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Page 2 of 4 Egro et al. Plast Aesthet Res 2019;6:15 I http://dx.doi.org/10.20517/2347-9264.2019.31

Finally, a gingivobuccal sulcus incision effectively exposes the maxilla for reduction and stabilization of
[4]
the ZM buttress with aesthetically pleasing postoperative results . Historically, with the anterior approach,
ZMC fractures required fixation of all three anatomical positions. However, recently there has been a trend
toward fixation of fewer points depending on severity of injury.

The authors present a retrospective study analyzing the epidemiology and surgical management using
open-reduction and internal fixation of 27 isolated ZMC fracture cases in Kings College London Hospital
during 2016. Average time between fracture and surgical intervention was 15 days. They found one-point
fixation was the most popular technique for surgical stabilization of zygomatic fractures, with the ZM
buttress as the most common fixation point. The authors described that sufficient stability was achieved
with one-point fixation when there is no comminution of the ZMC fracture. The authors concluded that
there is a lack of consensus in the repair methodology of ZMC fractures likely due to surgeon preference,
training, and experience.

Despite the efforts by the authors to assess the surgical management of ZMC fractures in their major
trauma center and compare those findings with the literature, there are certain limitations that readers
should consider when interpreting the results of this study. Firstly, edema after injury makes the exposure
of the ZMC fractures challenging and for this reason many surgeons advocate to wait for the edema to
decrease before operating. However, within fifteen days the fracture is often viscous in touch and difficult
[5]
to maneuver . From our experience, five to seven days after the onset of the fracture has shown to be ideal
time and we believe that waiting 15 days as highlighted in this paper might be too long.

Secondly, we do not agree that one-point fixation provides sufficient stability of the fracture and instead
recommend two or three-point fixation, due to multiple variables that can influence the fracture’s healing
process. For example, the masseter pull on the zygoma could potentially displace the malar fragments. This
is particularly important to take note of in a comminuted zygomatic fracture in which masseter forces could
[6]
displace the segments and have suboptimal aesthetic outcomes when set . Previous literature has described
that two-point or three-point fixation techniques of ZMC fractures provide more stability when compared
[10]
to one-point fixation [2,7-9] . A meta-analysis of randomized control trial data done by Jazayeri et al. suggests
that three-point fixation of ZMC fractures are superior, however, when two-point fixation appears to provide
stable fixation, potential benefits of a third fixation point should be weighed against costs such as operative
time and morbidity of additional incision.

The authors’ did not discuss the posterior approach to ZMC fractures, which involves open reduction and
fixation of the zygomatic arch. This can be achieved with a coronal approach, where the entire zygomatic
arch can be visualized while protecting the frontal branch of the facial nerve. Fractures with extreme
posterior displacement, and those with lateral displacement of the zygomatic arch benefit from this
approach. Benefits of the coronal incision include exposure of the entire zygomatic arch and roof of the
glenoid fossa which allows for precise zygomatic arch reconstruction, eliminating the need for an upper
blepharoplasty or lateral brow incision by exposing the ZF suture. Additionally, the bicoronal approach not
only provides improved contour of the zygomatic arch/ZMC fractures but also provides access to other
facial fractures like the naso-orbital ethmoid, frontal sinus, and superior and lateral orbits .
[1]
Alternatives to the coronal approach to zygomatic arch repair include the Gillies approach, which is a
[2]
temporal approach for reduction only of zygomatic arch fractures . In this study, the Gillies approach
was used for the majority (85%) of the 13 isolated zygomatic arch fractures in this trauma center. However,
based on our experience the Gillies approach produces less than ideal results in ZMC fractures and
should be used for isolated zygomatic arch fractures. Results with this approach never fully project the
malar eminence back to pre-morbid state, often resulting in a persistent depression of the lateral cheek. In