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

same study stated a preference for subtarsal incisions for ZMC fractures and transconjunctival incision for
isolated orbital floor fractures (blow-out fracture) . Despite some reservations on the transconjunctival
[12]
approach due to its close association with the eye, a study of 8 patients displayed no ocular complications
(such as chemosis) . Similarly, the 9 patients that underwent transconjunctival incision in our cohort did
[24]
not present with any complications. The transconjunctival approach was also favoured by another study
claiming that it has the advantages of both good intra-operative visualisation of the infraorbital rim, as well as
having favourable aesthetic results for the patient . In another study, Y-modification of a transconjunctival
[25]
incision has been advocated for access the IOM and FZ area, with the advantage of potentially avoiding a
second incision in the FZ area, although detailed knowledge of the lateral canthal anatomy is required and
may increase operating time . For FZ suture access, is in our cohort, the literature favoured the upper
[26]
blepharoplasty incision over the lateral eyebrow incision, with the latter tending to show more scarring and
less surgical access than the former, which often produces an inconspicuous scar that can only be seen when
the eye lids are closed [26,27] .

Limitations of the study: ZMC fractures that were treated conservatively were not included in our data
collection. It would be beneficial to elicit the epidemiology and presentations of conservatively treated cases
compared to surgically treated cases. There was insufficient documentation of alcohol and illicit drug use to
determine their possible link to ZMC fracture aetiology within our patient cohort. Additionally, further data
collection of pre-operative imaging and fracture displacement measurements to ascertain the correlation
between the radiographic findingsand each surgical procedure chosen would be useful. This would provide
valuable information regarding the correlation between the type of ZMC fracture i.e., degree of displacement
or comminution, and the subsequent choice of number of fixation points.

This study supports aspects of the current literature regarding the aetiology and surgical management of
ZMC fractures. It has been shown that the aetiology of ZMC fractures does indeed vary with geographical
areas and incidence of RTCs. At our centre, one-point fixation was the most popular technique for surgical
stabilization of ZMC fractures, with the ZM buttress being the most popular choice. It is generally accepted
that sufficient stability is obtained with one-point fixation when there is no comminution of the ZMC fracture,
with two-point and three-point fixation providing increasing stability where necessary, and often based on
fracture comminution and surgeon’s preference . The upper buccal sulcus incision is widely accepted as
[15]
the best approach for ZM buttress fixation. For IOM access, the transconjunctival and subciliary incisions
appear to be most popular within the literature, both having advantages of providing good intra-operative
views, low incidence of ocular complications, and good aesthetic outcomes. Interestingly, our incidence of
orbital floor exploration and orbital floor repair was lower than that reviewed in the literature. It would be of
benefit to further investigate this, with the aim of developing a specific protocol for orbital floor exploration
and repair based on pre-operative imaging and clinical signs.

Although there is some agreement amongst certain aspects of the surgical management of ZMC fractures,
there is still an ongoing lack of consensus in many aspects, particularly with regards to the number and
location of fixation points used and orbital floor exploration and repair. It appears that the surgeon's
experience, training background, and preferences may play a significant role in contributing to and
maintaining the variety of surgical approaches to ZMC fractures.

Further work in constructing a management protocol for ZMC fractures, alongside well-designed prospective
research, would minimise the lack of consensus and optimise care for ZMC fracture patients.

DECLARATIONS
Authors’ contributions
All authors contributed to the manuscript.