Fractures of the ZMC or zygomatic arch can often lead to unsightly malar depression, which should be corrected to restore a normal facial contour. The indications for operative management of zygomatic arch and ZMC fractures are to restore the form and function of the ZMC. If prescribed, antibiotics should cover sinonasal flora. No strong evidence supports the use of prophylactic antibiotics in upper and midface fractures, though some surgeons prescribe a 5 to 7-day course of antibiotics, particularly if a communication exists with the maxillary sinus. Additionally, medical management may be the choice if other comorbidities preclude safe surgery. Zygomatic fractures are usually observable if there is minimal or no displacement of fracture segments. Management of ZMC fractures is controversial and requires tailoring to each case. Management of ZMC fractures can broadly classify into three categories: medical management, closed reduction, and open reduction with internal fixation (ORIF). A comprehensive cranial nerve examination should be completed, paying special attention to facial movement and sensation. The face should be palpated, noting any bony step-offs or mobility of the underlying craniofacial skeleton. Enophthalmos may be visible from a worms-eye view. The clinician should note the position of the globe. In a patient with a ZMC injury, the facial flattening may be apparent from a birds-eye view, which is caused by depression of the malar eminence however, the facial flattening may get obscured by overlying soft tissue edema. An ophthalmologic exam should be performed, including visual acuity, visual fields, and extraocular movements. Ipsilateral epistaxis is common and requires controlling if severe. Inspect the face, noting any obvious asymmetry, lacerations, and ecchymosis of the skin. It is also vitally important to "clear" the cervical spine for any associated injury. One should ask about prior facial trauma or facial surgeries, which may make fracture repair more difficult.Īs with any trauma patient, it is important to start the examination with an evaluation of the "ABCs." Ensure the patient has an adequate airway, is breathing spontaneously, and that any bleeding is under control. Note whether the injury was caused by blunt or penetrating trauma, as penetrating trauma is more likely to involve deeper-lying neurovascular structures. It is crucial to ascertain the mechanism and timing of the injury. Tubercle of Whitnall: The attachment site of the lateral canthal tendon located on the medial surface of the frontal process of the zygoma. The zygomaticus major and minor are muscles of facial expression that originate on the zygoma and insert near the corner of the mouth to assist with commissure elevation. The masseter originates on the inferior aspect of the zygoma and zygomatic arch and inserts on the angle of the mandible. The temporalis originates along the temporal line of the parietal and frontal bones and travels medially to the zygomatic arch to insert on the coronoid process of the mandible. The frontal branch then transitions to the undersurface of the temporoparietal fascia where it travels to innervate the frontalis muscle. The facial nerve's frontal branch emerges from the parotid gland within the parotid-masseteric fascia and crosses superficial to the zygomatic arch in the innominate fascia deep to the superficial muscular aponeurotic system (SMAS). Severe ZMC fractures may also result in ipsilateral facial palsy since the facial nerve is intimately associated with the zygomatic arch. The zygomaticofacial and zygomaticotemporal branches then exit via identically named foramina in the zygoma. They are branches of the zygomatic nerve, which arises in the pterygopalatine fossa and enters the orbit via the inferior orbital fissure, and travels along the lateral orbital wall. The zygomaticofacial and zygomaticotemporal nerves transmit sensory input from the lateral cheek and anterior temporal area, respectively.
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