MOC

An Evidence-Based Approach to
Zygomatic Fractures
Gregory R. D. Evans, M.D.
The Maintenance of Certification module series is designed to help the clinician
Mark Daniels, M.S. IV structure his or her study in specific areas appropriate to his or her clinical
Lauren Hewell, M.S. IV practice. This article is prepared to accompany practice-based assessment of
Orange, Calif. preoperative assessment, anesthesia, surgical treatment plan, perioperative
management, and outcomes. In this format, the clinician is invited to compare
his or her methods of patient assessment and treatment, outcomes, and com-
plications, with authoritative, information-based references.
This information base is then used for self-assessment and benchmarking in
parts II and IV of the Maintenance of Certification process of the American
Board of Plastic Surgery. This article is not intended to be an exhaustive treatise
on the subject. Rather, it is designed to serve as a reference point for further
in-depth study by review of the reference articles presented. (Plast. Reconstr.
Surg. 127: 891, 2011.)

CLINICAL SCENARIO PubMed MeSH terms were used when available:

“zygomatic fractures,” “zygoma fracture,” “orbital

A
22-year-old woman is assaulted by her hus-
band and suffers a displaced fractured zy- fractures,” “orbital floor fractures,” “diagnosis,”
goma. She has diplopia and enophthalmos, “tomography,” “x-ray,” “computed,” “magnetic
and complains of decreased vision in the affected resonance imaging,” “preoperative assessment,”
eye. What is the best evidence to guide you in man- “risk factors,” “DVT prophylaxis,” “antibiotic pro-
aging this patient? phylaxis,” “anesthetics,” “premedication,” “recon-
Most surgeons manage zygomatic fractures structive surgical procedures,” “surgical treatment
based on what they learned in training, altered plan,” “treatment,” “surgery,” “outcome,” “com-
only by anecdotal evidence with regard to com- plications,” “postoperative complications,” “hema-
plications and personal outcomes. The purpose of toma,” “seroma,” “visual changes,” “blindness,”
this article is to provide a summary of the best “plate exposure,” “infection,” “pain manage-
available evidence on zygomatic fractures that, ment,” and “analgesia.” The initial search was lim-
when combined with individual clinical expertise, ited to human studies that were published from
can assist the surgeon in the continuing evolution 1999 to 2009 and indexed as meta-analyses, ran-
toward optimal outcomes. domized controlled trials, clinical trials, compar-
ative studies, or case series; however, additional
references were included if deemed necessary for
METHODS FOR IDENTIFYING discussion. Articles were excluded if they involved
EVIDENCE cadaver studies or if the full text was inaccessible
A literature search of PubMed, the Cumulative or of non-English language, as the study quality
Index to Nursing and Allied Health Literature, could not be evaluated. Relevant studies were ap-
and the Cochrane Library was performed to ob- praised for quality and validity according to crite-
tain the best available evidence on zygomatic ria published by the Critical Appraisal Skills
fractures, with emphasis on preoperative assess- Programme1 and assigned a level of evidence with
ment, treatment, and outcomes. The following the American Society of Plastic Surgeons Evidence
search terms were combined as appropriate, and Rating Scales (Tables 1 and 2). Studies included
From the Aesthetic and Plastic Surgery Institute, University
of California, Irvine.
Received for publication December 22, 2009; accepted Feb- Disclosure: The authors have no commercial asso-
ruary 24, 2010. ciations that might pose or create a conflict of inter-
Copyright ©2011 by the American Society of Plastic Surgeons est with information presented in this article.
DOI: 10.1097/PRS.0b013e31820456e5

www.PRSJournal.com 891
 Plastic and Reconstructive Surgery • February 2011

Table 1. American Society of Plastic Surgeons

Evidence Rating Scale for Diagnosis
Level of
Evidence Qualifying Studies
I High-quality, multicenter or single-center,
cohort study validating a diagnostic test (with
a criterion standard as reference) in a series
of consecutive patients; or a systematic review
of these studies
II Exploratory cohort study developing diagnostic
criteria (with a criterion standard as
reference) in a series of consecutive patient;
or a systematic review of these studies
III Diagnostic study in nonconsecutive patients
(without a consistently applied criterion
standard as reference); or a systematic review
of these studies
IV Case-control study; or any of the above
diagnostic studies in the absence of a
universally accepted criterion standard
V Expert opinion; case report or clinical example; Fig. 1. Classic clinical finding demonstrating periorbital ecchy-
or evidence based on physiology, bench
research, or “first principles” mosis associated with fractures of the zygomaticoorbital area.

