Correspondence
The Journal of Craniofacial Surgery
fillers through this cannula, and there are less injection pain and less edema and bruising than with needles. Finally, multiple punctures are unnecessary. In literature, nothing has been written about the advantages or disadvantages in facial wasting rehabilitation with polyacrylamide hydrogel injected with microcannula. An interesting article was published by Pallua and Wolter3 regarding risk in polyacrylamide hydrogel injections for cosmetic purpose, but subjectively they stated that the risk of having an adverse event increases with increasing numbers of injections; as serious adverse events are likely to be caused by bacterial infection, the more times the skin is pierced, the higher the risk of bacterial contamination, so the use of a blunt cannula, performing only 2 accesses per side to inject the filler, theoretically is safer than the use of needles. In our experience in facial wasting rehabilitation with polyacrylamide hydrogel, we both have used needle and microcannula, but reviewing retrospectively our complications in term of infections or migrations of the product, ecchymosis development, and number of filling session required to fulfill facial rehabilitation, no statistic differences were found; we only noted, regarding the use of microcannula, a slightly higher percentage of nodules due to product accumulation. Because these cannulas are bigger than needles, and because of the larger hole of the cannula, there is little back pressure on the syringe, requiring less effort and making the injection more fluid and faster than pushing a gel through a needle; this can explain why a slightly high percentage of nodules were recorded with the use of microcannula. The worst complication in the use of a nonabsorbable filler is the infection4; it can be easily avoided if asepsis rules are followed. From our point of view, infection is not due to the number of injections as hypothesized by Pallua and Wolter.3 We think that the most important thing in using a nonresorbable filler is to follow asepsis rules, as we are using a ‘‘solid prosthesis’’ (such as a breast or a malar implant, etc). Several articles are reported in nonabsorbable filler usefulness and complications,5Y8 but no one underlines the importance in following asepsis rules. From our experience, asepsis has a key role in avoiding complications with nonabsorbable fillers in facial wasting rehabilitation9 and consequently in noninfected patients too. Raffaele Rauso, MD Univeristy of Foggia, Foggia and Plastic Surgery Department ‘‘La Sapienza’’ University Rome, Italy Centro Polispecialistico Santa Apollonia Santa Maria Capua Vetere Caserta, Italy dr.raffaele. [email protected] Giuseppe Colella, MD, DDS Head & Neck Department Second University of Naples Naples, Italy Vincenzo Parlato, MD Second University of Naples Naples, Italy Gianpaolo Tartaro, MD Head & Neck Department Second University of Naples, Naples and Centro Polispecialistico Santa Apollonia Santa Maria Capua Vetere Caserta, Italy
1130
& Volume 25, Number 3, May 2014 REFERENCES
1. Gervasoni C, Ridolfo AL, Trifiro G, et al. Redistribution of body fat in HIV-infected women undergoing combined antiretroviral therapy. AIDS 1999;13:465Y471 2. Niamtu J III. Filler injection with micro-cannula instead of needles. Dermatol Surg 2009;35:2005Y2008 3. Pallua N, Wolter TP. A 5-years assessment of safety and aesthetic results after facial soft-tissue augmentation with polyacrylamide hydrogel (Aquamid): a prospective multicenter study of 251 patients. Plast Reconstr Surg 2010;125:1797Y1804 4. Christensen LC, Breiting V, Janssen M, et al. Adverse reaction to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005;29:34 5. de Santis G, Jacob V, Baccarani A, et al. Polyacrylamide hydrogel injection in the management of human immunodeficiency virusYrelated facial lipoatrophy: a 2 year clinical experience. Plast Reconstr Surg 2008;121:644Y653 6. Rauso R, Freda N, Parlato V, et al. Polyacrylamide gel injection for treatment of human immunodeficiency virus-associated facial lipoatrophy: 18 months follow-up. Dermatol Surg 2011;37:1584Y1589 7. Karim RB, de Lint CA, van Galen SR, et al. Long-term effect of polyalkylimide gel injections on severity of facial lipoatrophy and quality of life of HIV-positive patients. Aesthetic Plast Surg 2008;32:873Y878 8. Ho¨nig J. Cheek augmentation with Bio-Alcamid in facial lipoatrophy in HIV seropositive patients. J Craniofac Surg 2008;19:1085Y1088 9. Rauso R, Gherardini G, Parlato V, et al. Polyacrylamide gel for facial wasting rehabilitation: how many milliliters per session? Aesthetic Plast Surg 2012;36:174Y176
