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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘zygomatic fracture repair’

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 Osteotomies in Cheek Augmentation and Cheek Reduction

Thursday, August 27th, 2009

The cheek bone (zygoma) is a very valuable part of one’s appearance as it provides a prominent highlight and a width dimension to the face. It also provides support to the eyeball and serves as an attachment point to the tendons of the upper and lower eyelids.

Some people have naturally broad or narrow cheek widths, of which one component is caused by the development and shape of the dimensionally complex zygoma. The curvature of the zygomatic body and attached arch bone is responsible for some of this width.

The normal position of the zygoma cam also be altered through injury, with cheek or ‘tripod’ fractures being frequent. When the bone is fractured, it almost always is displaced downward and inward into the maxillary sinus cavity. As the pillar or support of it is lost, it can only fall in this direction. Technically, it rotates  (tilts, not just falls) and the cheek prominence is lost and the corner of the eye may be pulled down slightly also. While most of these zygoma fractures are repaired immediately, some never get fixed for a variety of reasons creating a secondary zygomatic deformity marked by a flatter cheek.

Zygomatic osteotomies are one potential method to improve these bone malpositions. Depending on the facial objective, the type of zygomatic osteotomy can differ which also influences the incisional approach.

In a purely cosmetic application, the zygomatic body (not arch) can have a wedge of bone removed for reduction or can be cut and expanded. (with or without grafting) By so doing, one can moderately help change the width of the face in this area. Because it is usually done on both sides of the face for cosmetic change, the total amount of change (by bone measurement) may be as much as 10 to 15 mms. Almost all cosmetic zygomatic osteotomies are done through an intraoral approach.

For reconstructive purposes, most zygomatic osteotomies are usually done on one side only. The objective being to match the opposite uninjured side. Deoending on how the bone must change position will determine what incisions are used. Usually the intraoral approach alone is not adequate as the zygomatic complex must be freed and rotated, not just changing one dimension of the zygomatic body. Thus two incisions are used, most commonly intraoral and lower eyelid. (blepharoplasty) Extensive three-dimensional complex movements may need a coronal (scalp) incision as well to fully mobilize the bone at each pillar of support. In my Indianapolis plastic surgery practice, I usually try to avoid the scalp approach as this is undesired by most patients and is reserved for those few patients who have had a more significant midface ‘crush-type- injury.

Zygomatic osteotomies will need bone fixation, using very small titanium plates and screws. These almost never need to be removed later and they rarely cause any problems.

When contemplating reconstructive zygomatic osteotmies, there is often an orbital component to the deformity that may require orbital floor reconstruction and repositioning of the lateral canthus to change the level of the corner of the eye as well.


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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