et al. recently compared computed tomography

Table 2. American Society of Plastic Surgeons and optical three-dimensional imaging with
Evidence Rating Scale for Therapy
Hertel exophthalmometry (Diagnosis: Level II
Level of Evidence).2 After evaluating 32 patients, 20 with-
Evidence Qualifying Studies out orbital abnormality and 12 with zygomatic
I High-quality, multicenter or single-center, fractures, no statistically significant differences
randomized controlled trial with adequate
power; or systematic review of these studies were found between Hertel exophthalmometry
II Lesser quality, randomized controlled trial; and optical three-dimensional imaging. On eval-
prospective cohort study; or systematic review uation of individual measurements, however,
of these studies
III Retrospective comparative study; case-control Hertel exophthalmometry showed protrusion
study; or systematic review of these studies and enophthalmos in patients with and without
IV Case series dislocated lateral orbital rims that were not ap-
V Expert opinion; case report or clinical example;
or evidence based on physiology, bench parent on computed tomographic slices. The
research, or “first principles” authors suggest that computed tomographic and
optical three-dimensional imaging provide more
realistic data on zygomatic fractures than Hertel
in this review are identified below by the type of exophthalmometry.
clinical question (diagnosis or therapy) and level Ultrasonography can also play a role in the
of evidence. Evidence ratings were not assigned to diagnosis of zygomatic fractures (Diagnosis: Level
studies with inadequately described methods II Evidence).3 Over a period of 10 months, 60
and/or worrisome biases or to references in- patients with orbital trauma were evaluated with
cluded for discussion purposes only (e.g., narra- ultrasonography, using a curved array transducer.
tive reviews). Computed tomography was used as a reference
method. The ultrasound investigation of the in-
fraorbital rim showed a sensitivity of 94 percent
EVIDENCE ON PREOPERATIVE and a specificity of 92 percent, with a diagnostic
ASSESSMENT accuracy of 92 percent. Ultrasonography was de-
A variety of mechanisms are at the heart of the termined to be a cost-effective and widely available
cause of zygomatic fractures. Whether they are method, without the disadvantages of radiation
associated with multiple facial injuries caused by exposure.3
motor vehicle accidents or isolated components Finally, although computed tomographic scan
secondary to direct trauma, the diagnosis and as- examination is the criterion standard for evalua-
sessment of these fractures are critical (Fig. 1). A tion of facial fractures, magnetic resonance imag-
multitude of diagnostic studies are available to ing combined with a microscopy orbital coil is a
classify and evaluate zygomatic fractures. Nkenke valuable alternative to the computed tomographic

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Volume 127, Number 2 • Zygomatic Fractures

scan in the primary diagnosis of pediatric orbital

fractures. Floor fractures, and particularly muscle
incarceration, should be diagnosed by high-reso-
lution magnetic resonance imaging combined
with a microscopy coil instead of computed to-
mography to avoid irradiation to the lens and to
obtain a better soft-tissue depiction (Diagnosis:
Level II Evidence).4

