Traumatic Arch Injury: Indications and an

Endoscopic Method of Repair

Marcin Czerwinski, M.D.
1
and Chen Lee, M.D., M.Sc., F.R.C.S.C., F.A.C.S.
1
ABSTRACT
The unique strategic position of the zygomatic arch makes it an important surgical
landmark in facial fracture repair. Because of the numerous negative sequelae associated
with the traditional coronal approach to the arch, it has frequently been omitted as a point
of reduction and xation. Endoscope-assisted repair allows accurate zygomatic arch
restoration without the setbacks of coronal access. The indications for arch repair include
markedly displaced isolated arch fractures, complex zygoma fractures with arch comminu-
tion, and Le Fort III level fractures. In complex zygoma fractures, the arch helps accurately
restore midface projection and width and serves as an additional stable anchor point. In Le
Fort III fractures, restoration and xation of the arch are essential components of the repair
necessary to stabilize the maxillary dentition to the cranial base. Endoscopic arch repair is a
novel, technically challenging procedure that requires a different set of surgical skills and
considerable training. Implementation of appropriate teaching programs and further
advances in instrument development will overcome the steep learning curve associated
with this technique and encourage its use.
KEYWORDS: Zygomatic arch, endoscope, Le Fort III
REGIONAL ANATOMY
The zygomatic arch is a narrow, laterally positioned
element of the craniofacial skeleton that has a
consistent structure and symmetry. In the axial plane,
the shape of the arch changes from a curved posterior
third to straight middle and anterior thirds. In the
sagittal plane the arch is parallel to the Frankfort
horizontal.
The arch is strategically positioned joining
the zygoma and the rest of midface to the stable
cranial base. Thus, it is a potentially important
landmark in the restoration of normal facial anatomy
following traumatic injury to the structures adjoining
it.
1,2
The length and shape of the arch in the axial
plane and its angulation from the sagittal plane can
be used to reestablish accurate projection and width of
the face.
Thorough knowledge of the regional soft tissue
anatomy and of its relationship with the frontal branch
of the facial nerve is essential to avoid injury during arch
exposure. The nerve pierces the supercial musculoapo-
neurotic system at the lower border of the zygomatic
arch and courses supercially to the temporoparietal
fascia in an anterosuperior direction.
3
The coronal inci-
sion has been used traditionally to reach the arch
(Fig. 1). The disadvantages associated with a coronal
incision have discouraged many surgeons from arch
repair. We introduce a novel endoscopic method of
arch repair with low risk of transection to the frontal
branch of the facial nerve (cranial nerve [CN] VII).
Current Considerations in Endoscopic Facial Plastic and Reconstructive Surgery; Editors in Chief, Fred Fedok, M.D., Gilbert J. Nolst Trenite,
M.D., Ph.D., Daniel G. Becker, M.D., Roberta Gausas, M.D.; Guest Editor, James C. Alex, M.D. Facial Plastic Surgery, Volume 20, Number 3,
2004. Address for correspondence and reprint requests: Chen Lee, M.D., M.Sc., F.R.C.S.C., F.A.C.S., Chairman, Division of Plastic Surgery,
Associate Professor, McGill University, Montreal General Hospital, D6.269, 1650 Cedar Avenue, Montreal (Quebec), Canada H3G 1A4.
1
Division of Plastic Surgery, Department of Surgery, McGill University Health Center, McGill University, Montreal, Quebec, Canada. Copyright
#2004 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001 USA. Tel: +1(212) 584-4662. 0736-6825,p;2004,20,03,
231,238,ftx,en;fps00518x.
231
TRAUMATIC INJURY PATTERNS
OF THE ARCH
Fracture displacement of the arch is determined by the
direction of the traumatic force and pull of the attached
masseter muscle. Three common patterns of arch injury
occur. First, a direct lateral impact fractures and displaces
the arch medially (Fig. 2). Second, posterior telescoping
of the arch can result from a frontal impact to the malar
prominence (Fig. 3). Third, lateral arch displacement is
less common and results from an anterior force vector to
the malar prominence with the energy dissipated at the
arch through an explosive burst with lateral displacement
of the comminuted arch fracture segments (Fig. 4A).
Recognition of this fracture pattern is important as
reduction attempts with lateral force applied under the
arch as described by Gillies and Keen further exacerbate
the degree of fracture displacement.
The clinical patterns of presentation include iso-
lated fractures of the zygomatic arch with temporal
depression, especially in patients with a prominent pre-
injury arch contour. A zygoma fracture results from
fracture disruption of all its normal bone attachments
to the cranial base. Because arch disruption is a necessary
component of a displaced zygomatic fracture, inclusion
of arch repair may enhance reduction and stability of a
complex zygomatic fracture.