Closed Management by Ginestet Hook Elevator of V-Shaped Fractures of the Zygomatic Arch To the Editor: Isolated fractures of the zygomatic arch constitute about 10% of all zygomatic fractures.1Y19 Such high incidence is related to the prominent position of the zygoma within the facial skeleton, which exposes it to traumatic forces.2 The zygomatic arch plays an important role in the face structure both aesthetically and functionally.2 In fact, depressed fractures of the zygomatic arch generally determine an obstruction of the movement of the condyle and/or the coronoid process of the mandible, thus limiting the opening or the closure of the mouth.3 Therefore, proper diagnosis and adequate treatment of zygomatic arch fractures to restore preinjury function and appearance are fundamental for the patient’s quality of life.2 Several open and closed techniques have been described to reduce zygomatic arch fractures.1Y8 The position of the fragment is usually confirmed by palpation or radiography during operation.1Y8 However, there is no consensus about the most appropriate technique for the reduction of isolated zygomatic arch fracture. Therefore, the aim of this study was to present and discuss our experience in the management of a specific type of zygomatic arch fracture by the Ginestet hook percutaneous technique. This study is based on a systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures in the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin, Italy, between January 1, 2001, and January 1, 2010. * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Correspondence
TABLE 1. Etiology of Zygomatic Arch Fractures
Assaults Sport accidents Motor vehicle accidents Fall Bicycle accidents Other Total
Patients
%
35 23 22 23 8 2 113
30.9 20.3 19.6 20.3 7.1 1.8 100
Only patients who underwent surgical closed treatment for class I zygomatic arch fractures (isolated tripod fracture) according to Ho¨nig classification10 or V-shaped fracture (I-B-D type) according to Ozyazgan classification11 were considered for this study. Incomplete patient charts were excluded from this study. The used Ginestet technique consisted of the following: after a punctiform incision on the skin, at the level of the lower border of the zygomatic arch, the Ginestet elevator is introduced, and the bone is pulled outward and upward. The following data for the injured patients were considered: sex, age, site and severity (Facial Injury Severity Scale) of facial fractures, etiology, and decreased mouth opening. Patients with other fractures of the middle third were excluded from this study. Preoperative and postoperative radiographic images were retrieved for 96 patients, and they were assessed. Statistical analysis was used to search for associations among multiple variables. Statistical significance was determined using the W2 or Fisher exact test, if the sample sizes were too small. This study was exempt from institutional review board approval as a retrospective study. We followed Helsinki Declaration guidelines. During the considered time frame, 1818 patients with maxillofacial fractures were admitted to the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin. On the whole, 113 patients (96 males, 17 females) with treated displaced zygomatic arch fractures were included. The mean age of the patients was 39.5 (SD, 14.2) years (range, 16Y74 years; median, 37 years). The most common causes of zygomatic arch fractures were assaults (30.9%), followed by sport accidents (20.3%) and falls (20.3%) (Table 1). The mean Facial Injury Severity Scale score in the study population was 1 (SD, 0.48) (range, 1Y5; median, 1). As for symptoms, 21 patients demonstrated limitation of mouth opening, which was the most frequent symptom after obvious swelling in correspondence of the fractured zygomatic arch. As for
FIGURE 1. Patient 1. Preoperative CT scan showing the fracture of the left zygomatic arch.
FIGURE 2. Patient 1. Appropriate and correct reduction at postoperative radiograph.
