title: Feasibility of 4-point fixation using the preauricular approach in a zygomaticomaxillary complex fracture.
abstract: OBJECTIVE
  A zygomaticomaxillary complex fracture is a facial bone fracture that commonly occurs as a centrally and laterally protruding zygomatic area. The exact reduction of the displaced fracture is the most important task in the treatment of a zygomatic fracture, from the aesthetic point of view. In some types of zygomaticomaxillary complex fracture, however, it is somewhat difficult to maintain the reduction after the surgery using 3-point fixation. In addition, surgery using 3-point fixation may cause malunion or nonunion. Thus, 4-point fixation using the coronal approach is alternatively considered. The authors performed 4-point fixation using the preauricular approach to counter the disadvantages of the coronal approach. The results and usefulness of 4-point fixation using the preauricular approach are reported in this study.
  
  
  METHODS
  This study was conducted on 172 patients who had a zygomaticomaxillary complex fracture and an isolated zygomatic arch fracture from March 2010 to September 2011. Open reduction and internal fixation were performed on the patients with a zygomaticomaxillary fracture, and closed reduction using the Gilles technique was performed on the patients with an isolated zygomatic arch fracture, among whom reduction using the preauricular approach was further performed on 17 patients who had insufficient intraoperative reduction or who had unsatisfactory intraoperative radiologic outcomes. An approximately 1.8-cm preauricular incision was made from 1.5 cm anterior to the helical root of the ear to 1 cm anterior to the tragus in a curved shape. After the incision, the temporoparietal fascia was dissected to confirm that the incision had reached the zygomatic arch behind the facture line. The reduction was performed, whereas the displaced fractured bone was being observed with the eyes, followed by the internal fixation. Plane x-ray and 3-dimensional head computed tomography were performed before the surgery, after the surgery, and 6 months after the surgery to examine the reduction status and outcomes of the displaced fracture. The mean follow-up period was 5.5 (range, 5-6) months.
  
  
  RESULTS
  Reduction using the preauricular approach was further performed on 17 patients who showed unsatisfactory reduction among 172 patients with a zygomaticomaxillary complex fracture and an isolated zygomatic arch fracture. Reduction using the preauricular approach was further performed on the displaced fractured site that remained unrepaired in an intraoperative radiologic examination. In the postoperative 3-dimensional head computed tomography and plane x-ray, satisfactory reduction that showed exact correction was observed. In an outpatient follow-up, no complication such as nonunion or malunion was found, and facial symmetry was also shown. In addition, the preauricular scar was hardly observed.
  
  
  CONCLUSIONS
  Exact reduction and internal fixation of a fracture site are required to restore the appearance and functions of the normal face and to reduce complications such as malunion or nonunion in patients with a zygomaticomaxillary complex fracture. If a complex fracture of the zygomatic body or facture of the zygomaticomaxillary buttress is accompanied by a fracture of the inferior orbital rim, and thus, if incomplete reduction or malunion is anticipated, 4-point fixation using the easier-to-manipulate preauricular approach would be more useful than the conventional method that uses the coronal approach.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Kyungpook National University Hospital, Daegu, Korea. kychoi@knu.ac.kr
authors.forename: Kang Young
authors.initials: KY
authors.lastname: Choi
authors.forename: Dong Wan
authors.initials: DW
authors.lastname: Ryu
authors.forename: Jung Dug
authors.initials: JD
authors.lastname: Yang
authors.forename: Ho Yun
authors.initials: HY
authors.lastname: Chung
authors.forename: Byung Chae
authors.initials: BC
authors.lastname: Cho
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D004431:Ear, External; D004954:Esthetics; D005240:Feasibility Studies; D005260:Female; D005593:Fracture Fixation, Internal / Q000379:methods*; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008440:Maxillary Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D008875:Middle Aged; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D015051:Zygomatic Fractures / Q000000981:diagnostic imaging / Q000601:surgery*