4,5
The mobile maxilla of a
Le Fort III level fracture is dened partially by the
fracture separation of the maxilla from the cranial base
at the arch.
6
Repair necessitates reduction and stabiliza-
tion at this cranial buttress.
EFFECT OF ARCH REPAIR ON
TREATMENT OUTCOME
The arch has frequently been omitted as a point of
reduction and xation. In contradistinction, anatomic
fracture repair using open methods of reduction and
internal rigid xation are the accepted current standards
in the operative management of most facial fractures.
This general disregard for arch restoration may have
arisen because of the disadvantages associated with the
traditional coronal approach to arch repair. An extensive
scalp incision and dissection has been traditionally
necessary with coronal arch repair. This exposure intro-
duces risk of temporal hollowing, weakness or perma-
nent paralysis of the frontal branch of the facial nerve,
alopecia, loss of sensation posterior to the incision,
excessive blood loss, and a lengthy operative time.
7
Thus, the potential role of the arch as a foundation
landmark has been neglected.
In isolated arch fractures, accurate visual reduc-
tion reestablishes the preinjury contour of the lateral
face. Stabilization prevents redisplacement due to
reinjury or pull of the masseter muscle, an issue not
addressed by the often used Gillies approach. Anatomic
repair is especially important in patients with prominent
arches, where the normal soft tissues may not hide the
underlying bone discrepancies.
Figure 1 Open reduction and rigid miniplate xation of the arch
have traditionally required an extensive coronal scalp incision.
Figure 2 Three patterns of comminuted arch injury are com-
monly observed. Medial arch displacement often results from a
direct lateral impact.
Figure 3 Posterior telescoping of the arch occurs secondary to
an anterior impact to the malar prominence.
232 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 3 2004
In complex zygoma fractures, restoration of
original arch shape, length, and angulation facilitates
an accurate reestablishment of midfacial projection
and width. The arch serves a secondary role as a point
of added fracture stabilization.
In associated Le Fort III fractures, the arch rigidly
suspends the mobile midface segment to the cranial base
and stabilizes the maxillary dentition. Here as well, the
arch is important in restoration of accurate midfacial
projection and width.
To benet from the advantages of arch repair
and simultaneously minimize surgical stigmata of cor-
onal exposure, we have developed an endoscope-assisted
technique.
EVOLUTION OF ENDOSCOPIC
REPAIR OF THE ARCH
In the laboratory, we evaluated the effectiveness of the
endoscope to reduce and xate the arch precisely and
avoid facial nerve injury on a cadaver fracture model.
Using remote minimal access incisions, excellent fracture
reduction and rigid miniplate stabilization were achieved
by endoscopically assisted fracture repair in all cadaver
skulls. Dissections of the frontal branch of the facial
nerve conrmed complete anatomic continuity in all
specimens.
7
Subsequently, we have used the endoscopic ap-
proach to zygomatic arch repair in 25 clinical cases.
8
Of
those, 3 were isolated arch fractures, 15 were associated
with zygoma fractures, and 7 involved Le Fort III
fractures (Fig. 5). All patients demonstrated excellent
reestablishment of facial width and projection, as con-
rmed by facial computed tomography scans. No per-
manent dysfunction of the frontal branch of CN VII
occurred in our series. Temporary palsies, probably
caused by aggressive traction, were present in 4 of 7 Le
Fort III, 3 of 15 complex zygoma, and 1 of 3 isolated
zygomatic arch fractures. Operating times for endo-
scope-assisted repairs were 2.0 hours for the isolated
arch, 4.9 hours with complex zygoma, and 9.7 hours for
the Le Fort III fractures (Fig. 6).
SURGICAL TECHNIQUE
Endoscopic Equipment
The endoscope used at this center is a 4-mm-diameter,
30-degree angle scope (Karl Storz, Germany). To
Figure 4 (A) Lateral arch displacement is the least common fracture pattern described. However, its recognition is important as most
techniques of fracture reduction employ a lateral force to the displaced arch segment. Application of such lateralizing techniques of arch
repair to an already laterally displaced arch only exacerbates the degree of fracture displacement. (B) Anatomic repair of the lateralized
arch was successfully accomplished with endoscopic assistance. Refer to Figure 8 to see associated clinical photographs of this patient.
Figure 5 The arch components of fractures were repaired
endoscopically in isolated arch, complex zygoma, and Le Fort III
injuries.
TRAUMATIC ARCH INJURY/CZERWINSKI, LEE 233
maintain an optical cavity and stabilize the orientation of
the endoscope simultaneously, a 4-mm endoscope-
mounted retractor (Isse Dissector Retractor, Karl Storz,
Germany) is required. The Olympus Video System
(Olympus America, Lake Success, N.Y.) is used to pro-
ject the endoscopic image to a video display.
