stable and predictable results. There are many different challenges and techniques that are acceptable to treat zygoma fractures. Surgeon preference and training dictate these methods that vary among specialties.

SUMMARY

ZMC fractures are commonly encountered in the trauma setting. Although there is a multitude of treatment methods available, the ultimate goal for any surgeon should be to reproduce premorbid form and function. The availability of techniques such as 3D navigation, contralateral mirroring, and advances in fixation technology have shown promise for better outcomes, particularly in severely comminuted or displaced fractures.

A new approach to treat bone gaps after midfacial and zygomatic fractures with a collagen membrane

PURPOSE

The aim of the study was to analyze the eligibility of resorbable collagen membrane in the treatment of midfacial fractures to prevent gap formation and subsequent cheek tissue retraction.

MATERIAL AND METHODS

We included nine patients (six males, three females; mean age 51; range 20-73 years; mean bone gap size 8.03 × 13.12 mm) in a retrospective study design. The defect size was assessed by ultrasound.

RESULTS

After a healing period of 4 to 55 weeks, treatment resulted in a significant reduction of gap size (residual mean bone gap size 6.14 × 7.32 mm).

CONCLUSIONS

Native resorbable collagen membrane is a promising tool to reduce the size of bony gap in midfacial defects.

[Application of modified coronal approach in treatment of craniomaxillofacial fractures]

OBJECTIVE

This study aimed to investigate clinical efficacy of a modified coronal approach in treatment of craniomaxillofacial fractures.

METHODS

Thirty-seven cases of craniomaxillofacial fractures underwent open reduction and rigid internal fixation through modified coronal approach. Clinical follow-up visits were conducted to evaluate facial nerve functional status, temporal shape, appearance restoration, and reduction of fracture and surgical area scars.

RESULTS

During follow-up period of 6-36 months, appearance and function of all 37 patients recovered well without facial nerve injury and temporal depression deformity. All cases presented hidden scars, except for one case with hypertrophic scar.

CONCLUSIONS

Applying modified coronal approach to craniomaxillofacial surgery effectively reduces incidence of temporal depression and facial nerve injury compared with traditional approach. The modified coronal approach produced more subtle scars compared with traditional approach and should be applied to treatment of craniomaxillofacial fractures.

Ophthalmic outcomes of fractured zygomas

In patients with fractures of the zygomatic complex, computed tomography (CT) often identifies extensive defects in the orbital floor. Some surgeons recommend routine exploration and repair of these defects during repair of the zygoma, while others advocate a more selective approach, but there is a paucity of evidence either way. We report a retrospective case series of 50 patients who had open reduction and internal fixation of zygomatic fractures by a single surgeon in the maxillofacial department at the John Radcliffe Hospital, Oxford, between 2011and 2014. The orbit was repaired only in those with severe diplopia, or restriction or malpositioning of the globe. Patients were evaluated by age, sex, aetiology, preoperative findings including diplopia and ocular malpositioning, fracture pattern, and morbidity. A total of 14 had preoperative ophthalmic signs. In five these were minimal so treatment was conservative. Nine (eight with diplopia and one with a malpositioned globe) had exploration and seven of them had the orbit repaired at the same time as the zygoma. This was not possible in the remaining two because of the complexity of the defect. There were no postoperative ophthalmic signs in the 41 who did not have orbit explored, or in the seven who had it repaired, and residual signs resolved after planned secondary reconstruction in the remaining two. We recommend that the orbit is explored only in patients with severe diplopia, or restriction or malpositioning of the globe.

Revision Surgery for Zygoma Reduction: Causes, Indications, Solutions, and Results from a 5-Year Review of 341 Cases

BACKGROUND

Many patients undergo a revision surgery after malar reduction, which is one of the most popular aesthetic surgeries in Asia. We reviewed the leading causes of revision for malar reduction surgery to establish proper indications for revision, seek adequate surgical strategies, and share the results from revision surgical cases.

METHODS

A retrospective review was conducted involving 341 patients who underwent malar reduction reoperation between March 2010 and June 2015. Surgical strategies were decided based upon specific problems and complaints from the previous surgery. Facial photographs, cephalography, and computed tomography images were analyzed, and a patient satisfaction survey was conducted before and after the surgery.

RESULTS

A total of 341 patients (321 women, 20 men; average age, 26.6 years, range 18-40 years) were included. The main causes of reoperations were subjective dissatisfaction and nonunion-related symptoms. Undercorrection of the zygomatic body and arch (n = 175, 51.3%) was the most frequent reason for dissatisfaction. The patients underwent revision surgeries via different techniques and strategies based on previous problems from primary surgery, and postoperative patient satisfaction was high. Complications occurred in 35 patients (10.3%) after revision.