EVIDENCE ON ANESTHESIA
Although no specific evidence could be found
on anesthesia, most patients undergo reduction
under general anesthesia. It is critical to ensure
that the anesthesia tube is away from the site of the
injury and that it is secured with wire fixation to
the teeth to prevent dislodgement during in-
traoral plating of the maxillary buttresses.
Fig. 2. Position of the zygoma and its relationship to the other
EVIDENCE ON ANTIBIOTIC
facial bones.
PROPHYLAXIS
Only one study was found on the use of
antibiotics for mandibular fractures and, con- ture with upward displacement at the infraorbital
sequently, no formal comments can be made margin or outward displacement at the zygomati-
regarding the use of antibiotics for zygomatic cofrontal suture; and group VI, complex commi-
fractures. Andreasen et al., however, did note nuted injury (Fig. 3).2–32
that a one-shot or 1-day administration of pro- Adequate reduction and stabilization is the
phylactic antibiotics seemed to be the best doc- mainstay of treatment. Wittwer et al. examined the
umented regimen for reducing infections in the use of biodegradable plates measuring 1.5 or 1.7
management of mandible fractures (Therapy: mm. Insufficient fracture stabilization, especially
Level II Evidence).5 at the infraorbital rim and the zygomaticomaxil-
lary crest/anterior sinus wall, was the main reason
EVIDENCE ON SURGICAL TREATMENT to switch to titanium osteosynthesis. The biode-
PLAN gradable screw design is possibly too bulky for
Approaches to the zygoma can be variable and these particular bony structures. However, no dif-
will depend on the extent of injury.6 –32 The zy- ferences in biodegradable fixation plates were
goma forms the lateral structure of the midfacial found (Therapy: Level II Evidence).6 Further-
skeleton and comprises the lateral and inferior more, no differences between biodegradable ma-
orbital rim and malar eminence. The projections terials and titanium fixation with respect to frac-
articulate with the sphenoid bone in the lateral ture healing and postoperative complications were
orbit and with the fontal bone superiorly, the max- noted (Therapy: Level II Evidence).7
illa medially, and the maxillary alveolus inferiorly. Twelve patients treated using the subtarsal ap-
The prominent position of the zygoma makes it proach for orbital floor fractures were evaluated.
susceptible to traumatic injury and accounts for its One patient suffered from mild lid edema, one scar
frequency in injury (Fig. 2). Zygomatic fractures, was noticeable, one patient had scleral show, and
with the exception of arch fractures, always in- one patient had keratoconjunctivitis. No other com-
clude a component of the orbital floor. These plications were recorded. The subtarsal approach is
injuries may be linear or more severe, such as a safe and simple procedure for treating orbital floor
orbital blowout fractures. A general classification fractures (Therapy: Level IV Evidence).8
of zygomatic fractures includes the following: Preseptal incisions were used in 80 patients for
group I, no significant displacement; group II, different fracture indications. All operative pro-
zygomatic arch fractures; group III, unrotated cedures were performed without an additional lat-
body fractures; group IV, medially rotated body eral canthotomy. There was no ectropion or en-
fractures with outward displacement at the zygo- tropion in any of the patients. One laceration to
matic prominence or inward at the zygomatic the tarsal plate and one temporary entropion oc-
frontal suture; group V, laterally rotated body frac- curred. The preseptal approach is preferable to a

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 Plastic and Reconstructive Surgery • February 2011

