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Posts Tagged ‘facial fractures’

Zygomatic Arch Fractures and Their Repair

Sunday, March 1st, 2015


NBA player cheekbone fractureFacial fractures are common injuries and sporting activities are a common source of them. This was well illustrated by a well chronicled facial injury sustained recently in the NBA. Oklahoma City’s Russell Westbrook was injured in a game last Friday in Portland when his teammate’s knee collided into the right side of his face in the last minute of the game. This left an immediate imprint in the side of his face between the eye and the ear. The next day he had surgery to repair a ‘cheekbone’ fracture.

Understanding the anatomy of the cheek bone, technically known as the zygomatico-orbital complex, will explain the specific type of facial fracture this NBA player sustained. The distinct imprint on the side of his face was caused by a zygomatic arch fracture. This is the very thin stick of bone that goes from the main body of the cheekbone (zygoma) back to its attachment to the temporal bone in front of the ear. It is like an arched bridge that spans the cheek and skull to let the large temporal muscle go underneath it.

zygomatic arch fracture Dr Barry Eppley Indianapoliscomminuted zygomatic arch fracture dr barry eppley indianapolisBecause the zygomatic arch is so thin, it is one of the most easily fractured bones on the face. But it requires a direct blow to the height of the arch to create a displaced fracture. It usually fractures inward like a V with two collapsing spans of a bridge. But it can also be a comminuted type zygomatic arch fracture where it breaks into multiple pieces and the entire ‘span of the bridge’ falls inward.

Zygomatic Arch Fracture Repair Dr Barry Eppley IndianapolisRepair of a displaced zygomatic arch fracture is unlike just about every other facial fracture other than that of the nasal bones. It is located in an area where direct surgical access is impossible due to branches of the facial nerve. Without direct access it is not possible to rigidly fix the fracture with plates and screws. (at least not very easily) Thus zygomatic arch fractures are repaired from a remote incision in the temporal scalp and are elecated back up into position off of the temporalis muscle.

Zygomatic arch fracture repairs are, by definition, unstable since they are not rigidly fixed back into place. This is why you will usually see some type of protective device over the side of the face to prevent secondary inward displacement while it heals.

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





Sports-Related Facial Fractures – Early Return to Activity after Treatment

Tuesday, November 24th, 2009

Over the past two decades, I have treated many hundreds of facial fractures from a wide variety of mechanisms. By far, domestic interactions and motor vehicle accidents make up the reason that almost two-thirds of these facial injuries as the cause. Facial fractures from sporting events make up a small (less than 10%) number and they often are less severe.

After reviewing numerous research studies on sport-related maxillofacial fractures, several trends are seen. First, males sustain the largest percent of these types of injuries as compared to women. Reports range from 10 to 15:1. This is no surprise given that there are more males than females who participate in contact sports at all age levels. Often, only a single facial bone is fractured with the nose, cheek, orbit, and mandible making up most of the isolated injuries. Dentoalveolar fractures (teeth loosening and avulsions), while still occurring, have decreased in the past decade as the availability and use of mouthguards have become more widely used.

Most of the facial fractures, in my Indianapolis plastic surgery experience, come from soccer, baseball, basketball and hockey…contact sports in which there is little to no facial protection. Flying objects are the main source in baseball and hockey due to the speed and small size of the baseball and puck. Head and upper extremity contact cause most soccer and basketball facial injuries.

With contemporary facial fracture repair methods, many athletes can return to training and competition sooner than in days past. Three-dimensional CT scans provide an immediate assessment of the injury so the need for surgery can be promptly determined. With knowing what to do, surgical repair can be done as soon as possible. With the exception of certain types of nasal fractures, most facial fractures can be promptly treated without waiting for swelling to subside.

Modern low-profile titanium plates and screws enable most facial fractures to be repositioned and secured quite accurately. They are strong enough to not only hold the bones in place but can resist repeat trauma during the bone healing period. They rarely need to be removed as titanium has superb biocompatibility with bone and often becomes overgrown with new healing bone. Resorbable plates and screws are also available but if one is interested in returning to sporting activities as soon as possible, metal fixation is a better choice for earlier return to activities.

Nasal fractures are the one exception to early treatment and bone plating. It is hard to know the full extent of nasal structure displacement since much of the nose is cartilage and not bone. It is usually better to let the swelling go down before attempting surgical repair. The small and thin size of the nasal bones do not permit rigid bone fixation to be done. This is why splinting and protection of the nose is critical for a long time even after returning to sports activity.

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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