Plastic Surgery
Dr. Barry Eppley

Explore the worlds of cosmetic
and plastic surgery with Indianapolis
Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Archive for the ‘facial reconstruction’ Category

Case Study: Delayed Cheekbone Fracture Repair

Thursday, July 11th, 2013


Background:  Fractures of the cheek bone, like the nose, are common due to the prominence of these bones on the face. They are frequently exposed to trauma from sporting activities to fisticuffs. It fractures along the numerous legs of its bony attachments which is where it gets its common name, tripod fracture. It also goes by many other names such as zygoma fractures, trimalar fractures, and orbitozygomatic fractures.

The tripod fracture, more anatomically described as a zygomaticomaxillary complex (ZMC) fracture, is comprised of three (technically four) bone fracture lines. The first portion of the fracture involves the maxillary sinus which includes the anterior and posterior buttresses or supports of the maxilla as well as an overlying floor of the eye socket. (orbit) The second portion involves the zygomatic arch which attaches to the main body of the zygoma. (cheek bone) The third portion involves the  outside bone of the eye socket (lateral orbital rim) up to the zygomaticofrontal suture line. The fourth fracture line, often overlooked, is the sphenozygomatic suture which is located deeper in the eye socket.

When the cheekbone sustains trauma, the impact force disrupts all four legs of the bone. When this happens the cheek bone tilts downward into the maxillary sinus causing a loss of cheek projection and the appearance of a lopsided face. Depending upon the severity of the impact force will determine how far the bone settles into the sinus and the degree of flattening of the cheek. If severe enough the eyeball will also drop down if the bone of the floor of the eye is sufficiently broken. This may cause a tilt downward of the corner of the eye also.

Case Study: This 28 year-old male was struck on the left side of his face in an altercation in a bar. His face became very swollen and bruised days later and he had persistent numbness of his upper teeth and lip. The swelling and bruising went down weeks later but the numbness continued. By a month after the injury he noticed his face was flat and sunken over his cheek area.

The sunken cheek area was obvious and it was painful to touch below the lower eye socket rim. A CT scan showed a severely displaced ZMC fracture with near complete rotation into the maxillary sinus. Compared to the opposite normal side, the degree of cheek bone displacement was considerable.

Under general anesthesia, a combined intraoral and transconjunctival lower eyelid incisions were used to approach the fracture. The cheek bone was disimpacted and rotated back upward into anatomic position and secured into place with multiple 1.5mm plates and screws. Any loose bone fragments were attached to the metal mesh. A fine metal mesh was used to rebuild the lower orbital rim. The large infraorbital nerve was entrapped in the fracture but not severed. Both mucosal incisions were closed with dissolveable sutures.

His postoperative recovery was just like the original injury, taking nearly three weeks for all swelling and any bruising to subside. At six weeks after surgery, he had much improved facial symmetry from all angles of viewing. His lip and teeth were still numb but hope remained for a full nerve recovery which could take up to a year to occur.

Delayed repair of cheekbone fractures can be done months after the initial injury as these thinner facial bones take a long time to heal. They initially heal by fibrous union as they can relatively easily be moved around even 3 to 6 months after being displaced.

Case Highlights:

1) Cheek bone fractures almost always cause a loss of cheek projection and lowering of the floor of the eye as the bone rotates into the maxillary sinus.

2) The key to good results from cheek bone fracture repair is to disimpact the bone from the sinus and re-establish the maxillary buttress and infraorbital rim contours with rigid miniature plate and screw fixation.

3) Delayed repair of cheek bone fractures can be successfully done even as late as 6 months after the initial injury.

Dr. Barry Eppley

Indianapolis, Indiana

Roger Ebert and Prosthetic Facial Reconstruction

Thursday, January 27th, 2011

Later this week, renowned movie critic Roger Ebert is returning to television for two new debuts. One is something of which he is very familiar, a new show entitled “Ebert Presents at the Movies”.Since his original Sneak Previews show started some 35 years ago, and I remember it well as a regular viewer in my youth, his new show will be old hat even being taped where his original show was done. His second debut, however, has a more recent history.

Ebert was diagnosed with thyroid cancer in 2002 which subsequently spread to his lower jaw despite the cancerous gland being removed. This required the front part of his lower jaw to be removed as well as to needing radiation to the cancer that surgery couldn’t. He suffered complications after this surgery that landed him back in the hospital to next get a tracheostomy tube for breathing. All of these procedures combined left him with no chin and a total loss of his voice by 2006.

