1 Principles top
If the zygomatic arch is properly elevated (in an isolated zygomatic arch fracture), and the periosteum has been left intact, the arch will commonly retain its reduction. Unless a surgeon is willing to perform a coronal approach, or has endoscopic facilities for plating the zygomatic arch, an internal fixation is not possible.
For many years surgeons have argued that following this technique the arch remains unstable and may collapse. There is evidence to suggest that the problem was inadequate reduction and not necessarily a loss of a proper alignment of the zygomatic arch.
One of the biggest challenges with this technique is assessing proper reduction. This is difficult to determine if the surgeon does not have access to intraoperative imaging.
2 Reduction top
Selection of approach
Reduction using the transoral (Keen) approach
The instrument (zygoma elevator, Boise elevator, etc) is used to elevate the zygomatic arch into its proper position.
Because of the close proximity of the intraoral incision, the surgeon can often use their finger to palpate whether proper reduction has been achieved.
The use of intraoperative imaging for confirmation of proper reduction would be ideal.
Reduction through the temporal (Gillies) approach
Through the temporal (Gillies) incision a tunnel is created to pass an instrument superficial to the temporalis muscle and deep to the zygomatic arch.
An instrument is then used to elevate the zygomatic arch into its proper position.
The elevator passes between the temporalis muscle and the deep layer of the deep temporalis fascia.