Letters
RESEARCH LETTER Results | There were 22 patients identified as having ZMC
Zygomaticomaxillary Complex–Orbit Fracture
Alignment: Comparison of Buccal and Orbital
Approach Techniques
Zygomaticomaxillary complex (ZMC) fractures are one of the
most common fractures seen as a result of trauma to the mid-
facial region.1,2 Fracture patterns in this area often involve the
inferior orbital rim (IOR) and the orbital floor (OF). Tradition-
ally, the maxillary fractures are accessed via sublabial inci-
sions, 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 Uni-
versity 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 frac-
ture alignment at the orbital rim for both groups was
assessed by reviewing the images of preoperative and post-
operative 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 left B Isolation of infraorbital nerve
sublabial incision
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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 tomo-
graphic (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.
Discussion | Repair of ZMC fractures requires restoration of the
maxillofacial buttresses supporting the midface via an infra-
orbital, 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 pri-
mary outcomes. There was a higher incidence of preopera-
tive numbness in group 2 than in group 1. Using the sublabial
approach, there is the possibility of neuropraxic injury to the
C Placement of fixation hardware
A, Exposure of fracture through left
sublabial incision. B, Isolation of
infraorbital nerve. C, Placement of
fixation hardware.
(Reprinted) JAMA Facial Plastic Surgery Published online May 17, 2018 E1
 Letters

Meryam A. Shikara, BA
Table. Demographics, Causes of Fracture,
and Surgical Outcomes in 17 Study Patientsa Kalpesh T. Vakharia, MD
Jewel D. Greywoode, MD
Group 1 Group 2
Characteristic (n = 10) (n = 7)
Demographics Author Affiliations: Department of Otorhinolaryngology–Head and Neck
Surgery, University of Maryland School of Medicine, Baltimore (Shikara,
Age, mean [range], y 31 [19-77] 38 [21-81] Vakharia, Greywoode); University of Maryland Medical Center, Baltimore
Male 8 5 (Shikara, Vakharia, Greywoode); University of Maryland Shock Trauma Center,
Cause of damage Baltimore (Vakharia, Greywoode).

Assault 3 3 Accepted for Publication: March 13, 2018.

Fall 0 4 Corresponding Author: Jewel D. Greywoode, MD, University of Maryland, 16 S

Eutaw St, Ste 500, Baltimore, MD 21201 (jgreywoode@som.umaryland.edu).
Motor vehicle collision 5 0
Published Online: May 17, 2018. doi:10.1001/jamafacial.2018.0411
Sports related 2 0
Author Contributions: Dr Greywoode had full access to all of the data in the
Type of orbital repair study and takes responsibility for the integrity of the data and the accuracy of
Rim repaired 10 5 the data analysis.
Floor repaired NA 5 Study concept and design: Vakharia, Greywoode.
Acquisition, analysis, or interpretation of data: All authors.
Rim and orbital floor repaired NA 3 Drafting of the manuscript: Shikara, Greywoode.
Surgical outcomes Critical revision of the manuscript for important intellectual content: All authors.
Follow-up, mean, mo 2.4 2.0 Statistical analysis: Greywoode.
Administrative, technical, or material support: All authors.
Satisfactory orbital rim plate position 10 of 10 5 of 5 Study supervision: Vakharia, Greywoode.
(CT interpretation)
Conflict of Interest Disclosures: None reported.
Preoperative numbness 5 6
Meeting Presentation: This work was presented at the Combined
Resolution of numbness at last visit 3 2
Otolaryngology Spring Meeting; April 26-30, 2017; San Diego, California.
Eyelid malposition 0 0
1. de Souza Carvalho ACG, Pereira CCS, Queiroz TP, Magro-Filho O. Intraoral
Complications 1 1 approach to zygomatic fracture: modified technique for infraorbital rim fixation.
J Craniofac Surg. 2012;23(2):537-538. doi:10.1097/SCS.0b013e3182418ea6
Abbreviation: CT, computed tomography; NA, not applicable.
a
Data are given as numbers of patients except where noted. 2. Boffano P, Roccia F, Zavattero E, et al. Assault-related maxillofacial injuries:
the results from the European Maxillofacial Trauma (EURMAT) multicenter and
prospective collaboration. Oral Surg Oral Med Oral Pathol Oral Radiol. 2015;119
infraorbital nerve. However, in our patient population, there (4):385-391. doi:10.1016/j.oooo.2014.12.004
was recovery of sensation by the 6-month follow-up. This sug- 3. Wilson S, Ellis E III. Surgical approaches to the infraorbital rim and orbital
gests that the buccal approach provided satisfactory out- floor: the case for the subtarsal approach. J Oral Maxillofac Surg. 2006;64(1):
104-107. doi:10.1016/j.joms.2005.09.018
comes with no additional morbidity or injury to the eye struc-
4. Farber SJ, Nguyen DC, Skolnick GB, Woo AS, Patel KB. Current management
tures, as well as resolution of the preoperative numbness. There
of zygomaticomaxillary complex fractures: a multidisciplinary survey and
were no other major complications reported for the sublabial literature review. Craniomaxillofac Trauma Reconstr. 2016;9(4):313-322.
approach. doi:10.1055/s-0036-1592093

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