Preauricular approach

The preauricular approach can be used to access and treat fractures at the root of the zygomatic arch.

The illustration demonstrates the limited access and amount of exposure.

For this reason, this approach is not recommended in midface trauma surgery.

Limited access and amount of exposure – preauricular approach.

Neurovascular structures

Branches of the facial nerve may be involved in this incision and dissection.

The superficial temporal artery and vein are commonly encountered in this surgical approach. The vessels should be conserved if at all possible.

Anatomical features – preauricular approach.

General consideration

The use of a local anesthetic with a vasoconstrictor may impair the facial nerve function and impede the use of a nerve stimulator during the surgical procedure. Therefore, consideration should be given to using a physiological solution with a vasoconstrictor alone or injecting the local anesthetic with a vasoconstrictor very superficially.

Skin incision

Make the incision in a preauricular skin crease.

incision in a preauricular skin crease – preauricular approach.

Locating the temporalis fascia

Carry the incision through the skin and subcutaneous tissue to the depth of the temporalis fascia. The temporalis fascia is a glistening white tissue layer best visualized in the superior portion of the incision.

The superficial temporal vessels may be retracted anteriorly with the skin flap (sectioning some posterior and superior branches) or left in place (sectioning frontal branches).

The root of the zygomatic arch can easily be palpated at this point of the dissection. The lateral pole of the mandibular condyle can also be palpated. This can be facilitated by a surgical assistant manipulating the jaw.

Locating the temporalis fascia – preauricular approach.

Incising the temporalis fascia

Make an oblique incision parallel to the temporal branch of the facial nerve through the superficial layer of the deep temporal fascia above the zygomatic arch.

Insert the periosteal elevator beneath the superficial layer of the deep temporal fascia and strip the periosteum off the lateral zygomatic arch.

Dissection is carried inferiorly to expose the capsule of the TMJ.

Insert the periosteal elevator beneath the superficial layer of the deep temporal fascia – preauricular approach.

Coronal view of the dissection to the lateral portion of the zygomatic arch and mandibular condyle region.

Note: The temporal branch of the facial nerve is protected within the superficial layer of the temporalis fascia.

Periosteal elevators are used to dissect over the superior aspect of the zygomatic arch onto the temporal bone. Dissection of the arch anteriorly approximately 2 cm is performed by subperiosteal dissection. Fractures at the root of the zygomatic arch should be easily visible.

The temporalis fascia is closed.

Skin and subcutaneous sutures are placed.

A pressure dressing may be placed over this wound according to the surgeon’s preference.