etiology, no statistically significant associations were found between limitation of mouth opening and causes of fractures. The assessment of preoperative and postoperative radiographic images allowed obtaining a correct reduction in 91 of 96 patients (Figs. 1 and 2), whereas in 4 cases a further intervention of closed reduction was needed. In the remaining case, an open surgical treatment was decided to appropriately reduce the fracture after the first unsuccessful attempt (Figs. 3Y4). Fractures of the zygomatic arch are usually treated by closed techniques. As the fracture lines cannot be visualized directly during closed reduction, digital exploration and crepitus noise or conventional radiographic imaging are used as a guide to reposition the fragments.3 Although several authors suggest that such techniques may often determine an unsatisfactory reduction, in the authors’ experience, closed reductions may still play a role, in particular when the structures of the hospital do not allow an intraoperative radiographic check. In fact, it is clear that digital exploration and crepitus have the disadvantage that successful reductions are often difficult to evaluate clinically because of the great amount of swelling that often accompanies
FIGURE 3. Patient 2. Preoperative CT scan showing the fracture of the right zygomatic arch.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1131
Correspondence
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014 Fabio Roccia, MD Cesare Gallesio, MD, DDS Division of Maxillofacial Surgery Head and Neck Department San Giovanni Battista Hospital University of Turin Turin, Italy
K. Hakki Karagozoglu, MD, DDS Tymour Forouzanfar, MD, DDS Department of Oral and Maxillofacial Surgery/Oral Pathology Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam Amsterdam, The Netherlands
REFERENCES
FIGURE 4. Patient 2. Postoperative radiograph showing an unsuccessful attempt to reduce the fracture.
these fractures. However, not every hospital can afford the use of intraoperative computed tomography (CT) scan or C-arm during maxillofacial surgery interventions.3,12Y15 In such conditions, a traditional technique such as the closed reduction by Ginestet hook maneuver may still be fundamental and should remain in the armamentarium of the maxillofacial surgeon. After a reassessment of the inappropriately reduced cases, we became aware that the unsuccessful outcome was associated with an excessively posterior positioning of the hook near the temporal bone, which has determined a clear increase of the displacement of the fragments in the case presented in Figures 3 and 4. Thus, it is important to remember that a correct positioning of the hook is extremely important before performing the reduction of the fracture. It should be remembered that in several cases of zygomatic arch fractures, the surgical reduction alone of the fractures is not enough as a definitive treatment. In fact, because of the movement of fragments, it is indispensable to have a complementary treatment aimed at the stabilization and fixation of the arch in the correct position until the conclusion of the calcification process.16 However, we believe that an appropriate reduction for class I zygomatic arch fractures (isolated tripod fracture) according to Ho¨nig classification10 or V-shaped fracture (I-B-D type) according to Ozyazgan classification11 could still be sufficient. Finally, it is important to remember that some patients may be willing to exchange a bit of asymmetry for avoidance of surgery.16 The Ginestet surgical technique allows limiting anesthesia to intravenous sedation, and it also allows avoiding surgical incisions. In conclusion, the management of zygomatic arch fractures is crucial to restore the pretrauma facial contour and mandibular function. The ultimate goal of the treatment is to obtain a result that can be considered acceptable by the patient by the least invasive surgical technique. To this aim, Ginestet technique can still be considered, and it should remain in the armamentarium of the maxillofacial surgeon. Paolo Boffano, MD Erik G. Salentijn, MD, DDS Department of Oral and Maxillofacial Surgery/Oral Pathology Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam Amsterdam, The Netherlands
1132
