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CHEEKBONE FRACTURE
ZYGOMATIC FRACTURE
ZYGOMATICOMAXILLARY COMPLEX (ZMC) FRACTURE
 

INTRODUCTION:
 
 


 

The zygoma (cheekbone) is not only very prominent on the face, but it also makes up a large component of the bony orbit (space in the facial skeleton where the eye sits). Trauma to the face whether from a fist, other blunt object, or during motor vehicle accidents can result in fracture of this bone. Repairing these fractures is not only important in restoring the proper contour and shape to the face, but also is important in providing the eye (globe) its proper support structure.


SYMPTOMS:


Patients that have a fracture of the cheekbone can present with a multitude of symptoms that are the direct result of the location of this bone on the face, and its association to other structures. Besides the usual swelling, bruising, and pain that are seen with any significant trauma, especially if bone fractures are the result, other symptoms are possible:

Double vision:
As this bone is one of the bones which make up the orbit (space where the eye sits), displaced fractures of this bone can result in changes in the support mechanism of the globe and disrupt some of the muscles that make the eye move. Although double vision can be the result of these effects, it is important to eliminate the possibility of injury to the eye itself as the cause of this symptom.

Flat cheekbone or facial contour:
As the cheekbone is one of the more prominent spots on the midface, fracture of this bone can result in its displacement into the plane of the face. Even with the swelling seen after the trauma, it is often easy to notice that the side of the face with the fracture is flatter than the normal side. It is important in treating these fractures, to bring the bone into its proper alignment in order to restore the proper contour to this area of the face.

Palpable steps or sharp edges of bone around the eye:
As the cheekbone makes up the side and lower part of the orbit, fractures of this bone when displaced can be easily palpable around the eye. These sharp edges of bone mean that the alignment of the different bones has been lost, and the resultant sharp edges are palpable as these areas of the face have very little fat and muscle under the skin.

Numbness of the cheek:
One of the nerves that provide sensation to the area of the cheek and the skin under the eye exits the bone right below the orbit just to the center of the cheekbone. Sometimes fractures of the cheekbone run very close to this point and can result in pressure being applied to this nerve. The result is partial or total loss of sensation over this area of the face. This loss of sensation is most times temporary and will return to normal days to weeks after the fracture is fixed.

Bleeding in the white part of the eye (sclera):
Sometimes patients with this fracture can have the white part of the eye turn red (subconjuctival hemorrhage). This is caused by bleeding under the soft tissues of the face that can track into the soft tissues of the eyes. This condition usually resolves spontaneously after a few days. Again, it is important in these fractures to have an ophthalmologic evaluation to ensure that no injury to the eye has taken place.

Inability to open mouth wide (trismus):
One of the muscles which helps in closing the mouth inserts in the cheekbone. Fractures of this bone can sometimes cause spasm of this muscle leading to difficulty in opening the mouth. This problem will usually resolve with time and normal jaw function will resume.

 
Eye that appears sunken or receded in the orbit (enophthalmos): When the cheekbone is fractured, the volume of the orbit is disrupted and usually made bigger. Furthermore, the thin floor of the orbit is usually fractured into the sinus. These two things can cause the eye (globe) to appear receded or sunken in the orbit. This condition usually appears late (after a few days) as the initial swelling seen with this fracture tends to mask this finding. Sometimes this condition is seen even after the fracture is treated, and secondary surgery in the form of bone grafts to the floor of the orbit is necessary in order to treat it.
 

Obstructed nasal passage or blood from the nose: The cheekbone also makes up part of the maxillary sinus (an air filled space that is next to and drains into the nose), and fractures can cause bleeding into the sinus. This blood in the sinus can result in an obstructed nasal passage on the same side of the fracture as well as, bleeding from that nostril.


TREATMENT:

In evaluating these kinds of injuries, not only clinical exam is important but radiologic evaluation in the form of a CT scan is also very informative. A CT scan of the face including very detail images around the eyes can delineate these fractures very well and help the surgeon plan for the corrective surgery. As part of the preoperative assessment, an ophthalmologist might be consulted to assess the eye and make sure that there are no injuries to the eye itself. If the eye is injured, surgical plans might need to be altered or delayed.

Once all other injuries have been either ruled out or addressed, the principles in dealing with fractures of the cheekbone revolve around the exposure of the fractured bone, bringing that bone back into alignment, and securing it in its proper place. This is done with the help of either wire or metal plates and screws.

The surgery to treat these fractures usually requires general anesthesia and a hospital setting. Exposing the fractured bone is done through several incisions which might include:

Brow incision: this incision is either made on the eyebrow itself or in a crease on the upper eyelid. This incision allows for exposure to the joint between the cheekbone and forehead which is usually separated or fractured with these injuries. The fracture at this site is treated with either a wire or a small bone plate with screws.

Buccal incision:
This incision is performed inside the mouth above the upper teeth on the side of the fracture. This incision allows access to the cheekbone itself and to the sinus wall. Oftentimes, the anterior sinus wall is badly fractured and treatment involves repositioning the fractured segments and placement of one or more metal bone plates.

Eyelid incision:
This incision can be made in several locations—either on the outside of the lower lid, or inside of the lower lid where it is not visible. This incision allows exposure to the lower portion of the orbital rim which is usually displaced in these fractures, and allows exposure to the floor of the orbit. Exploration of the floor of the orbit is important as significant fractures here must be treated by placing either bone or some other material to prevent the eye from sinking in the orbit in the postoperative period (enophthalmos).

Coronal incision:
Sometimes the nature of the fracture requires more extensive exposure to the involved bones and the coronal incision is used. This incision is performed on top of the head above the hair line and allows exposure to the entire upper part of the facial skeleton. Although this incision is not normally done for cheekbone fractures, it might be required in certain cases where the fracture is grossly displaced or is part of other fractures of the face.
 

Once all of the incisions are made allowing for the necessary exposures to the fractured bone, the bony fragments are placed in their normal position and held in place with either wires or metal plates and screws. If the fracture on the floor of the orbit is significant, oftentimes a graft needs to be placed there in order to reconstruct the defect. A graft might also be necessary to reconstruct the anterior wall of the maxillary sinus if there is bone missing. Although several different synthetic materials can be used to reconstruct the floor of the orbit, some surgeons might prefer to use bone for this. The bone is taken from either the skull or the hip, and a separate incision is necessary for this. If the bone is taken from the skull, an incision is made on scalp behind the hair line and the outer layer of the skull is harvested for this purpose. This procedure might result in a slight palpable depression of the skull in this area, but should not result in any other findings.
 
The incisions made for the treatment of a cheekbone fracture are all very inconspicuous either inside the mouth or along normal creases of the eyelids and will leave minimal visible scarring if any. The residual contour difference which might be palpable in the skull if a bone graft is harvested is subtle and the incision should be well behind the hairline.



AFTER THE SURGERY:

With the manipulation of the fractured bone during the surgery, there will be associated swelling and bruising which might be evident for a few days after the surgery. With time however, all this will disappear leaving a normal facial contour and good support for the eye. For the care of the incision inside the mouth, it is extremely important that it is maintained as clean as possible. This is usually done by rinsing thoroughly especially after meals. Over the course of the next few weeks, as the swelling disappears, the final position of the eye will be reached. It is a this time that a decision will be made whether further bone grafting will be necessary to correct any residual enophthalmos.

 

The information provided above is for educational purposes only.  Individual results may vary.  A personal consultation with your plastic surgeon is the best way to gain information about your particular complaint, and about potential treatment options to address the same.