PDF
Citation
Print
I. Introduction
The zygomatic bone forms the lateral portion of the midface and upper third of the face. It articulates with several bones of the craniofacial skeleton and constitutes a significant part of both the inferior and lateral orbital walls1,2. Zygomatic bone fractures account for approximately 23% to 43% of all facial fractures1, whereas frontal bone fractures represent 5% to 15% of traumatic facial injuries. Both types of fractures can result in significant aesthetic and functional morbidity, and their management must be tailored to the individual patient1. Multiple surgical approaches have been described for these injuries. Among them, the coronal approach is considered the standard method for managing fractures of the upper facial third and complex or extended fractures3.
For orbito-malar fractures, minimally invasive techniques, such as closed reduction with or without fixation, are available; however, open reduction with rigid internal fixation remains the most effective and widely accepted treatment. Nonetheless, complications such as visible scarring, eyelid malposition, and canthal deformities can occur following surgery4.
The upper eyelid approach is regarded as the most aesthetic technique in this region, providing access to the superolateral orbit through a natural skin crease incision5,6. This versatile method has been described in various neurosurgical and craniofacial procedures, including tumor resection, optic nerve decompression, cerebrospinal fluid leak repair, fracture management, and drainage of hematomas or abscesses4.
Lateral canthotomy is a complementary procedure that involves an incision along the lateral palpebral fissure, transecting the skin, orbicularis oculi muscle, orbital septum, lateral canthal tendon, and conjunctiva. This technique aims to release the lateral attachment of the eyelid to the orbital rim, thereby increasing surgical exposure6.
This article proposes the upper eyelid approach combined with lateral canthotomy as an effective and aesthetically favorable alternative for the management of fronto-orbito-zygomatic fractures, supported by a review of the current literature on surgical access techniques for this region.
II. Case Report
A 69 year-old male patient without comorbidities was admitted to the regional hospital of Rancagua with a diagnosis of a left fronto-orbito-zygomatic fracture.(Fig. 1) Due to the complexity of the fracture, conservative treatment was not feasible, and the patient underwent surgical intervention under general anesthesia. The chosen approach was an upper eyelid incision combined with a lateral canthotomy (Fig. 2), followed by reduction and osteosynthesis of the lateral orbital wall and part of the frontal bone.
Authorization was obtained for the use of clinical photographs, complementary imaging, and the patient’s informed consent for research purposes.
For the surgical procedure, 1 cc of 2% lidocaine with 1:100,000 epinephrine was infiltrated under the eyelid skin and orbicularis oculi muscle, and an additional 0.5 cc was injected into the lateral canthal region. The cornea was protected with a plastic shield following the application of ophthalmic ointment. A skin incision was made along the supratarsal crease, extending 5 mm toward the lateral canthus. Dissection was performed through the orbicularis oculi muscle to expose the fracture site, which was then reduced and stabilized with osteosynthesis.(Fig. 3) Wound closure was carried out in three layers—periosteum, muscle, and skin—with meticulous alignment of the lateral canthal structures. The procedure was completed without intraoperative complications.
Postoperative clinical and radiographic evaluations revealed no alterations in photomotor reflexes, visual acuity, or extraocular motility. Follow-up assessments were conducted at 7, 14, and 21 days, and at 1, 3, and 6 months postoperatively, all showing satisfactory functional and aesthetic outcomes.(Fig. 4)
In addition, a literature search was conducted in the MEDLINE, Epistemonikos, Scopus, and Web of Science databases using the keywords: “Orbital Fracture,” “Zygomatic Fracture,” “Frontal Fracture,” and “Superior Eyelid Approach,” in order to develop a bibliographic review of the surgical approaches used for the reduction of fronto-orbito-zygomatic fractures.
A total of 179 articles were initially identified. After the removal of duplicates, title and abstract screening, and full-text review, 8 articles were selected for analysis. These studies, summarized in Table 13,7-14, include 5 systematic reviews, 1 randomized clinical trial, 1 cadaveric study, 1 descriptive study, and 1 clinical case report.
With regard to the management of fronto-orbito-zygomatic fractures, several authors report that the majority of cases were managed using a coronal approach. A secondary strategy involved combining multiple approaches, such as the lateral eyebrow incision (tail of the eyebrow) with a transconjunctival approach and lateral canthotomy3,11,13. Melek and Noureldin8 emphasize that, in their experience, no single limited approach—except for the coronal approach—can adequately address the full extent of fronto-orbito-zygomatic fractures.
