Abstract
This study proposes the use of a sublabial incision without a lower eyelid incision to address zygomaticomaxillary complex fractures involving the orbital rim.
Zygomaticomaxillary complex (ZMC) fractures are one of the most common fractures seen as a result of trauma to the midfacial region.1,2 Fracture patterns in this area often involve the inferior orbital rim (IOR) and the orbital floor (OF). Traditionally, the maxillary fractures are accessed via sublabial incisions, and the periorbital fractures are accessed via eyelid incisions.3 However, in cases that do not involve the orbital floor but do involve the orbital rim, using a transconjunctival approach or a transcutaneous eyelid incision may place the lower eyelid structures at risk for potential complications. We propose the use of a sublabial incision without a lower eyelid incision to address ZMC fractures involving the orbital rim. We believe that this is an effective alternative which avoids unwanted complications involving the orbit and minimizes morbidity.
Methods
The surgical technique for repairing ZMC fractures with orbital rim involvement via a sublabial approach is described in the Figure. This medical record review study was approved by the institutional review board at the University of Maryland School of Medicine. We reviewed the medical records of patients at the University of Maryland Shock Trauma Center and University of Maryland Medical Center, who underwent surgical repair of ZMC fractures between July 2012 and April 2016. The postoperative fracture alignment at the orbital rim for both groups was assessed by reviewing the images of preoperative and postoperative computed tomographic (CT) scans by the primary surgeons, and confirmed by the radiologist interpretation. Each patient consented to repair of their fracture in the operating room. They were not compensated for their participation.
Figure. Transoral Surgical Procedure.
A, Exposure of fracture through a left sublabial incision. B, Isolation of the infraorbital nerve. C, Placement of fixation hardware.
Results
There were 22 patients identified as having ZMC fractures, with or without orbital rim involvement, repaired by the otorhinolaryngology service between July 2012 and April 2016. Five patients were excluded because they did not have any OF or IOR fracture. Of the remaining 17 patients, group 1 consisted of 10 patients with ZMC fractures that involved the orbital rim, which were repaired using only a sublabial approach without a lower eyelid incision (8 of the 10 were men; age range, 19-77 years). Group 2 included 7 patients with repair of ZMC and OF/IOR via a combined intraoral-transorbital approach (5 of the 7 were men; age range, 21-81 years). Most patients were male in both groups. Group 1 patients were younger than those in group 2 patients (mean age, 31 vs 38 years). There was a higher incidence of motor vehicle collisions (MVC) and sports-related injuries in group 1.
In both groups, inferior orbital rim plate position was confirmed to be satisfactory in all patients (Table). This was based on reviewing postoperative axial computed tomographic (CT) scans by the surgeon and confirming this with the radiologist interpretation. By the 6-month follow-up, 3 of 5 patients (60%) in group 1 and 2 of 6 patients (33%) in group 2 had resolution of their documented preoperative numbness. There was 1 complication in each group—a patient with a persistent, depressed zygomatic arch fracture in group 1, and a patient requiring repositioning of the orbital floor plate in group 2.
Table. Demographics, Causes of Fracture, and Surgical Outcomes in 17 Study Patientsa.
| Characteristic | Group 1 (n = 10) | Group 2 (n = 7) |
|---|---|---|
| Demographics | ||
| Age, mean [range], y | 31 [19-77] | 38 [21-81] |
| Male | 8 | 5 |
| Cause of damage | ||
| Assault | 3 | 3 |
| Fall | 0 | 4 |
| Motor vehicle collision | 5 | 0 |
| Sports related | 2 | 0 |
| Type of orbital repair | ||
| Rim repaired | 10 | 5 |
| Floor repaired | NA | 5 |
| Rim and orbital floor repaired | NA | 3 |
| Surgical outcomes | ||
| Follow-up, mean, mo | 2.4 | 2.0 |
| Satisfactory orbital rim plate position (CT interpretation) | 10 of 10 | 5 of 5 |
| Preoperative numbness | 5 | 6 |
| Resolution of numbness at last visit | 3 | 2 |
| Eyelid malposition | 0 | 0 |
| Complications | 1 | 1 |
Abbreviation: CT, computed tomography; NA, not applicable.
Data are given as numbers of patients except where noted.
Discussion
Repair of ZMC fractures requires restoration of the maxillofacial buttresses supporting the midface via an infraorbital, subciliary, or transconjunctival approach. There is no consensus in the literature as to which approach provides the best results.4 Our study examined both satisfactory orbital plate placement and infraorbital nerve distribution numbness as primary outcomes. There was a higher incidence of preoperative numbness in group 2 than in group 1. Using the sublabial approach, there is the possibility of neuropraxic injury to the infraorbital nerve. However, in our patient population, there was recovery of sensation by the 6-month follow-up. This suggests that the buccal approach provided satisfactory outcomes with no additional morbidity or injury to the eye structures, as well as resolution of the preoperative numbness. There were no other major complications reported for the sublabial approach.
References
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