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Dr. Barry Eppley

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Posts Tagged ‘ZMC 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

‘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

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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