1. de Santana Santos T, da Rocha Neto AM, Medeiros R Jr, et al. Treatment of zygomatic arch fracture with lag screws. J Craniofac Surg 2011;22:1468Y1470 2. Krishnan B, El Sheikh MH. Dental forceps reduction of depressed zygomatic arch fractures. J Craniofac Surg 2008;19:782Y784 3. Badjate SJ, Cariappa KM. C-Arm for accurate reduction of zygomatic arch fractureYa case report. Br Dent J 2005;199:275Y277 4. Bezuhly M, Lalonde J, Alqahtani M, et al. Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: long-term quantitative outcomes. Plast Reconstr Surg 2008;121:948Y955 5. Camilleri AC, Gilhooly M, Cooke ME. Stabilisation of the unstable fractured zygomatic arch with a Kirschner wire. Br J Oral Maxillofac Surg 2005;43:183Y184 6. Carter TG, Bagheri S, Dierks EJ. Towel clip reduction of the depressed zygomatic arch fracture. J Oral Maxillofac Surg 2005;63: 1244Y1246 7. Chatziavramidis A, Kynigou M. Reduction of fractures of the zygomatic arch using a finger. Br J Oral Maxillofac Surg 2009;47:490Y491 8. Chin SH, Chicarilli ZN, Narayan D. Alloderm stabilization of zygomatic arch fractures. J Craniofac Surg 2006;17:403Y404 9. El-Hadidy AM. The use of a Foley catheter in isolated zygomatic arch fractures. Plast Reconstr Surg 2005;116:853Y856 10. Ho¨nig JF, Merten HA. Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg 2004;15:986Y989 11. Ozyazgan I, Gu¨nay GK, Eskitaz0ioglu T, et al. A new proposal of classification of zygomatic arch fractures. J Oral Maxillofac Surg 2007;65:462Y469 12. Chen RF, Chen CT, Hao Chen C, et al. Optimizing closed reduction of nasal and zygomatic arch fractures with a mobile fluoroscan. Plast Reconstr Surg. 2010;126:554Y563 13. Czerwinski M, Parker WL, Beckman L, et al. Rapid intraoperative zygoma fracture imaging. Plast Reconstr Surg. 2009;124:888Y898 14. Imai T, Michizawa M, Fujita G, et al. C-arm-guided reduction of zygomatic fractures revisited. J Trauma 2011;71:1371Y1375 15. Ramanoojam S, Gadre P, Shah S, et al. Assessment of the adequacy of closed reduction in fractures of the zygomatic arch using ‘‘C’’-arm image intensifier. J Craniofac Surg 2011;22:1383Y1386 16. Evans BG, Evans GR. MOC-PSSM CME article: zygomatic fractures. Plast Reconstr Surg 2008;121(1 suppl):1Y11 17. Boffano P, Roccia F, Gallesio C, et al. Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:275Y280 18. Roccia F, Bianchi FA, Zavattero E, et al. Etiology and patterns of facial lacerations and their possible association with underlying maxillofacial fractures. J Craniofac Surg 2011;22:e19Ye23 19. Roccia F, Boffano P, Bianchi FA, et al. Maxillofacial injuries due to work-related accidents in the North West of Italy. 2013;17:181Y186
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
fillers through this cannula, and there are less injection pain and less edema and bruising than with needles. Finally, multiple punctures are unnecessary. In literature, nothing has been written about the advantages or disadvantages in facial wasting rehabilitation with polyacrylamide hydrogel injected with microcannula. An interesting article was published by Pallua and Wolter3 regarding risk in polyacrylamide hydrogel injections for cosmetic purpose, but subjectively they stated that the risk of having an adverse event increases with increasing numbers of injections; as serious adverse events are likely to be caused by bacterial infection, the more times the skin is pierced, the higher the risk of bacterial contamination, so the use of a blunt cannula, performing only 2 accesses per side to inject the filler, theoretically is safer than the use of needles. In our experience in facial wasting rehabilitation with polyacrylamide hydrogel, we both have used needle and microcannula, but reviewing retrospectively our complications in term of infections or migrations of the product, ecchymosis development, and number of filling session required to fulfill facial rehabilitation, no statistic differences were found; we only noted, regarding the use of microcannula, a slightly higher percentage of nodules due to product accumulation. Because these cannulas are bigger than needles, and because of the larger hole of the cannula, there is little back pressure on the syringe, requiring less effort and making the injection more fluid and faster than pushing a gel through a needle; this can explain why a slightly high percentage of nodules were recorded with the use of microcannula. The worst complication in the use of a nonabsorbable filler is the infection4; it can be easily avoided if asepsis rules are followed. From our point