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Superior Cantholysis for Zygomatic Fracture Repair

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Superior Cantholysis for Zygomatic Fracture Repair ORIGINAL ARTICLE Superior Cantholysis for Zygomatic Fracture Repair Robert W. Dolan, MD; Daniel K. Smith, MD Objective: To determine if performing a superior can- tion, and rigid fixation. It also expedites exposure and tholysis eases the surgical exposure, reduction, and rigid assessment of the sphenozygomatic suture. No postre- fixation of the zygomaticofrontal suture in the open re- duction ZMC malunions or malpositions occurred dur- pair of zygomatic complex (ZMC) fractures. ing the study. There were 4 complications, none of which could be attributed to superior cantholysis. The compli- Patients and Methods: Fifteen superior cantholysis pro- cations related primarily to the transconjunctival and lat- cedures were used in 14 patients who presented with ZMC eral canthotomy incisions. fractures requiring open reduction and internal fixation. Follow-up ranged from 6 to 18 months. Collected data in- Conclusions: Superior cantholysis eases the surgical cluded patient demographics, cause of fracture, fracture exposure, reduction, and rigid fixation of the zygomati- classification, associated facial injuries, methods of frac- cofrontal suture in the open repair of ZMC fractures. ture exposure and reduction, type and location of fixa- The superior cantholysis added no morbidity in open tion, procedure-related complications, and postoperative ZMC fracture repair, and it simplified exposure of the outcome, including adequacy of fracture reduction. lateral orbital rim, without the need for overzealous tis- sue retraction. Results: Superior cantholysis opens a direct surgical route to the zygomaticofrontal suture for exposure, reduc- Arch Facial Plast Surg. 2000;2:181-186 RADITIONAL methods of several drawbacks, including a notice- exposing the zygomatico- able scar, and a small strip of intervening frontal (ZF) suture during skin is created between the upper blepha- the repair of zygomatic roplasty and lower canthotomy incisions complex (ZMC) fractures that is prone to scar contracture. In the late Toften lead to unsightly scarring or pro- 1980s, access to the ZF suture was de- longed soft tissue swelling. Approaching scribed via the lateral canthotomy inci- the ZF suture by superior cantholysis sion alone. To expose the suture and lat- avoids these problems, while providing su- eral orbital rim, complete mobilization of perior access to the lateral orbital rim and the lateral canthal ligament (lateral reti- sphenozygomatic suture. naculum), periorbita along the lateral or- The ZF suture has traditionally been bital rim, and soft tissues over the lateral accessed through a coronal flap, an in- orbital rim is required. Although this tis- frabrow incision, lateral extension of the sue mobilization avoids an additional skin upper eyelid crease incision, or a lateral incision, exposure is more difficult than canthotomy. Although the coronal ap- with a separate skin incision, and “the proach provides wide exposure of the up- strong traction and mobilization re- per ZMC and the ZF suture, it is best re- quired result in more postoperative swell- served for severely comminuted zygomatic ing.”1 Supplementing the lateral canthal in- fractures that are combined with midfa- cision with superior cantholysis directly cial or cranial fractures. The infrabrow in- exposes the ZF suture, similar to the ex- cision is a transcutaneous approach for di- posure provided in the upper blepharo- From the Department of rect exposure of the ZF suture. It is the plasty incision, but without the added mor- Otorhinolaryngology, University most convenient and simplest method with bidity of an additional skin incision. of Oklahoma Health Science which to expose the suture, but it can lead Superior cantholysis frees the lat- Center, Oklahoma City (Dr Dolan); and the Department to obvious scarring and contour irregu- eral aspect of the upper eyelid margin to of Otolaryngology–Head and larities in the lateral and infrabrow areas. swing superiorly, directly exposing the Neck Surgery, Boston University The lateral extension of the upper eyelid ZF suture. There is no need for extensive School of Medicine, Boston, crease (blepharoplasty) incision pro- tissue retraction or mobilization of the Mass (Dr Smith). vides direct access to the ZF suture but has tissues over the lateral orbital rim. Ac- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, JULY-SEP 2000 WWW.ARCHFACIAL.COM 181 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 PATIENTS, MATERIALS, superior lateral eyelid margins is critical. The configura- tion of the palpebral slit gives the illusion that the canthi AND METHODS are on different levels with respect to