1 Principles top
If the surgeon considers the zygomatic arch deformity so severe that it cannot be adequately treated with a transoral (Keen) or temporal (Gillies) approach, or too unstable to be treated without fixation, an open treatment can be considered. This has the advantage that it allows direct visualization of the zygomatic arch for fixation. It may be particularly desirable in a patient where a coronal approach has to be made for other reasons (such as for the treatment of a frontal sinus fracture or the harvest of a split calvarium bone graft). Another reason for open treatment is secondary treatment of a zygomatic arch malunion where osteotomy and internal fixation are needed. Existing lacerations may also be used.
Although it is referred to as a zygomatic arch, most surgeons consider it is rather flat. It is very important to restore the previous anatomy so that it matches the uninjured contralateral arch.
The temporal branch of the facial nerve runs in close proximity to the periosteum of the zygomatic arch. Care must be taken not to injure this nerve.
In most patients, there is little soft tissue over the zygomatic arch. If the decision is made to perform an open reduction and internal fixation, one must be concerned about the plate size, and possible palpation of the plate through the skin.
2 Reduction topenlarge
The fragments of the zygomatic arch may be elevated under direct vision through the coronal approach, using digital reduction, or any common instruments.
3 Fixation topenlarge
The order of placement of screws in the fracture segments is highly variable depending on the degree of comminution of the zygomatic arch. One consideration can be to begin with a screw nearest the fracture, on the stable portion of the zygoma, with the second screw being placed nearest the fracture on the stable portion of the temporal bone, making sure that the entire span of the plate is not canted above or below the zygomatic arch. The order of the additional screws can be according to the convenience of the surgeon and the fracture pattern.