of view, infection is not due to the number of injections as hypothesized by Pallua and Wolter.3 We think that the most important thing in using a nonresorbable filler is to follow asepsis rules, as we are using a ‘‘solid prosthesis’’ (such as a breast or a malar implant, etc). Several articles are reported in nonabsorbable filler usefulness and complications,5Y8 but no one underlines the importance in following asepsis rules. From our experience, asepsis has a key role in avoiding complications with nonabsorbable fillers in facial wasting rehabilitation9 and consequently in noninfected patients too. Raffaele Rauso, MD Univeristy of Foggia, Foggia and Plastic Surgery Department ‘‘La Sapienza’’ University Rome, Italy Centro Polispecialistico Santa Apollonia Santa Maria Capua Vetere Caserta, Italy dr.raffaele. [email protected] Giuseppe Colella, MD, DDS Head & Neck Department Second University of Naples Naples, Italy Vincenzo Parlato, MD Second University of Naples Naples, Italy Gianpaolo Tartaro, MD Head & Neck Department Second University of Naples, Naples and Centro Polispecialistico Santa Apollonia Santa Maria Capua Vetere Caserta, Italy
1130
& Volume 25, Number 3, May 2014 REFERENCES
1. Gervasoni C, Ridolfo AL, Trifiro G, et al. Redistribution of body fat in HIV-infected women undergoing combined antiretroviral therapy. AIDS 1999;13:465Y471 2. Niamtu J III. Filler injection with micro-cannula instead of needles. Dermatol Surg 2009;35:2005Y2008 3. Pallua N, Wolter TP. A 5-years assessment of safety and aesthetic results after facial soft-tissue augmentation with polyacrylamide hydrogel (Aquamid): a prospective multicenter study of 251 patients. Plast Reconstr Surg 2010;125:1797Y1804 4. Christensen LC, Breiting V, Janssen M, et al. Adverse reaction to injectable soft tissue permanent fillers. Aesthetic Plast Surg 2005;29:34 5. de Santis G, Jacob V, Baccarani A, et al. Polyacrylamide hydrogel injection in the management of human immunodeficiency virusYrelated facial lipoatrophy: a 2 year clinical experience. Plast Reconstr Surg 2008;121:644Y653 6. Rauso R, Freda N, Parlato V, et al. Polyacrylamide gel injection for treatment of human immunodeficiency virus-associated facial lipoatrophy: 18 months follow-up. Dermatol Surg 2011;37:1584Y1589 7. Karim RB, de Lint CA, van Galen SR, et al. Long-term effect of polyalkylimide gel injections on severity of facial lipoatrophy and quality of life of HIV-positive patients. Aesthetic Plast Surg 2008;32:873Y878 8. Ho¨nig J. Cheek augmentation with Bio-Alcamid in facial lipoatrophy in HIV seropositive patients. J Craniofac Surg 2008;19:1085Y1088 9. Rauso R, Gherardini G, Parlato V, et al. Polyacrylamide gel for facial wasting rehabilitation: how many milliliters per session? Aesthetic Plast Surg 2012;36:174Y176
Closed Management by Ginestet Hook Elevator of V-Shaped Fractures of the Zygomatic Arch To the Editor: Isolated fractures of the zygomatic arch constitute about 10% of all zygomatic fractures.1Y19 Such high incidence is related to the prominent position of the zygoma within the facial skeleton, which exposes it to traumatic forces.2 The zygomatic arch plays an important role in the face structure both aesthetically and functionally.2 In fact, depressed fractures of the zygomatic arch generally determine an obstruction of the movement of the condyle and/or the coronoid process of the mandible, thus limiting the opening or the closure of the mouth.3 Therefore, proper diagnosis and adequate treatment of zygomatic arch fractures to restore preinjury function and appearance are fundamental for the patient’s quality of life.2 Several open and closed techniques have been described to reduce zygomatic arch fractures.1Y8 The position of the fragment is usually confirmed by palpation or radiography during operation.1Y8 However, there is no consensus about the most appropriate technique for the reduction of isolated zygomatic arch fracture. Therefore, the aim of this study was to present and discuss our experience in the management of a specific type of zygomatic arch fracture by the Ginestet hook percutaneous technique. This study is based on a systematic computer-assisted databases that have continuously recorded patients hospitalized with maxillofacial fractures in the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin, Italy, between January 1, 2001, and January 1, 2010. * 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014