CONCLUSIONS

Based on the results of this study, patient dissatisfaction with the procedure can be minimized beforehand through accurate goal identification and careful planning. Bone nonunion is usually due to excessive bone resection during zygoma reduction surgery. Careful selection of the reposition site and appropriate fixation based on a thorough understanding of masseter action are essential in ensuring satisfactory outcomes without adverse side effects.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Current Management of Zygomaticomaxillary Complex Fractures: A Multidisciplinary Survey and Literature Review

Despite the prevalence of zygomaticomaxillary complex (ZMC) fractures, there is no consensus regarding the best approach to management. The aim of this study is to determine differences in ZMC fracture treatment among various surgical specialties. A survey was conducted regarding treatment of patients with different ZMC fractures that included a minimally displaced fracture (Case 1), a displaced fracture without diplopia (Case 2), a displaced fracture with diplopia (Case 3), and a complex comminuted fracture (Case 4). The survey was distributed to members of plastic surgery, oral maxillofacial surgery, and otolaryngology societies. The rates of surgical treatment, exploration of the orbital floor, and plating three or more buttresses were analyzed among the specialties. A total of 173 surgeons participated (46 plastic and reconstructive surgeons, 25 oral and maxillofacial surgeons, and 102 otolaryngologists). In Case 1, a significantly higher percentage of plastic surgeons recommend an operation (p < 0.01) compared with other specialties. More than 90% of surgeons would perform an operation on Case 2. Plastic surgeons explored the orbital floor (p < 0.01) and also fixated three or more buttresses more frequently (p < 0.01). More than 93% of surgeons would operate on Case 3, with plastic surgeons having the greatest proportion who fixed three or more buttresses (p < 0.01). In Case 4, there was no difference in treatment patterns between specialties. Across the specialties, more fixation was placed by surgeons with fewer years in practice (<10 years). Conclusion There is no consensus on standard treatment of ZMC fractures, as made evident by the survey. Significant variability in fracture type warrants an individualized approach to management. A thorough review on ZMC fracture management is provided.

Delayed Facial Nerve Palsy After Open Reduction of an Isolated Zygomaticomaxillary Complex Fracture

Facial nerve paralysis is a devastating complication which can occur after a variety of otolaryngic procedures, including facial trauma repair. The frontal and marginal branches are most often placed at risk. However, facial nerve paralysis is not typically described as a risk in most uncomplicated facial trauma repairs of the zygomaticomaxillary complex (ZMC). In particular, buccal branch injury has not been described in a delayed setting following repair of the ZMC. The authors present a patient of delayed buccal branch paralysis following a simple ZMC repair which has not been previously reported.The diagnosis, clinical course, and management strategies for delayed facial nerve paralysis in the setting of a ZMC repair are discussed. This rare complication after facial trauma repair should be discussed with patients as a possible complication.

Does Training Background Influence Decision-Making in the Management of Zygomaticomaxillary Complex Fractures?

PURPOSE

Management of zygomaticomaxillary complex (ZMC) fractures should be based on injury patterns and not on training background. This study assessed management decisions for ZMC injuries among surgeons with different training backgrounds.

MATERIALS AND METHODS

This was a cross-sectional study of surgeons who evaluated 5 ZMC injury cases. The primary predictor variable was training background: plastic and reconstructive surgeons (PRSs), craniofacial PRSs (c-PRSs), and oral and maxillofacial surgeons (OMSs). Other variables were years in practice, fellowship training, practice scope, and comfort with managing facial injuries. The primary outcome variable was management of the ZMC and orbital floor (operative vs nonoperative). Secondary outcome measurements were related to surgical approaches and fixation. Descriptive, bivariate, and regression statistics were computed.

RESULTS

Twenty-one surgeons (7 PRSs, 7 c-PRSs, and 7 OMSs) with an average of 14.4 ± 12.6 years of experience provided a total of 105 treatment plans. There was significant agreement between c-PRSs and OMSs for management of ZMC and orbital floor injuries (rs = 0.70 and 0.76, respectively; P ≤ .001). PRSs did not have substantial agreement with c-PRSs or OMSs with regard to ZMC fractures (rs = 0.39 and 0.49, respectively; P ≤ .06), but significant agreement with regard to orbital floor injuries (rs = 0.70 and 0.76, respectively; P < .001). In a regression model, injury pattern was the only factor associated with operative management (P ≤ .001).

CONCLUSIONS

There is substantial agreement between OMSs and c-PRSs regarding the management of ZMC fractures and associated orbital floor injuries.

Trauma of the midface

Fractures of the midface pose a serious medical problem as for their complexity, frequency and their socio-economic impact. Interdisciplinary approaches and up-to-date diagnostic and surgical techniques provide favorable results in the majority of cases though. Traffic accidents are the leading cause and male adults in their thirties are affected most often. Treatment algorithms for nasal bone fractures, maxillary and zygomatic fractures are widely agreed upon whereas trauma to the frontal sinus and the orbital apex are matter of current debate. Advances in endoscopic surgery and limitations of evidence based gain of knowledge are matters that are focused on in the corresponding chapter. As for the fractures of the frontal sinus a strong tendency towards minimized approaches can be seen. Obliteration and cranialization seem to decrease in numbers. Some critical remarks in terms of high dose methylprednisolone therapy for traumatic optic nerve injury seem to be appropriate. Intraoperative cone beam radiographs and preshaped titanium mesh implants for orbital reconstruction are new techniques and essential aspects in midface traumatology. Fractures of the anterior skull base with cerebrospinal fluid leaks show very promising results in endonasal endoscopic repair.