Inappropriate treatment of untreated frac-

tures of the zygomaticoorbital area can result in
secondary deformities such as loss of malar pro-
jection, enophthalmos, and dystopia. Although
contour restoration can be performed with bone
grafting, the use of porous polyethylene implants
for contour restoration of mild to moderate sec-
ondary deformities is safe, with minimal morbidity
(Therapy: Level IV Evidence).13
Assessing intraoperative reduction is often dif-
ficult. Recently, 14 patients underwent intraoper-
ative cone-beam computed tomography for eval-
uation of adequate reduction. This technique
assisted with evaluating bony reduction, with a low
level of metal artifacts in primary and secondary
reconstruction (Diagnosis: Level III Evidence).14
The integration of a flat-panel detector with the
cone-beam computed tomographic imaging will
Fig. 3. Complex comminuted zygomatic injury.
overcome the limitations of the currently available
systems. The size of the field of view is increased,
allowing visualization of the whole facial skeleton.
retroseptal approach in reconstructive orbital sur- This is important particularly in unilateral frac-
gery because of the minimal disturbance of the tures (Diagnosis: Level III Evidence).15 It is now
intraorbital connective tissue framework (Therapy: possible and financially viable to make relatively
Level IV Evidence).9 inexpensive anatomical models on the basis of
Open reduction and internal fixation may not computed tomographic images that can be used as
be necessary in all patients. Bezuhly et al. dem- templates to form titanium mesh implants that are
onstrated that Gillies elevation combined with used in reconstruction of the orbit (Therapy:
percutaneous Kirschner wire fixation provides fa- Level IV Evidence).16
cial contour restoration that is not significantly The optimal surgical method for managing
different from that of open reduction and internal blowout fractures is still controversial. Kwon et al.
fixation, with less soft-tissue morbidity (Therapy: have evaluated 102 patients with pure inferior
Level IV Evidence).10 This technique should be blowout fractures. Patients with large orbital floor
considered in isolated zygomatic fractures.10 fractures or posterior half-fractures of the orbit
Posttraumatic enophthalmos can occur pri- should undergo surgery through a transantral or
marily or because of inadequate fracture reduc- a combined approach. Patients with a trapdoor
tion and restoration of orbital volume. Eighty pa- fracture or anterior half-fracture of the orbit
tients were treated with primary or sequential should undergo surgery by means of a transorbital
enophthalmos. Treatment consisted of orbital re- or a combined approach (Therapy: Level IV
construction in combination with bone grafts or Evidence).17 Ozyazgan et al. have recently re-
biomaterials. Satisfactory results were obtained in viewed the efficacy of conchal cartilage grafts in
all cases. Perfect correction is difficult to achieve, defects in the orbital wall that are encountered
and soft-tissue changes may limit the aesthetic and isolated or in combination with other orbitozygo-
morphologic results despite adequate bony recon- matic factures. They examined 10 patients who
struction (Therapy: Level IV Evidence).11 had defects varying from 100 to 400 mm2. In the
Dolan and Smith used superior cantholysis postoperative period, cartilage grafts were pal-
access when treating 14 patients with open re- pated slightly in two patients at the edge of the
duction and internal fixation. There were no infraorbital rim. Limitation in eye movement, dip-
complications attributed to the superior can- lopia, and enophthalmos did not occur in the
tholysis. Superior cantholysis eases the surgical patients. Conchal cartilage could then be consid-
exposure, reduction, and rigid fixation of the ered as one of the autogenous materials among
zygomaticofrontal suture in the open repair of those materials suitable for the repair of defective
zygomatic fractures. No morbidity was added, and orbital wall fractures that are not oversized. It has
it simplified exposure of the lateral orbital rim the following advantages: it is adequate for recon-
(Therapy: Level IV Evidence).12 struction of the facture, easily obtainable, and eas-

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Volume 127, Number 2 • Zygomatic Fractures

