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Posts Tagged ‘facial fracture repair’

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

Case Study: Craniofacial Reconstruction of a Severe Zygomatico-Maxillary Complex (ZMC) Fracture

Wednesday, August 1st, 2012

Background:  Facial fractures occur from a wide variety of mechanisms, most commonly blunt trauma. The cheekbone or zygomatico-maxillary complex (ZMC) is one of the facial bones that is commonly broken due to its prominence on the face. Usually blunt trauma such as being hit by a sporting ball or a fist causes the cheekbone to be knocked out of place, down and into the maxillary sinus. The legs or attachments of the cheek bone behind its frontal prominence are fourfold, being attached superiorly to the tail end of the brow, medially to the lower rim of the eye socket, inferiorly to the maxilla and out laterally to the arch process/temporal bone. To displace the cheekbone, all four legs must be fractured.

Gunshot injuries to facial bones are unique because they have a blast effect, similar to the forces of blunt trauma, but also have a penetrating disruptive force of a high-velocity bullet. The path of the bullet slices the bones creating a wedge effect in its path. When bullets penetrate the face, they are frequently deflected from their path by the initial bone that they hit. This creates non-straight line bullet paths that can be completely unpredictable. The facial fracture pattern of each bullet wound injury is unique.

Case Study: This 39 year-old female has sustained a severe facial injury from a gunshot wound. The bullet entered her right temple and angled through her cheekbone area downward, incredulously exiting out her mouth. She retained her right eye but became blind due to optic nerve impingement from the blast effect and bony displacement. When seen for reconstruction four months after her injury, she had a severely displaced ZMC fracture pattern with impingement and fibrosis to the coronoid process of the lower jaw and temporalis muscle. As a result she had more than a centimeter of orbital dystopia, very significant facial asymmetry and she could not open her mouth.

A 3-D model made from a CT scan shows the severe amount of ZMC bony displacement.

She subsequently underwent a craniofacial reconstructive procedure that was done through a combined coronal (scalp), lower eyelid and intraoral incisions. The entire ZMC complex (or what remained of it, was displaced downward into the maxillary sinus and well scarred into the temporalis muscle. It was osteotomized and repositioned along the lateral orbital rim, zygomatic arch and the underlying maxilla. The bones were stabilized with titanium plates and bone gaps repaired with split-thickness cranial bone grafts. The orbital floor was also built up with cranial bone grafts in layers until the eye position was at the same level as the normal size. Her lower jaw was remobilized by removing the coronoid process and releasing it from the scarred muscle.

After six weeks of healing, she could be seen to have substantial improvement in her facial symmetry with better eye position and cheek projection. Equally important she could open her mouth to almost a normal amount. While she will need further refinements, such as temporal augmentation, the underlying facial skeleton has been anatomically restored.

Case Highlights:

1) ZMC facial fractures can affect the position of the eye and eyelid, the prominence of the cheek bone, opening of the lower jaw and the integrity of the maxillary sinus.

2) Severe ZMC fractures require extensive osteotomies using a multiple incisional approach, cranial bone grafts and rigid titanium plate and screw fixation.

3) Orbito-zygomatic bone and eye symmetry is a main objective of extensive ZMC reconstruction.

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.

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