Exposure
A preauricular incision at the anterior margin of the
helical crus, extending superiorly 2 cm above the auricle,
is made. This incision is carried through the skin and
the temporoparietal fascia to expose the deep temporal
fascia. To create an adequate optical cavity, a periosteal
elevator is used to dissect supercial to the deep temporal
fascia. To avoid injury to the frontal branch of the
facial nerve, the nonendoscopic component of the dis-
section does not extend below an imaginary line joining
the helical crus and the superior orbital rim. Following
dissection of the optical cavity, the retractor-mounted
endoscope is inserted in the plane supercial to the deep
temporal fascia and visualized dissection is performed
down to the zygomatic arch (Fig. 7A, B). Temporal
hollowing is avoided by maintaining the integrity of
the deep temporal fascia. Once the arch is reached, the
periosteum is incised and the dissection is carried in the
subperiosteal plane to expose the entire zygomatic arch
and identify all sites of fracture.
Reduction
Commonly, reduction of the arch is performed in situ.
The fracture segments are aligned, according to the
fragmentation pattern, to restore the preinjury form of
the arch. When the comminution is severe and results in
a highly unstable pattern, the fracture segments can be
removed from the operative eld, stripped of attached
soft tissues, and reduced on a side table. The latter
method, however, suffers from an increased rate of
postoperative bone resorption because of the interrup-
tion of the periosteal blood supply.
9
Fixation
A short miniplate (in isolated zygomatic arch fractures)
or a long miniadaptation plate (in associated midface
fractures) is plated onto the arch in situ or on a side table.
The long miniadaptation plate extends onto the lateral
orbital rim, restoring and rigidly xing midface anatomy.
Following conrmation of accurate alignment at all
fracture sites and accurate arch positioning, the plate is
anchored, under endoscopic guidance, with screw xa-
tion (Fig. 7C).
SEQUENCING OF COMPLEX REPAIRS
With complex facial fractures, multiple sites of fracture
repair may be necessary to achieve accurate restoration of
preinjury facial form. When arch restitution is an im-
portant component of the repair, we have found the
following sequences of fracture reduction and xation to
be most accurate and expedient.
Complex Zygoma
Anatomic repair of complex zygomatic fractures may
require reduction and xation at all the major fracture
interfaces. This includes the zygomaticofrontal suture,
infraorbital rim, zygomaticomaxillary buttress, and the
zygomatic arch. We have found repair most facile
when the zygomaticofrontal suture and infraorbital rim
are reduced and xated rst. This serves to restore the
external skeletal frame of the orbit. Next, accurate
projection of the orbital frame is achieved by repairing
the arch. Last, the fracture at the zygomaticomaxillary
buttress is addressed.
Le Fort III
Le Fort III level fracture requires reduction and xation
of the midface to the cranial base to provide a stable
platform for dental occlusion. Repair is most expeditious
if the cranio-orbital and maxillomandibular units are
restored separately and then joined at the Le Fort I level.
The cranio-orbital unit is repaired by reduction and
xation at the frontozygomatic suture and infraorbital
rim to recreate the orbital frame. Accurate projection of
the orbital frame is established through arch repair. The
maxillomandibular unit is restored using maxilloman-
dibular xation. Last, the cranio-orbital and maxillo-
mandibular units are joined by rigid xation of the
anterior buttresses of the maxilla.
Figure 6 Mean operative times of endoscope-assisted repair of
facial fractures involving the zygomatic arch. The length of
surgery correlates well with the complexity of injury.
234 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 3 2004
CASE PRESENTATIONS
Complex Zygoma
A young male was a driver in a motor vehicle accident.
The force of the collision resulted in his face striking the
steering wheel. He suffered a left lateral orbital lacera-
tion. In addition, he complained of numbness in the left
infraorbital nerve distribution and atness and pain in
the affected cheek. Radiographic imaging demonstrated
a complex left zygomatic fracture with lateral displace-
ment of a comminuted arch. Access for fracture repair
was preauricular (endoscopic arch xation), upper buccal
sulcus (zygomaticomaxillary buttress and inferior orbital
rim), and lateral orbital laceration (zygomaticofrontal
buttress). The highly comminuted laterally displaced
arch was dissected as a free graft and rigidly plated on
a side table, then repositioned anatomically as the arch
component of the four-point zygomatic fracture repair
(Figs. 4 and 8).