This is a devastating facial deformity that plastic surgeons have seen for decades after cancer removals. Known historically as an ‘Andy Gump’ facial deformity, it poses a major reconstructive challenge which defied a really satisfactory solution until the 1990s. Prior to that time, skin and muscle from the chest (pectoralis myocutaneous flap) was brought up as a pedicled flap and wrapped around a metal bar made in the shape of the front part of the lower jaw. While this was often successful, it left patients with far from a really satisfactory reconstruction. That all changed with the development and refinement of microvascular tissue transfer. Such problems today are much better done with a free fibular bone and skin flap to make the front part of the upper jaw and skin for the new chin. This would usually be done at the time of the chin removal so the patient would not go through an ‘Andy Gump’ facial phase.

But having had so many complications and a long difficult course of cancer treatments, Ebert is understandably hesitant about undergoing a long and stressful operation on his body. As a result, he has opted for prosthetic reconstruction which will be debuted on his upcoming new show.

Maxillofacial prosthetics is an often unheard of field of dentistry of which its practitioners are masters of making facial prostheses of all kinds. Their abilities can rival anything seen in Hollywood. Most facial prostheses today are attached to the remaining facial bones with dental implants so they can be more reliably held in place. Presumably due to inadequate bone that has been exposed to radiation, Ebert’s new chin prosthesis will be externally supported as it will rest on his shoulders like a collar. This will enable him to have a facial appearance that, while not being normal, will be something more comfortable for the viewer to see. Because of his voice loss, a laptop computer will serve to make his voice.

While the technology to make a prosthetic chin and to have his voice emanate from a computer are modern day marvels, the real miracle is the fortitude and strength for him to press forward in a public forum with such a difficult set of facial problems. If he were a movie, I would give him two thumbs up and urge you to rush and get your ticket. You will be inspired by this script.

Dr. Barry Eppley

Indianapolis Indiana

Zygomatic (Cheek Bone) Fracture Repair with LactoSorb Fixation

Sunday, March 22nd, 2009

Cheek bone (zygomatic) fractures are one of the most common facial fractures, Over the years, I have seen many cheek bone (malar) fractures and they are commonly the result of personal assaults (being punched in the face) and sports injuries. The cheek bone sits on a very prominent part of the face and, as a result, is easily struck. It acts as a protector for the eye which is situated above and behind it.

The bulk of the cheek bone is what we see but it sticks out as such because it is attached by four ‘legs’ to the deeper parts of the face. When the cheek bone breaks, it moves because these attachments fracture, allowing it to collapse inward and downward. As it falls back and in, it goes directly into the underlying maxillary sinus which is just an open air space. Because part of the cheek bone makes up a portion of the floor of the eye, a fractured cheek bone results in loss of the cheek prominence and an eye which make look like it is fallen lower.

Repair of these fractures involves putting it back in place and securing one or more of these legs with plates and screws. Fixing the fracture can be done by an incision inside the  mouth, through the lower eyelid, or both depending upon the degree of bone displacement. Plate and screw fixation composed of the metal titanium and being very small in size works quite well for repairing these facial bone injuries. I have done many with this metallic method and it is the standard of care today.

Over the past ten years, I have also repaired cheek bone fractures with a resorbable plate and screw system composed of the polymer, LactoSorb. These resorbable plates and screws have been used in over 100,000 craniofacial cases since 1996 and has a proven track record of safety and effectiveness. In properly selected cheek bone fractures, LactoSorb plates and screws can provide good stable results. Plates of 2.0mm size are placed vertically along the posterior maxillary buttress (if possible) and obliquely from the zygoma to the pyriform aperture. (which is always possible). Plates smaller than 2.0mm are not of adequate strength. The cheek fractures that work best with this resorbale fixation method are what I call simple fractures, where an intraoral approach with only one or two plates is all that is needed to adequately restore their pre-injury anatomic position.

Repositioning the cheek bone back in place will almost always leave a bone gap between it and the front wall of the maxillary sinus. If this bone gap is unduly large, one might want to consider a bone graft for long-term stability.

My experience with cheekbone fracture repair with LactoSorb fixation has always been satisfactory. I have not experienced any infections, collapse of the cheek bone, or adverse reactions to the material as the bone heals and the material absorbs up to a year after surgical  repair.

Dr. Barry Eppley

Indianapolis, Indiana    

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

Read More

Free Plastic Surgery Consultation

*required fields

Military Discount

We offer discounts on plastic surgery to our United States Armed Forces.

Find Out Your Benefits