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Dr. Barry Eppley

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Posts Tagged ‘cheekbone fractures’

‘Unwrapping’ Cheekbone (ZMC) Fractures

Thursday, August 23rd, 2012


Facial fractures are a common injury and occur to the most prominent portions of the face in the vast majority of cases. These include the nose, cheeks, and jaw as frequent sites of facial fractures.. Blunt trauma is the most common cause with fists, falls, sporting activities and automobile accidents being the most common causes.

Cheek bone fractures, technically known as zygomatico-maxillary complex (ZMC) fractures, happen frequently. The cheek bone is less prominent than the centrally positioned nose but it is the most protruding structure on the side of the face and there are two of them.  The cheek bones are a unique facial bone because, although it is a sturdy stock of bone, it is attached to the eye superiorly, the upper jaw inferiorly and the temple posteriorly by relatively thin legs of bone. This is why it is often called a tripod fracture when it becomes broken. (even though technically there are four legs or attachments) Once impacted by enough force, the thinner legs break causing the body of the cheek bone to be pushed inward and usually downward as well. This flattens the cheek bone and causes a tremendous amount swelling and bruising, particularly around the eye area.

This appears to be the exact injury suffered recently by Food Network TV host, Marc Summers, in Philadelphia. This story drew my attention not only because of the recognizeable facial injury pattern but because I have always liked his well known show, ‘Unwrapped’. So to ‘unwrap’ his facial injury, the mechanism as he described the events of his injury is a classic example of what can cause a ZMC fracture. Rapid deceleration with his face planted right up against the glass partition of a cab in a rainstorm is how the accident happened.

Because it is a natural reaction to turn one’s head even in the split-second of the event, the side of the face where the cheekbone is prominent slams into an immoveable object. The legs of the cheekbone fracture, pushing it inward and down into the maxillary sinus. This was described as ‘wiping out half of my face’ which is somewhat accurate. Fortunately this is a blunt injury where the bone is fractured but no soft tissue is lost. Despite the magnitude of this facial fracture, it can be successfully repaired through an incision inside the mouth with or without an external lower eyelid incision. It requires the cheek bone to be repositioned and then held there to heal with small titanium plates and screws.

Many ZMC fractures can be very successfully repaired and patients can have a complete recovery with no long-term sequelae or facial deformity. It will takes about six weeks for the cheek and eye area to resolve all of its swelling and up to three months for all feeling to return to the skin and teeth. May we wish March Summers a speedy and full recovery and look forward to seeing him again on the show later this year.

Dr. Barry Eppley

Indianapolis, Indiana

Secondary Revisions of Soft Tissue Problems of Cheekbone (Zygomatic) and Orbital Facial Fracture Repairs

Thursday, December 10th, 2009

Cheekbone (zygomatic) and orbital fractures are very common results of blunt trauma to the face. Methods to put the displaced bones back in place and secure them with plates and screws so they can heal properly are well known. But even when these facial bones are put back into perfect anatomic position and the operation has been scored as a complete success, the facial appearance may still not be completely normal.

Cheeks can look flat, the orbital area may look hollowed, and the lower eyelid may be uneven or retracted downward. All of these are not rare sequelae from this type of facial fracture repair and are a reflection of soft tissue problems. Periorbital soft tissues can be affected by three factors; incisional problems, soft tissue retraction from surgical elevation, and traumatic fat atrophy.

Lower eyelid incisions are needed for exposure and treatment of cheek (zygomatic) and eyebone (orbital) fractures. There are three types of these incisions which can  be done from the skin on the outside of the eyelid to the lining on the inside. Each of these approaches has its surgical advocates but eyelid complications can occur with any of them. By far, the most common problem is that of ectropion or the lower eyelid margin being pulled downward away from the eyeball. Besides causing problems with irritation and tearing, it causes a very noticeable aesthetic distraction as more white of the eye is seen and has horizontal eyelid margin asymmetry compared the opposite side. The other eyelid problem is entropion, where scarring causes the eyelid margin to turn inward. This changes the direction of the eyelashes which now rub against one’s cornea rather than pointing outward. Either eyelid problem can be successfully improved by revisional surgery and can make for a significant aesthetic improvement and elimination of uncomfortable symptoms.

Many cheekbone fractures use a combined lower eyelid and intraoral approach for access. This requires the soft tissues of the cheek to be lifted off during the dissection. If they are not put back at the end of the procedure, soft tissue retraction occurs. This can make the cheek area look flat even though the underlying bone may be properly positioned. This can be improved by revisional surgery through either a cheek resuspension technique (midface lift) or a cheek implant. Each treatment approach can be successful and which one is appropriate for any patient must be determined on an individual basis.

The trauma to the soft tissues, either from the initial injury or from the surgical bone repair, can cause fat around the eye and cheek to shrink and resorb. Fat atrophy from trauma and hematomas (blood collections) is a well known phenomenon. I have seen it not uncommonly in my Indianapolis plastic surgery practice and the cheek area seems to be particularly prone to this soft tissue problem. Fat injections to the cheek and strip fat grafts to the eyelids and orbital rim can be used to help partially restore the lost soft tissue volume.

Secondary reconstruction of soft tissue problems from fractures around the eye and cheek may be needed to treat complications from these injuries. A perfect bone repair does not always lead to a complete restoration of facial appearance.

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.

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