Correspondence
TABLE 1. Etiology of Zygomatic Arch Fractures
Assaults Sport accidents Motor vehicle accidents Fall Bicycle accidents Other Total
Patients
%
35 23 22 23 8 2 113
30.9 20.3 19.6 20.3 7.1 1.8 100
Only patients who underwent surgical closed treatment for class I zygomatic arch fractures (isolated tripod fracture) according to Ho¨nig classification10 or V-shaped fracture (I-B-D type) according to Ozyazgan classification11 were considered for this study. Incomplete patient charts were excluded from this study. The used Ginestet technique consisted of the following: after a punctiform incision on the skin, at the level of the lower border of the zygomatic arch, the Ginestet elevator is introduced, and the bone is pulled outward and upward. The following data for the injured patients were considered: sex, age, site and severity (Facial Injury Severity Scale) of facial fractures, etiology, and decreased mouth opening. Patients with other fractures of the middle third were excluded from this study. Preoperative and postoperative radiographic images were retrieved for 96 patients, and they were assessed. Statistical analysis was used to search for associations among multiple variables. Statistical significance was determined using the W2 or Fisher exact test, if the sample sizes were too small. This study was exempt from institutional review board approval as a retrospective study. We followed Helsinki Declaration guidelines. During the considered time frame, 1818 patients with maxillofacial fractures were admitted to the Division of Maxillofacial Surgery, San Giovanni Battista Hospital, Turin. On the whole, 113 patients (96 males, 17 females) with treated displaced zygomatic arch fractures were included. The mean age of the patients was 39.5 (SD, 14.2) years (range, 16Y74 years; median, 37 years). The most common causes of zygomatic arch fractures were assaults (30.9%), followed by sport accidents (20.3%) and falls (20.3%) (Table 1). The mean Facial Injury Severity Scale score in the study population was 1 (SD, 0.48) (range, 1Y5; median, 1). As for symptoms, 21 patients demonstrated limitation of mouth opening, which was the most frequent symptom after obvious swelling in correspondence of the fractured zygomatic arch. As for
FIGURE 1. Patient 1. Preoperative CT scan showing the fracture of the left zygomatic arch.
FIGURE 2. Patient 1. Appropriate and correct reduction at postoperative radiograph.
etiology, no statistically significant associations were found between limitation of mouth opening and causes of fractures. The assessment of preoperative and postoperative radiographic images allowed obtaining a correct reduction in 91 of 96 patients (Figs. 1 and 2), whereas in 4 cases a further intervention of closed reduction was needed. In the remaining case, an open surgical treatment was decided to appropriately reduce the fracture after the first unsuccessful attempt (Figs. 3Y4). Fractures of the zygomatic arch are usually treated by closed techniques. As the fracture lines cannot be visualized directly during closed reduction, digital exploration and crepitus noise or conventional radiographic imaging are used as a guide to reposition the fragments.3 Although several authors suggest that such techniques may often determine an unsatisfactory reduction, in the authors’ experience, closed reductions may still play a role, in particular when the structures of the hospital do not allow an intraoperative radiographic check. In fact, it is clear that digital exploration and crepitus have the disadvantage that successful reductions are often difficult to evaluate clinically because of the great amount of swelling that often accompanies
FIGURE 3. Patient 2. Preoperative CT scan showing the fracture of the right zygomatic arch.
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1131
Correspondence
The Journal of Craniofacial Surgery
& Volume 25, Number 3, May 2014 Fabio Roccia, MD Cesare Gallesio, MD, DDS Division of Maxillofacial Surgery Head and Neck Department San Giovanni Battista Hospital University of Turin Turin, Italy
K. Hakki Karagozoglu, MD, DDS Tymour Forouzanfar, MD, DDS Department of Oral and Maxillofacial Surgery/Oral Pathology Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam Amsterdam, The Netherlands
REFERENCES
FIGURE 4. Patient 2. Postoperative radiograph showing an unsuccessful attempt to reduce the fracture.
