In a fracture of this nature, the reduction and fixation of the zygoma, including the zygomatic arch, orbital rim, and zygomaticomaxillary buttress should be performed first. Reconstruction of the orbital floor should be performed after the zygoma has been reduced and fixated.
The first step should be the placement of a plate or wire at the frontozygomatic suture. If a plate is used, we recommend placing only one screw on each side of the fracture, allowing the zygoma to swing into its proper position for reduction. After the other plates and screws have been placed at the zygomatic arch, infraorbital rim, and zygomaticomaxillary buttress, the final screws can be placed in the frontozygomatic plate.
Using the 4-point technique it is controversial as to the proper order of placement of the second, third and fourth plate. The 4-point technique is unique from the 3-point technique in that the surgeon has visualization of the zygomatic arch. If the lateral wall of the orbit is not comminuted, this reference point is still singularly the most important landmark to determine whether a proper reduction has been performed. If this reference point is comminuted, the order of placement of the other three plates will be dependent on which landmarks are the least damaged. The zygomatic arch may be an excellent reference as to whether the proper AP projection of the midface has been restored. In cases where the arch has been fractured and displaced at several different levels, use of the arch to reposition the zygoma may be less reliable. A general principle is to begin with the reference points that are least comminuted. At the same time it is important to have wide exposure of all the reference points, and to recheck the reduction of each reference point as each new plate is placed.
Whenever possible the surgeon should try to achieve a perfect reduction of the lateral wall of the orbit. This requires the alignment of the greater wing of the sphenoid and the zygoma. This should be achievable if the lateral wall is a simple fracture. 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. It would be unusual to have to place a mesh to reconstruct the lateral wall of the zygoma, because the comminuted segments of bone are supported by the temporalis muscle.
The size and strength of the plate along the zygomatic arch depends on the comminution and instability of the fracture. Extreme care should be taken during the dissection around the zygomatic arch so as not to injure the temporal branch of the facial nerve. This nerve lies very close to the periosteum of the zygomatic arch.
A smaller plate is recommended for the infraorbital rim. A larger plate (commonly an L-shaped plate) is recommended for the zygomaticomaxillary buttress.
Many surgeons argue that the 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.