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Page 2 of 13 Bradley et al. Plast Aesthet Res 2019;6:11 I http://dx.doi.org/10.20517/2347-9264.2019.06

Keywords: Zygomatic complex fractures, ZMC, open reduction internal fixation, zygomaticomaxillary buttress

INTRODUCTION
Zygomatic complex (ZMC) fractures are relatively common. A literature search showed ZMC fractures
to account for approximately 15%-23.5% of maxillofacial fractures . The incidence of ZMC fractures
[1-3]
varies with geographical location, socioeconomic trends, and incidence of road traffic collisions (RTCs),
alcohol abuse and drug abuse . A number of studies had shown ZMC fractures to be the second most
[4]
common facial fracture, after nasal bone or mandible fractures . Common causes of ZMC fractures
[3-6]
include interpersonal violence (15%-64.5%), RTCs (13.9%-49%), as well as falls, occupational accidents, and
sport-related injuries [3,7,8] . Furthermore, ZMC fractures are more common in men than women, and most
commonly occur in the third decade of life .
[2]
An intact zygoma (or zygomatic bone) and its surrounding bony anatomy are essential for maintaining
facial contour, such as cheek prominence, as well as orbital integrity . Anatomically, the zygoma is attached
[5]
to the frontal bone (via the frontozygomatic suture), the maxilla (via the zygomaticomaxillary suture),
the squamous part of the temporal bone (via the zygomaticotemporal suture) and the sphenoid bone (via
the zygomaticosphenoid suture) [Figure 1] . Fractures that involve the zygoma often occur at these four
[6]
suture sites, leading to a “tetrapod” fracture pattern, known as a “zygomatic complex fracture” (ZMC).
Furthermore, the zygoma is connected to the maxilla and sphenoid bone as part of the inferior orbital
floor, and forms the lateral orbital margin with the frontal bone. Thus, fractures of the zygomatic complex
inevitability lead to a certain degree of orbital defect. Other fracture patterns, include isolated zygomatic
arch fractures, or ZMC fractures with associated pan-facial fractures, such as Le Fort II and III fracture
patterns. Indication for fixation of zygomatic fractures includes aesthetic defects (e.g., cheekbone flattening
or a dimple) or functional defects (e.g., restrictive mouth opening, malocclusion or ophthalmic issues such
as diplopia, restricted eye movements, enopthalmus and hypoglobus).

There are currently no widely accepted treatment protocols or guidelines on the surgical management of
ZMC fractures. The fixation points used in the Open Reduction and Internal Fixation (ORIF) of ZMC
fractures are shown in Figure 2. A review of the literature shows that for ORIF of ZMC fractures, the
number of fixation points used, their location, as well as the incisional access to these fixation points is
variable . A multidisciplinary survey by Farber et al. in 2016 involving Otorhinolaryngology (ENT),
[1-4]
[10]
Plastic and Oral and Maxillofacial (OMF) surgeons, demonstrated variable treatment choices for ZMC
fractures regarding the location and number of fixation points, surgical approaches, as well as the need for
orbital floor exploration. Interestingly, across all three specialties, it was demonstrated that a greater number
of fixation points were chosen by surgeons with less than 10 years’ experience .
[10]

With regards to one-point fixation, there is variable support from the literature regarding its efficacy,
and there is no consensus regarding the optimum anatomical position for one point fixation between the
zygomaticomaxillary (ZM) buttress, the infraorbital margin (IOM) and the frontozygomatic (FZ) region,
as well as the optimum surgical access to these anatomical fixation points [4,11,12] . The ZM buttress has been
quoted to be a popular choice for one-point fixation in some literature, whilst others have quoted the FZ
suture as their first choice, but beyond this, there is little consensus [4,11-13] . Some literature advocates the
fixation of both the IOM and FZ suture for any displaced ZMC fractures, and for cases with displacement
greater than 5mm, the use of 3-point fixation is recommended .
[13]

METHODS
We retrospectively retrieved, from an online database, all operative cases (ORIF) of zygomatic complex
fractures, isolated zygomatic arch fractures, with and without other associated operative procedures (e.g.,