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