FINDINGS:
This is a *** year-old *** who suffered blunt trauma to the right face. The case was discussed at length with patient. Risks, benefits, and alternative therapies reviewed. The clinical indications discussed, understood, and accepted. Risks of bleeding, infection, hardware failure, injury to the inferior alveolar nerve, and reoperation were discussed, understood, and accepted. The patient is incarcerated in a Rockland County jail. A diagnosis of significantly displaced right ZMC fracture was made. The patient was discharged and to returned for open reduction and internal fixation of the facial fracture. Chart was reviewed, imaging was reviewed. The patient has a significantly displaced zygomatic fracture which requires surgical intervention for best outcome.
PROCEDURE:
The patient was taken to the Operating Room and placed on the operating room table in the supine position. The patient was induced and general anesthesia maintained via orotracheal intubation. The patient was prepped and draped in a standard fashion for an open reduction and internal fixation of the right ZMC. CT imaging was available in the Operating Room for review.
Approximately four ml of 1% Xylocaine was infiltrated into the area of the right lateral brow and into the substance of the lower eyelid. The eye was irrigated with balanced salt solution, lubricated, a corneal shield was placed over the right globe. With the use of a #15 Bard Parker blade, a release incision was made at the inferior canthal ligament through skin approximately five mm. A 5-0 nylon suture was placed through the lateral aspect of the tarsal plate and the lower lid elevated. The inferior canthal ligament was identified and cut with the use of a sharp scissor. Subconjunctival dissection proceeded below the tarsal plate through the lower eyelid and incised with a small scissor.
Elevation of the conjunctiva over the corneal shield and elevation of the lower lid allowed for simple blunt dissection in a preseptal fashion through the level of the displaced orbital rim. With good exposure gained in a preseptal fashion, palpation of the displaced infraorbital rim made. With the use of a needle tip Bovie, the periosteum was incised extending from the most medial aspect of the rim laterally. A fragmented and compressed rim fracture was noted and compromised the floor of the orbit. There was a significant medial rotation of rim extending into the floor of the orbit and sinus pivoting around the frontozygomatic suture. Once fully exposed, multiple skin hooks were placed below the two main orbital rim fragments, and were elevated in an outwardly lateral and anterior manner. Appropriate reduction was gained but was noted to be unstable.
Attention was directed to the right lateral brow. A 15 mm skin incision was made with a #15 Bard Parker blade over the right lateral rim. Sharp dissection with a needle tip Bovie to the bony rim was completed. Isolation of the FZ suture and associated fracture was made. Minimal displacement was noted. Good facial projection of the zygomatic process was noted. Forces duction test was complete which showed no restriction of the globe. At this time, internal fixation proceeded.
A 1.7 mm curved mini plate was adapted to the right lateral rim. A six hole plate was used, two fixation holes were placed superior and inferior to the fracture line. Monocortical screw fixation was placed, good stability was noted. A second curved mini plate was extended from the most medial aspect of the rim just inferior to the lacrimal orifice extending over a segment of approximately ten mm and a segment of 25 mm encompassing the rim fracture. The fractures were stabilized with the skin hooks with placement of internal fixation. Monocortical screws were used, stable reduction and alignment of segments were noted. Good lateral projection of the zygomatic prominence was noted clinically. Elevation of the tissues within the floor of the orbit denoted comminution wiht bony defects throughout the lateral, medial and posterior aspects of the
floor. No severe orbital floor defect was noted although it was fibrosed. It was elected not to pursue internal fixation along the orbital floor at this time.
The area was thoroughly irrigated with normal saline. Subcutaneous tissue were reapproximated with with 5-0 plain gut suture. The transconjunctival approach was closed with the 5-0 gut suture. Canthal suspension was completed with the use of 4-0 Vicryl and skin at the canthotomy area was closed with the use of 5-0 fast gut.
The eye was thoroughly irrigated with balanced salt solution. A forced duction test was again completed and showed no restrictive movement of the globe. This concluded the surgical portion of the case. The patient was extubated in the Operating Room, taken to the Recovery Room in stable condition.