Le Fort III
A young male was assaulted with a baseball bat. He
complained of left facial attening as well as mobility of
his maxilla and malocclusion. Radiographic imaging
demonstrated left Le Fort III and right Le Fort II facial
fractures. The patients preinjury occlusion was restored
using maxillomandibular xation. Access for fracture
repair was achieved using preauricular (endoscopic
arch xation), upper buccal sulcus (zygomaticomaxillary
Figure 7 The technique of endoscopic arch repair utilizes remote minimal access portals to effect repair. (A) The endoscope-mounted
retractor is inserted through a preauricular incision, in a plane supercial to the deep temporal fascia, to reach the zygomatic arch. (B)
Endoscopic view of the medially displaced, fractured arch fragments. (C) This endoscopic view demonstrates the arch to be
anatomically repositioned and xated.
TRAUMATIC ARCH INJURY/CZERWINSKI, LEE 235
buttress and inferior orbital rim), and lateral orbital
upper blepharoplasty incisions (zygomaticofrontal but-
tress). The left arch component of the Le Fort III
fracture was dissected as a free graft and rigidly plated
on a side table, then repositioned anatomically as the
arch component of the midface fracture repair (Figs. 9
and 10).
DISCUSSION
The zygomatic arch has a consistent shape and sym-
metry. Its strategic position makes it a key surgical
landmark in facial fracture repair.
1,2
In isolated arch
fractures, its reduction restores the contour of the lateral
face. In complex zygoma fractures, it helps accurately
reduce midfacial projection and width and recreate
Figure 8 (A) Preoperative photograph of a patient who sustained a complex zygomatic fracture demonstrates reduced malar
projection and increased facial width. The increase in facial width has resulted from a laterally displaced arch. (B) This 5-month
postoperative photograph demonstrates correction of the facial deformities following four-point reduction and xation of the zygoma.
The arch component of the repair was achieved using endoscopic assistance. Refer to Figure 4 to see pre- and postoperative
radiographic images of this patient.
Figure 9 (A) Preoperative photograph of a patient with a left Le Fort III and right Le Fort II facial fractures, showing facial attening and
unstable maxillary dentition. (B) Photograph several months following the surgery. The right central incisor was electively extracted
because of preexisting periodontal disease.
236 FACIAL PLASTIC SURGERY/VOLUME 20, NUMBER 3 2004
Figure 10 (A, B) Preoperative coronal and axial computed tomography images demonstrating left Le Fort III and right Le Fort II level
fractures with severe left zygomatic arch comminution. (C, D) Postoperative computed tomography images showing accurate
restoration of the arch and dental occlusion.
TRAUMATIC ARCH INJURY/CZERWINSKI, LEE 237
preinjury bony orbital volume to position the ocular
globe properly. In Le Fort III fractures, it principally
stabilizes the midface and maxillary dentition through its
stable attachment to the cranial base. The usefulness of
arch repair increases as does the complexity of facial
injury, being most important in Le Fort III fractures and
least so in isolated arch injuries. Nevertheless, the arch
has frequently been ignored in facial fracture repair
because of the surgical access and undesirable sequelae
associated with a coronal incision.
7
Decreased scalp
sensation, facial nerve injury, excessive bleeding, scar-
ring, and alopecia have all been associated with the
traditional coronal access to repair the arch.
An endoscopic approach to the arch introduces
numerous advantages. The exposure involves small,
well-concealed incisions and direct visualized dissection.
Reduction and xation are also performed inside the
optical cavity using specialized endoscopic equipment.
This minimal access approach diminishes the problems
customarily associated with coronal arch repair.
Endoscopic arch repair also suffers from several
drawbacks. First, it requires a different set of surgical
skills. Tactile surgical feedback is impaired as all tech-
nical aspects of the endoscopic intervention are remotely
performed through limited access portals using specia-
lized equipment. Perceived visual depth in the surgical
eld is absent as the endoscopic image is projected on a
two-dimensional monitor. Second, the purchase of the
necessary surgical instruments and electronic devices
represents a signicant expense. Third, the learning
curve is steep with initial long operative times. However,
when rigid xation is undertaken the operative times for
the endoscopic arch component of repair are similar to
those with coronal access.
8
Traditional coronal access for arch repair is in-
dicated for markedly displaced isolated arch fractures,
complex zygoma fractures with arch comminution, and
Le Fort III level fractures. These are the same as the
indications for endoscope-assisted zygomatic arch repair.
We believe endoscopic arch repair should be considered
whenever traditional coronal access to the zygomatic
arch is contemplated and we encourage its use. The
initial steep learning curve can be overcome by the
institutionalization of appropriate training programs
and further advances in instrument development. In-
creased familiarity with the endoscopic procedure has
resulted in shorter and more efcient operative times.
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