ily adaptable to the orbital walls, and it has min- ylene ultrathin sheets. There were four cases of
imum morbidity at the donor site (Therapy: Level postoperative facial infections: two resolved with
IV Evidence).18 systemic antibiotics, one resolved with bone se-
Orbital floor fractures can occur isolated or questrum resection, and one required removal of
with zygomatic arch fractures. Computed tomo- the implant. The orbital infections were related in
graphic scan examination appears to be the first- all cases to titanium osteosynthesis miniplates or
choice investigation for an orbital floor fracture skull bone graft. Correction of hypoglobus is tech-
(Fig. 4).19 Various materials such as autogenous nically easier than enophthalmos, because enoph-
bone, cartilage, and alloplastic implants have been thalmic correction requires a wide, deep subpe-
used to reconstruct orbital floor fractures. Floor riosteal dissection and implant positioning,
fractures larger than 2.0 cm should be considered posterior to the equator of the globe, with the
for repair.32 Between 2002 and 2004, 17 maxillo- inherent risk of orbital apex injury (Therapy:
facial trauma patients complicated with orbital Level IV Evidence).21 Xu et al. further followed 68
floor fractures were treated with resorbable mesh patients who underwent corrected for orbital
plate through a subciliary or transconjunctival in- blowout fractures. Only one patient developed
cision. Patients were evaluated by computed to- postoperative ectropion, for which local suspend-
mographic examination at 3, 6, and 12 months. ing was required. All orbital floors were recon-
No infections, diplopia, or gaze restrictions were structed with porous polyethylene sheets that were
noted. Three patients had scleral show. Resorb- determined to be reliable. Overcorrection by 1 to
able mesh appears to be safe and effective for 2 mm is necessary during surgery to neutralize the
reconstruction of the nonextensive orbital floor tissue swelling or atrophy (Therapy: Level IV
fracture (Therapy: Level IV Evidence).20 Other Evidence).22 Reconstruction of the inferior orbital
implants have been used for the orbital floor. Vil- wall with the use of bone grafts harvested from the
larreal et al. reviewed 32 patients with orbital floor anterior maxillary wall have been reviewed. In 11
fractures that were treated with porous polyeth- patients, these fractures were “blowout,” and in
seven the orbital wall accompanied zygomatico-
orbital fractures. In all cases, full improvement was
affirmed and there were no postoperative com-
plications (Therapy: Level V Evidence).23
Wolfe et al. recently reviewed 317 patients op-
erated on for orbital fractures. A number of causes
for reoperation seen in the posttraumatic, post-
surgical orbital deformity group were not seen in
the group that was operated on primarily. These
included lower eyelid retraction attributable to
use of the subciliary incision, displacement and
extrusion of alloplastic materials, and fixation of
fractures in a nonreduced position. These differ-
ences validate the application of the basic princi-
ples of craniofacial reconstruction set forth by
Paul Tessier for these posttraumatic orbital defor-
mities to achieve the best overall results (Therapy:
Level IV Evidence).24
Although plate-and-screw fixation is the main-
Fig. 4. Three-dimensional reconstruction following surgical re- stay for zygomatic and orbital fractures, Yone-
pair of orbital floor fracture with titanium mesh. The drawback is hara et al. recommend that fixation of the in-
its unpredictable resorption. In the present study, among the hy- ferior orbital rim with miniplates or microplates
pophthalmic orbits, intense bone resorption was observed in 60 should be avoided because of postoperative scar-
percent. The decrease in the vertical support of the globe may ring and sensory disturbances caused by a sub-
lead to minor hypophthalmos without enophthalmos. Overcor- ciliary incision. They confirm the status of the
rection of the fracture area is recommended. (From Kontio RK, inferior orbital rim reduction by palpation. Nat-
Laine P, Salo A, Paukku P, Lindqvist C, Suuronen R. Reconstruction urally, fixation for comminuted fractures of the
of internal orbital wall fracture with iliac crest free bone graft: inferior orbital rim with herniation of internal
Clinical, computed tomography, and magnetic resonance imag- orbital components is recommended (Therapy:
ing follow-up study. Plast Reconstr Surg. 2006;118:1365–1374.) Level IV Evidence).25

