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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.