the true axial plane. However, the canthi and the insertions of the canthal liga- PATIENTS AND MATERIALS ments should be on the same plane, falling directly on a true horizontal line extending across the nasion (Figure 1). Fifteen superior cantholysis procedures were used in 14 pa- The lateral aspect of the lower eyelid should gently slope tients who presented with ZMC fractures requiring open upward toward its lateral insertion, and the eyelid margin reduction and internal fixation. Follow-up ranged from 6 should appear to fold under the lateral aspect of the upper to 18 months. Collected data included patient demograph- eyelid margin (Figure 2). The lateral palpebral ligament ics, cause of fracture, fracture classification, associated fa- includes superficial and deep limbs that course from the cial injuries, methods of fracture exposure and reduction, orbital septum and lateral tarsal borders to the lateral or- type and location of fixation, procedure-related complica- bital rim. The superficial component is thin and ill de- tions, and postoperative outcome, including adequacy of fined, inserting into the fascia over the superficial aspect fracture reduction. The fractures were classified as fol- of the lateral orbital rim. The deep limbs are distinct fas- lows according to a simplified schema described by Zingg cial bands that originate at the lateral borders of the supe- et al2: type A1, isolated zygomatic arch fracture; type A2, rior and inferior tarsal plates and insert onto the medial as- isolated lateral orbital wall fracture; type A3, isolated in- pect of the lateral orbital rim at Whitnall tubercle. Whitnall fraorbital rim fracture; type B, tetrapod fracture; and type tubercle is located approximately 4 mm deep to the lateral C, multifragmented ZMC fracture. orbital rim and 9 mm inferior to the ZF suture.3 SURGICAL TECHNIQUES Transconjunctival Approach With Lateral Canthotomy Anatomy A corneal shield (crescent-shaped plastic or metal conform- ing cup) was placed and later supplanted by pulling the in- Zygomatic complex fractures involve at least 4 skeletal dis- feriorly based conjunctivocapsulopalpebral flap over the cor- ruptions, including the sphenozygomatic suture, inferior neal surface using traction sutures. Loop magnification was orbital rim and floor, ZF suture, and zygomaticomaxillary helpful to accurately identify the layers of the lower eyelid. suture. To perform the superior canthal approaches in a By dissecting anterior to the orbital septum (preseptal ap- safe manner and to mobilize the lateral retinaculum, a thor- proach) after traversing the capsulopalpebral fascia, pro- ough understanding of the relevant anatomy is essential for lapse of orbital fat into the wound was avoided. Avoidance maximizing surgical exposure, while minimizing the risk of orbital fat was helpful to maximize the surgical exposure of injury to adjacent structures. An appreciation of the sur- and to prevent inadvertent injury to the inferior oblique face anatomy regarding the relationship of the inferior and muscle, which may be obscured by prolapsing fat. 1/3 1/3 1/3 Figure 1. The lateral palpebral commissures should fall within 2 mm of a horizontal line that passes through the medial palpebral commissures. Figure 2. Note that the lower eyelid margin appears to fold under the lateral extent of the upper eyelid margin. Meticulous reposition of the lower lateral cess to the lateral orbit and sphenozygomatic suture is canthal tendon should re-create this configuration. facilitated. Herein, we describe the technique, applica- tion, and results of superior cantholysis in a consecu- tive series of 14 patients with ZMC fractures requiring the orbital floor, complications, cause of fracture, par- open reduction. ity, and associated facial injuries are shown in the Table. All the fractures were rigidly fixed with 1.7 miniplates RESULTS over the ZF suture using at least 2 screws on each side of the fracture line. The inferior orbital rim was fixed by The study included 12 male and 2 female patients (me- either wire osteosynthesis (patient 9) or a 1.3 miniplate dian age, 35 years). Treatment date, patient age and sex, using at least 2 screws on either side of the fracture line. fracture classification, surgical approaches, treatment of Gel film was placed over the orbital floor in all but 3 pa- (REPRINTED) ARCH FACIAL PLAST SURG/ VOL 2, JULY-SEP 2000 WWW.ARCHFACIAL.COM 182 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 In preparation for the preseptal approach to the or- the midportion of the exposed tendon, 4-0 nonabsorbable bital floor, the surgeon stood at the head of the operating sutures were passed and held away with hemostats, and the table and everted the patient’s lower eyelid to view the in- tendon was cut between the sutures (Figure
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