these fractures. However, not every hospital can afford the use of intraoperative computed tomography (CT) scan or C-arm during maxillofacial surgery interventions.3,12Y15 In such conditions, a traditional technique such as the closed reduction by Ginestet hook maneuver may still be fundamental and should remain in the armamentarium of the maxillofacial surgeon. After a reassessment of the inappropriately reduced cases, we became aware that the unsuccessful outcome was associated with an excessively posterior positioning of the hook near the temporal bone, which has determined a clear increase of the displacement of the fragments in the case presented in Figures 3 and 4. Thus, it is important to remember that a correct positioning of the hook is extremely important before performing the reduction of the fracture. It should be remembered that in several cases of zygomatic arch fractures, the surgical reduction alone of the fractures is not enough as a definitive treatment. In fact, because of the movement of fragments, it is indispensable to have a complementary treatment aimed at the stabilization and fixation of the arch in the correct position until the conclusion of the calcification process.16 However, we believe that an appropriate reduction for class I zygomatic arch fractures (isolated tripod fracture) according to Ho¨nig classification10 or V-shaped fracture (I-B-D type) according to Ozyazgan classification11 could still be sufficient. Finally, it is important to remember that some patients may be willing to exchange a bit of asymmetry for avoidance of surgery.16 The Ginestet surgical technique allows limiting anesthesia to intravenous sedation, and it also allows avoiding surgical incisions. In conclusion, the management of zygomatic arch fractures is crucial to restore the pretrauma facial contour and mandibular function. The ultimate goal of the treatment is to obtain a result that can be considered acceptable by the patient by the least invasive surgical technique. To this aim, Ginestet technique can still be considered, and it should remain in the armamentarium of the maxillofacial surgeon. Paolo Boffano, MD Erik G. Salentijn, MD, DDS Department of Oral and Maxillofacial Surgery/Oral Pathology Vrije Universiteit University Medical Center/Academic Center for Dentistry Amsterdam Amsterdam, The Netherlands
1132
1. de Santana Santos T, da Rocha Neto AM, Medeiros R Jr, et al. Treatment of zygomatic arch fracture with lag screws. J Craniofac Surg 2011;22:1468Y1470 2. Krishnan B, El Sheikh MH. Dental forceps reduction of depressed zygomatic arch fractures. J Craniofac Surg 2008;19:782Y784 3. Badjate SJ, Cariappa KM. C-Arm for accurate reduction of zygomatic arch fractureYa case report. Br Dent J 2005;199:275Y277 4. Bezuhly M, Lalonde J, Alqahtani M, et al. Gillies elevation and percutaneous Kirschner wire fixation in the treatment of simple zygoma fractures: long-term quantitative outcomes. Plast Reconstr Surg 2008;121:948Y955 5. Camilleri AC, Gilhooly M, Cooke ME. Stabilisation of the unstable fractured zygomatic arch with a Kirschner wire. Br J Oral Maxillofac Surg 2005;43:183Y184 6. Carter TG, Bagheri S, Dierks EJ. Towel clip reduction of the depressed zygomatic arch fracture. J Oral Maxillofac Surg 2005;63: 1244Y1246 7. Chatziavramidis A, Kynigou M. Reduction of fractures of the zygomatic arch using a finger. Br J Oral Maxillofac Surg 2009;47:490Y491 8. Chin SH, Chicarilli ZN, Narayan D. Alloderm stabilization of zygomatic arch fractures. J Craniofac Surg 2006;17:403Y404 9. El-Hadidy AM. The use of a Foley catheter in isolated zygomatic arch fractures. Plast Reconstr Surg 2005;116:853Y856 10. Ho¨nig JF, Merten HA. Classification system and treatment of zygomatic arch fractures in the clinical setting. J Craniofac Surg 2004;15:986Y989 11. Ozyazgan I, Gu¨nay GK, Eskitaz0ioglu T, et al. A new proposal of classification of zygomatic arch fractures. J Oral Maxillofac Surg 2007;65:462Y469 12. Chen RF, Chen CT, Hao Chen C, et al. Optimizing closed reduction of nasal and zygomatic arch fractures with a mobile fluoroscan. Plast Reconstr Surg. 2010;126:554Y563 13. Czerwinski M, Parker WL, Beckman L, et al. Rapid intraoperative zygoma fracture imaging. Plast Reconstr Surg. 2009;124:888Y898 14. Imai T, Michizawa M, Fujita G, et al. C-arm-guided reduction of zygomatic fractures revisited. J Trauma 2011;71:1371Y1375 15. Ramanoojam S, Gadre P, Shah S, et al. Assessment of the adequacy of closed reduction in fractures of the zygomatic arch using ‘‘C’’-arm image intensifier. J Craniofac Surg 2011;22:1383Y1386 16. Evans BG, Evans GR. MOC-PSSM CME article: zygomatic fractures. Plast Reconstr Surg 2008;121(1 suppl):1Y11 17. Boffano P, Roccia F, Gallesio C, et al. Bicycle-related maxillofacial injuries: a double-center study. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:275Y280 18. Roccia F, Bianchi FA, Zavattero E, et al. Etiology and patterns of facial lacerations and their possible association with underlying maxillofacial fractures. J Craniofac Surg 2011;22:e19Ye23 19. Roccia F, Boffano P, Bianchi FA, et al. Maxillofacial injuries due to work-related accidents in the North West of Italy. 2013;17:181Y186
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
