In a zygomatic fracture that requires orbital floor reconstruction, after exposing the zygoma and orbital floor, the zygoma should be disimpacted prior to dissecting herniated orbital soft tissues from the maxillary sinus.
In a fracture of this nature, the reduction and fixation of the zygoma should be performed first. Reconstruction of the orbital floor should be performed after the zygoma has been reduced and stabilized.
It is debated whether the second site for fixation should be the orbital rim or the zygomaticomaxillary buttress.
Note: Check the proper alignment of the repositioned zygomatic complex along the lateral wall of the orbit (sphenozygomatic junction) before performing the fixation at the other points.
It is easier to visualize whether a proper reduction of the lateral orbital wall is achieved by placing the plate on the infraorbital rim as the second plate after the zygomaticofrontal suture plate. A smaller plate is recommended for the infraorbital rim. A larger plate (commonly an L-shaped plate) is recommended for the zygomaticomaxillary buttress.
When the lateral wall is comminuted, the lateral wall is not so reliable as a landmark in determining the proper reduction of the zygoma. In this situation the surgeon has to place higher emphasis in the reduction of other sites. Reconstruction of the lateral wall of the orbit with mesh, even when comminuted, is not necessary due to the bone support of the temporalis muscle.
It should be noted that using this 3-point fixation technique we have chosen not to plate the zygomatic arch. It is difficult to plate the zygomatic arch without performing a coronal or preauricular exposure. Perfect reduction of the zygoma through three approaches will generally result in a good alignment of the zygomatic arch. Click here for a description of the 4-point fixation.
Many surgeons argue that potential cosmetic defects caused by a coronal approach to the zygomatic arch are worse than the defect of a minimally displaced arch. These cosmetic defects include alopecia from the coronal scar, risk of injury to the temporal branch of the facial nerve, and temporal hollowing.