Reply

Sir: Dr. Gerry Sparkes and I have a combined experience of several hundred patients and more than 55 years of excellent results with treating most zygoma fractures with Gillies elevation and temporary buried Kirschner wire fixation. We felt compelled to publish this old technique, as we believe it is the baby that has almost been thrown out with the bath water. It offers the simplicity of less than 15 minutes of operating time, almost no requirement for revisions, and almost no soft-tissue problems. As we go to meetings and read the literature, we are constantly taken aback by the high incidence of scleral show, ectropion, visible scars, and plate problems (exposure and temperature intolerance) in commonly performed zygoma surgery today, not to mention the extensive dissection and long, expensive operations. I am grateful that Dr. Parashar and colleagues have taken the time to carefully read and eloquently write a letter about our article, and I appreciate the opportunity to respond to their comments. I agree that direct visualization and plate fixation of all fracture sites will provide a more perfect anatomical reduction than Gillies elevation and Kirschner wire fixation. I also have the utmost respect for and gratitude toward Drs. Joe Gruss and Paul Manson, who rightfully advanced facial fracture treatment by popularizing anatomical reduction and plate fixation. When it comes to panfacial fractures, Le Fort fractures, and several types of mandibular fractures, I gleefully strip soft tissues and plate as they do, as I believe this is the best treatment. Where I disagree with these fine gentlemen is that I believe that the soft-tissue stripping and perfect anatomical reduction with plate fixation are not necessary to achieve an excellent result for most zygomatic fractures. Tearing off all of the periosteal and ligamentous support clearly weakens nature’s mechanism of using soft tissues to hold bone fragments together. I also disagree with Dr. Parashar that you cannot achieve a good enough reduction by examining the patient’s symmetry from a bird’s-eye view and palpating the orbital rim after having reduced the zygoma in the operating room. Yes, there is swelling there. However, you can still tell whether the malar eminences are symmetrical or not, and you can feel the reduced infraorbital rim fracture line. I also get to examine the patients the following week, when the three scalp sutures required to perform the technique are removed. At that time, the swelling is usually mostly gone, and I get to reassess (1) the symmetry of the malar eminences, (2) the feel of the orbital rim to be sure the reduction has not fallen, and (3) the presence of enophthalmos and the need to go back in to repair the orbital floor. If necessary, the patient can then be taken back to the operating room for wide fracture exposure and plating for asymmetry, for fallen zygomas, or for enophthalmos, but the fact is that they almost never need that. Our patients are always informed that we will try to reduce their zygoma “the easy way,” with Gillies elevation and Kirschner wire, but that there is a very small chance that this may not work and that we might need to return to the operating room the following week to do it “the more difficult way,” with more extensive dissection, plates, and screws. They are always delighted that they get “the easy way,” which works well, and so am I. The bottom line is that, when blinded, our senior plastic surgery residents could not tell which zygoma had been fractured in almost all of the long-term patients my colleague and I could find for follow-up.1 In addition, almost none of our patients felt asymmetrical, nor did they receive comments about asymmetry. I agree with Larry Hollier2 in his discussion of Connor et al.’s article3 that, in live humans, very little force is required to keep a reduced zygoma in its anatomical position. This is particularly true if all of the ligamentous and periosteal attachments of the zygoma are left intact and not stripped away. How often have you seen a gross displacement of the zygomaticofrontal suture line when you have opened a simple fracture of the zygoma? The answer is not very often, because of the soft-tissue attachments. Rigid fixation should not equal rigid thinking. I agree with Dr. Ed Ellis4 that rigid fixation is not always required, and that we should be seeking functionally stable fixation. Functionally stable fixation means that there is enough rigidity in fixation that the fracture will heal in such a manner that the goals of treatment will be reached. In the case of the typical zygoma fracture, the goals of treatment are restored eye function and position with zygomatic and facial symmetry. Those goals also include normal soft tissues around the eye and in the mouth. I believe that Gillies elevation and Kirschner wire fixation require the least amount of soft-tissue dissection to achieve functionally stable fixation, and that the technique allows us to consistently reach the goals of treatment with minimal morbidity. Donald H. Lalonde, M.D. Division of Plastic Surgery Dalhousie University 3D North 400 University Avenue P.O. Box 2100 Saint John, New Brunswick E2L 4L2, Canada [email protected]

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