Airway management should be discussed with nursing, patient and anesthesia providers prior to the day of surgery, if possible.Depending on degree of pre op trismus, may require re-expansion of inter incisor distance with TheraBite (Atos Medical) or similar device or incremental expansion with tongue blades.soft diet (depending on whether isolated ZMC repaired) for one to two weeks.Depending on degree of orbital involvement and manipulations would consider post operative vision checks.No drains usually required with the exception of if a coronal approach is required, then two 10 mm fully-perforated Jackson Pratt drains are used.Maintain full access to mouth and ipsilateral eye.possible erythromycin ophthalmic ointment.oral retractor tray that should include Spandex retractor, McKesson bite block,.Each has a separate set of indications and risks involved and should be enumerated including the risk of ectropion with the transconjunctival and subciliary approaches. Consent should detail the planned approach including a maxillary vestibular approach (AKA sublabial or buccal sulcus), possible transconjunctival, subciliary, lateral brow, hemicoronal.Axial and coronal CT images are the most useful in determining location of severity of displacement of ZMC.Evaluation of the buttresses (see pertinent anatomy).Evaluation of orbits - to judge whether exploration of orbit is warranted and therefore involvement of oculoplastics.Severe displacement may cause direct impingement on the coronoid process, however, and trismus is more pronounced leading to interincisor distance of ~1cm. Limited mouth opening may be present and is generally mild and is typically due to pain with masseteric pull given its attachment to the zygoma.Complete visual exam including acuity testing and rule out of retrobulbar hematoma.In patients with multiple facial fractures it is imperative to rule out cervical spine injury that can occur in >5% of cases.As always, consider ABCs first, including the need for surgical airway - cricothyrotomy or tracheostomy as conceivably the safest options bearing in mind that direct laryngoscopy may be hindered by either blood and/or possible cervical spine injury depending of severity of overall facial fractures.Minimal displacement and/or no remediable functional deficits - the majority of patients will have varying degrees of V2 hypesthesia that may or may not recover depending on the original nerve injury and surgery should not be undertaken for the latter alone.Indications - generally aimed at realignment of mid face skeleton with restoration of relative symmetry including projection of malar eminence, as well as restoration of unrestricted motion of the globe and mandible.The ZMC makes of a large portion of the inferior and lateral orbital walls.Buttresses: two major buttresses of the ZMC are the upper transverse maxillary (across the zygomaticomaxillary and zygomaticotemporal sutures) and the lateral vertical maxillary (across the zygomaticomaxillary and frontozygomatic sutures).Fractures occur along the zygomaticofrontal and zygomaticomaxillary junctions, zygomaticotemporal attachment and sphenoid - another term might by tetrapod fracture.Second most common mid face fracture (nasal fracture is first), usually from lateral blunt force like a blow from a fist.See also: Case Example Zygomatic Complex Fracture (Tripod Fracture) Reconstructive Procedures Protocols Return to: Facial Fracture Management Handbook Zygomaticomaxillary Complex Fracture (Tripod Fracture)
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