Open reduction with fixation

If the surgeon considers the zygomatic arch deformity so severe that it cannot be adequately treated with a transoral (Keen) or temporal (Gillies) approach, or too unstable to be treated without fixation, an open treatment can be considered. This has the advantage that it allows direct visualization of the zygomatic arch for fixation. It may be particularly desirable in a patient where a coronal approach has to be made for other reasons (such as for the treatment of a frontal sinus fracture or the harvest of a split calvarium bone graft). Another reason for open treatment is secondary treatment of a zygomatic arch malunion where osteotomy and internal fixation are needed. Existing lacerations may also be used.

Although it is referred to as a zygomatic arch, most surgeons consider it is rather flat. It is very important to restore the previous anatomy so that it matches the uninjured contralateral arch.

The temporal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch. Care must be taken not to injure this nerve.

In most patients, there is little soft tissue over the zygomatic arch. If the decision is made to perform an open reduction and internal fixation, one must be concerned about the plate size, and possible palpation of the plate through the skin.

The fragments of the zygomatic arch may be elevated under direct vision through the coronal approach, using digital reduction, or any common instruments.

The order of placement of screws in the fracture segments is highly variable depending on the degree of comminution of the zygomatic arch. One consideration can be to begin with a screw nearest the fracture, on the stable portion of the zygoma, with the second screw being placed nearest the fracture on the stable portion of the temporal bone, making sure that the entire span of the plate is not canted above or below the zygomatic arch. The order of the additional screws can be according to the convenience of the surgeon and the fracture pattern.

Evaluation of the patients vision is performed as soon as they are awakened from anesthesia and then at regular intervals until they are discharged from the hospital.
A swinging flashlight test may serve in the unconscious and/or noncooperative patient; alternatively electrophysiological examination has to be performed but is dependent on the appropriate equipment (VEP).

Keeping the patient’s head in an upright position both preoperatively and postoperatively may significantly improve periorbital edema and pain.

To prevent orbital emphysema, nose-blowing should be avoided for at least 10 days following orbital fracture repair.

The use of the following perioperative medication is controversial. There is little evidence to make strong recommendations for postoperative care.

• No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs) for 7 days
• Analgesia as necessary
• Antibiotics (many surgeons use perioperative antibiotics. There is no clear advantage of any one antibiotic, and the recommended duration of treatment is debatable.)
• Nasal decongestant may be helpful for symptomatic improvement in some patients.
• Steroids, in cases of severe orbital trauma, may help with postoperative edema. Some surgeons have noted increased complications with perioperative steroids.
• Ophthalmic ointment should follow local and approved protocol. This is not generally required in case of periorbital edema. Some surgeons prefer it. Some ointments have been found to cause significant conjunctival irritation.
• Regular perioral and oral wound care has to include disinfectant mouth rinse, lip care, etc.

Postoperative examination by an ophthalmologist may be requested. The following signs and symptoms are usually evaluated:

• Vision (except for alveolar ridge fracture, palatal fracture)
• Extraocular motion (motility) (except alveolar ridge fracture, palatal fracture)
• Diplopia (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Globe position (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Perimetric examination (except Le Fort I, alveolar ridge fracture, palatal fracture)
• Lid position
• If the patient complains of epiphora (tear overflow), the lacrimal duct must be checked.

Note: In case of postoperative double vision, ophthalmological assessment has to clarify the cause. Use of prism foils on existing glasses may be helpful as an early aid.

Postoperative imaging has to be performed within the first days after surgery. 3-D imaging (CT, cone beam) is recommended to assess complex fracture reductions. An exception may be made for centers capable of intraoperative imaging.
Especially in fractures involving the alveolar area, orthopantomograms (OPG) are helpful.

Remove sutures from skin after approximately 5 days if nonresorbable sutures have been used.
Apply ice packs (may be effective in a short term to minimize edema).
Avoid sun exposure and tanning to skin incisions for several months.

Diet depends on the fracture pattern.
Soft diet can be taken as tolerated until there has been adequate healing of the maxillary vestibular incision.
Intranasal feeding may be considered in cases with oral bone exposure and soft-tissue defects.
Patients in MMF will remain on a liquid diet until such time the MMF is released.

Clinical follow-up depends on the complexity of the surgery, and whether the patient has any postoperative problems.

With patients having fracture patterns including periorbital trauma, issues to consider are the following:

• Globe position
• Double vision
• Other vision problems

Other issues to consider are:

• Facial deformity (incl. asymmetry)
• Sensory nerve compromise
• Problems of scar formation

Issues to consider with Le Fort fractures, palatal fractures and alveolar ridge fractures include:

• Problems of dentition and dental sensation
• Problems of occlusion
• Problems of the temporomandibular joint (TMJ), (lack of range of motion, pain)

Implant removal is rarely required. It is possible that this may be requested by patients if the implant becomes palpable or visible. In some countries it will be more commonly requested. There have been cases where patients have complained of cold sensitivity in areas of plate placement. It is controversial whether this cold sensitivity is a result of the plate, a result of nerve injury from the original trauma, or from nerve injury due to trauma of the surgery. Issues of cold sensitivity generally improve or resolve with time without removal of the hardware.

Generally, orbital implant removal is not necessary except in the event of infection or exposure. Readmission might be indicated if long term stability of the orbital volume has not been maintained.

The duration and/or use of MMF is controversial and highly dependent on the particular patient and complexity of the trauma. In some cases where long-term MMF may be recommended, the surgeon may choose to leave the patient out of MMF immediately postoperatively because of concerns of edema, postoperative sedation, and airway. In these cases the surgeon may choose to place the patient in MMF after these concerns have been resolved.

The need and duration of MMF is very much dependent on:

• Fracture morphology
• Type and stability of fixation (including palatal splints)
• Dentition
• Coexistence of mandibular fractures
• Premorbid occlusion

Patients with arch bars and/or intraoral incisions and/or wounds must be instructed in appropriate oral hygiene procedures. The presence of the arch bars or elastics makes this a more difficult procedure. A soft toothbrush (dipped in warm water to make it softer) should be used to clean the surfaces of the teeth and arch bars. Elastics are removed for oral hygiene procedures. Chlorhexidine oral rinses should be prescribed and used at least 3 times a day to help sanitize the mouth.
For larger debris, a 1:1 mixture of hydrogen peroxide/chlorhexidine can be used. The bubbling action of the hydrogen peroxide helps remove debris. A Waterpik® is a very useful tool to help remove debris from the wires. If a Waterpik is used, care should be taken not to direct the jet stream directly over intraoral incisions as this may lead to wound dehiscence.