895
 Plastic and Reconstructive Surgery • February 2011

Alternative approaches to reduction and fix- and eye movements were assessed. The resorption
ation can also occur. Recently, segmental osteot- rate was high, but most of it was advantageous
omy techniques of the zygoma have been used remodeling. The overall outcome was good. Sec-
with success. At 1-year follow-up, the segmental ondary operations led to poor outcomes. Thin
osteotomies have reduced complications and at- computed tomographic and magnetic resonance
tained a better aesthetic result. Subjective assess- imaging sections are needed to evaluate accurately
ment of the patient’s globe position found that bone graft placement and posture and orbital vol-
88.5 percent of the patients were satisfied with ume (Therapy: Level IV Evidence).30
the outcome, and 11.5 percent of the patients Delayed treatment frequently leads to less ideal
found it unacceptable. Compared with the tra- reconstructions. Delayed panfacial fractures with ac-
ditional method, segmental osteotomy is a sim- companying mandible fractures can increase the
ple technique that requires less dissection and risk for unreduced segments and increase the rate of
can reconstruct the orbital anatomical structure complications. Reconstruction of the mandible first
and restore globe position effectively (Therapy: with Le Fort I osteotomy is a good way of treating
Level IV Evidence).26 delayed panfacial fractures. Computed tomography
Endoscopic repair of orbital floor fractures and three-dimensional computed tomography and
offers an alternative method of approaching the model surgery are occasionally able to identify three-
orbital floor. Studies in cadavers indicate that en- dimensional asymmetries which were often the fac-
doscopic repair is efficacious compared with tra- tors that caused an unfavorable outcome.31
ditional techniques.27
Finally, computer-aided surgery has been SUGGESTED TREATMENT FOR
found to be useful in reconstructive craniomax- CLINICAL SCENARIO
illofacial surgery. Preoperative planning for zy- When practicing evidence-based medicine,
gomatic fractures may improve overall outcome. the surgeon should consider the strength of the
The symmetry of unaffected human skulls and available evidence and integrate the evidence with
faces was evaluated by midface computed tomo- his or her clinical expertise and the patient’s val-
graphic data of 20 skulls and surface-scan data ues and preferences to develop an appropriate
of 20 healthy individuals. In addition, 18 con- treatment plan. The treatment plan below is an
secutive cases were selected that had been example of how the surgeon might use the evi-
treated with computer-aided surgery. No differ- dence to care for this particular patient.
ences between the skull and face symmetry were A 22-year-old woman is assaulted by her hus-
found. The natural asymmetries in humans in- band and suffers a displaced fractured zygoma.
fluence the accuracy of preoperative planning She has diplopia and enophthalmos, and com-
procedures. Transforming the planning to the plains of decreased vision in the affected eye. She
surgical reconstruction using computer-aided is evaluated by means of computed tomography.
surgery depends on the location, the surgical After determining appropriate diagnosis of bony
approach, and the manner of reconstruction injury and after evaluation of the globe for injury
(Therapy: Level III Evidence).28 secondary to decreased vision, the patient is taken
to the operating room for open reduction and
EVIDENCE ON POSTOPERATIVE internal fixation (Level II, IV Evidence). Place-
OUTCOMES ment of bone grafts or porous propylene for or-
The critical aspect of all care is to evaluate the bital support and volume restoration completes
outcomes. Merten and Hönig compared two dif- the surgery (Level IV Evidence). Resuspension of
ferent methods of internal rigid fixation of the the soft tissues assists with overall outcomes (Level
frontozygomatic suture line in one group with IV Evidence).
miniplates and in another group with lag screws.
Lag screw fixation in malar fractures could lower Gregory R. D. Evans, M.D.
Aesthetic and Plastic Surgery Institute
hardware treatments costs and is an alternative University of California, Irvine
method that provides sufficient stability in indi- 200 South Manchester Avenue, Suite 650
cated patients.29 Orange, Calif. 92868
Questions have often arisen regarding resorp- gevans@uci.edu
tion and bone grafting. Kontio et al. examined 24
patients with unilateral orbital wall fractures that PATIENT CONSENT
underwent reconstruction with iliac bone grafts. The patient provided written consent for the use of
At each follow-up visit, globe posture, diplopia, her image.

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Volume 127, Number 2 • Zygomatic Fractures

ACKNOWLEDGMENTS 14. Heiland M, Schulze D, Blake F, Schmelzle R. Intraoperative

The authors thank the following individuals for imaging of zygomaticomaxillary complex fractures using a
3D C-arm system. Int J Oral Maxillofac Surg. 2005;34:369–375.
their assistance with this project: American Society of 15. Pohlenz P, Blake F, Blessmann M, et al. Intraoperative cone-
Plastic Surgeons staff member Jennifer Swanson, B.S., beam computed tomography in oral and maxillofacial sur-
M.Ed., for project management and editorial support; gery using a C-arm prototype: First clinical experiences after
American Society of Plastic Surgeons staff member Karie treatment of zygomaticomaxillary complex fractures. J Oral
Rosolowski, M.P.H., for literature searches; and Mich- Maxillofac Surg. 2009;67:515–521.
16. Kozakiewicz M, Elgalal M, Loba P, et al. Clinical application
elle Secic, M.S., of Secic Statistical Consulting, Inc., for of 3D pre-bent titanium implants for orbital floor fractures.
critical appraisal of studies included in this review. J Craniomaxillofac Surg. 2009;37:229–234.
17. Kwon JH, Kim JG, Moon JH, Cho JH. Clinical analysis of
surgical approaches for orbital floor fractures. Arch Facial
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