In terms of complications, the most frequently reported for both the coronal and tail of the eyebrow approaches include alopecia, visible scarring, paresthesia, and frontal nerve paresis. Specifically for the tail of the eyebrow approach, visible alopecic scarring is cited as the main drawback. However, Jones et al. note that this scarring can be minimized through the use of a cold scalpel.
Additionally, studies11,12 suggest that the choice of surgical approach is largely influenced by factors such as the degree of fracture comminution, displacement, and the presence of associated fractures. An approach through an existing wound is only considered when the wound is located near the fracture site and its use is appropriate given the extent of the injury.
III. Discussion
The surgical management of fronto-orbito-zygomatic fractures presents a significant challenge for specialists, who aim to restore both form and function, with particular emphasis on facial symmetry and projection15,16. The coronal approach is the most commonly described technique for fractures involving the upper third of the face. While it offers excellent visibility of the operative field, it also has important disadvantages, including increased bleeding, alopecia, sensory deficits in the scalp, and a high risk of injury to the temporal and frontal branches of the facial nerve15-17.
Adequate exposure of the affected area can also be achieved through a combination of approaches, such as the transconjunctival approach (with or without lateral canthotomy) and the tail of the eyebrow incision, particularly in fronto-zygomatic fractures16. However, the use of an upper eyelid approach with extension to the lateral canthus is not documented in the current literature. The tail of the eyebrow approach is a quick and simple technique that provides good access to the fronto-zygomatic suture. Nevertheless, it can leave a visible scar, especially in patients with sparse eyebrow hair, or lead to hair loss in the area postoperatively3,7,8.
Although numerous case reports and literature reviews describe the various surgical approaches to the fronto-orbito-zygomatic complex, few studies directly compare the performance of these techniques7,12. In our review, these studies differ in methodology, sample size, and research objectives, limiting their comparability. Among all approaches, the upper eyelid technique is one of the least reported and is rarely evaluated in comparative studies. Specifically, the combination of the upper eyelid approach with lateral canthotomy has not been documented in the existing scientific literature.
Based on our clinical case and its outcomes, we observed that the upper eyelid approach combined with lateral canthotomy provides a fast, aesthetically favorable technique with wide exposure of the frontal region, including the lateral orbital wall. This is especially relevant in cases involving multifragmentary fractures or comminution, where multiple fixation points must be accessed and visualized. The rapid execution of this technique, as with other approaches, depends largely on the surgeon’s experience and consistency. Efficient and broad exposure of the fracture site allows for a significant reduction in operative time, which in turn leads to decreased costs in terms of operating room resources and personnel.
Although the findings of this review do not provide robust scientific evidence to conclusively support the superiority of the upper eyelid approach with lateral canthotomy, our clinical experience suggests that it offers meaningful advantages in terms of aesthetics, surgical access, and functional outcomes when compared to more commonly used techniques. Given the current lack of literature evaluating this approach, the authors propose conducting future studies—ideally beginning with retrospective analyses, followed by randomized, double-blind clinical trials—to directly compare this technique with existing methods. Such research would provide a clearer understanding of the potential benefits, limitations, and complications associated with this approach, thereby supporting evidence-based decision-making for the surgical treatment of fronto-orbito-zygomatic fractures.
Fractures of the fronto-orbito-zygomatic complex are frequently managed through surgical intervention. Among the various available techniques, the upper eyelid approach combined with lateral canthotomy offers rapid and effective exposure of the fracture site, making it particularly valuable in cases of complex or comminuted fractures. This technique also provides excellent postoperative aesthetic outcomes, as the incision is placed within the natural palpebral crease, rendering the scar virtually imperceptible. Additionally, it poses a low risk of injury to critical anatomical structures, has a relatively simple learning curve, and can be reliably performed by experienced surgeons. Despite these potential advantages, the use of the upper eyelid approach with lateral canthotomy has not been previously described in the literature, and there are currently no studies supporting its efficacy or outcomes. Therefore, further research is warranted to document and evaluate the benefits of this technique. Well-designed clinical studies would help validate its use and promote its adoption as a safe, effective, and aesthetically favorable alternative for the surgical management of fronto-orbito-zygomatic fractures.
XML Download