ANATOMIC STUDY

Orbital Restoration Surgery in the Zygomaticotemporal and Zygomaticofacial Nerves and Important Anatomic Landmarks
Figen Govsa, MD, Servet Celik, MD, and Mehmet Asim Ozer, MD
Abstract: A variety of etiologies may result in functional and aesthetic deciencies requiring orbital reconstruction. Fractures of the zygomaticomaxillary complex in the acute stage are frequently accompanied by sensory disturbances of the zygomatic nerve (ZN). The purpose of the current study was to describe the anatomic and topographic landmarks of the ZN in 18 adult human cadavers regarding the localization and dimensions in the orbit. The zygomaticotemporal (ZTN) and zygomaticofacial nerves (ZFN) along the lateral wall of the orbit passed through the zygomaticotemporal and zygomaticofacial foramens, respectively. The angle between the ZTN and the ZFN within the orbit was approximately 42.21 degrees. The mean (SD) distance between the orbital opening of the ZTN and the meeting point of the ZTN was measured as 9.21 (5.18) mm. The mean (SD) distance between the orbital opening of the ZFN and the meeting point of the ZTN was calculated as 11.22 (4.25) mm. The mean (SD) distance between the orbital opening of the ZFN and the infraorbital margin of the orbit was 13.04. (3.21) mm. A detailed knowledge of the ZNs passage in the orbit is necessary for a surgeon while performing maxillofacial surgery. If these measurements are taken into account, there will be little surgical risk, and this will be helpful in identifying the extent of the operative eld. Key Words: Zygomaticotemporal nerve, zygomaticofacial nerve, orbital reconstruction, orbital restoration, orbitozygomatic complex, sensory disturbance (J Craniofac Surg 2009;20: 540Y544) dysesthesia and neuralgiform pain, to the skin of the lower eyelid, cheeks, lateral side of the nose, upper lip, and the labial mucosa, gingiva, and teeth.6Y8 The ZN from the maxillary nerve arises from the pterygopalatine fossa, enters the orbit by running along the lateral wall of the orbit, and divides into zygomaticofacial and zygomaticotemporal branches. The most commonly used treatment of these deformities, when indicated, consisted of external pin xation and orbital reconstruction (eg, bone, titanium mesh, silicone sheets, Gore-Tex, and polypropylene).9 The techniques not only reconstructed the best contour of the orbit and midface but also improved the dysfunction of the enophthalmos and diplopia. In their study, previous researchers recommended an open reduction and xation with a miniplate, mainly in the frontozygomatic suture, because this method provided the best results in the recovery of the injured ZN.8Y12 A treatment guideline was based on the anatomy of zygomaticotemporal nerve (ZTN) and zygomaticofacial nerve (ZFN). For that reason, knowledge of certain anatomic relations such as the route of the ZTN and ZFN, their exact locations in the orbit, and their surgical landmarks are of signicant importance for the success rate of surgical repair and the evaluation of medicolegal questions. We aimed to standardize some specic dimensions and nd out certain surgical landmarks to facilitate the surgery and incision of ZN, if possible.

MATERIALS AND METHODS

For this study, dissection was performed on 18 adult male human cadavers from the Aegean region (bilaterally, a total of 36 specimens) with no macroscopic pathologies in the orbital region, xed with 10% formalin in the Anatomy Department, Faculty of Medicine, Ege University. All the procedures were performed under an operating microscope (Mo ller-Wedel spectra) equipped with a camera and video system. The surrounding orbital fat was then excised so that the muscles, nerves, and vessels of the lateral wall and orbital oor could be clearly displayed. Under an operating microscope, the course and relationship of nerves and vascular structures passing through the inferior orbital ssure (IOF) were studied. The ZN, ZTN, and ZFN on the zygomaticomaxillary complex were exposed. The ZTN and ZFN were traced throughout their courses, from the IOF to the orbital opening of the ZTN and the ZFN on the lateral wall of the orbit (Fig. 1). Electronic digital calipers with a precision of 0.02 mm were used in the measurements, and a 1-mm marked ruler was used in the photographs. The distances between 2 different points were measured as follows: & the distance between the orbital opening of the ZTN and the zygomaticofrontal suture, & the distance between the orbital opening of the ZTN and the lateral margin of the orbit, & the distance between the orbital opening of the ZTN and the diverging point of the ZN (B and C),

rbital and periorbital deformities are common craniofacial deformities, and they are difcult to treat. Various pathogenic factors such as traumatic orbit, congenital hypoplastic orbit, secondary deformities after tumor resection, or radiated orbit may be responsible for these deformities.1Y5 The zygomaticomaxillary fractures are the most common facial injuries. The injury of the zygomatic nerve (ZN) causes paresthesia in the area. They are distributed, and its entrapment induces protractive pain in case of manipulation of the lateral wall, a Gillies or Dingman reduction procedure for a zygomatic fracture, or an endoscopic subperiosteal facelift. This results in a sensory disturbance, including all kinds of
From the Department of Anatomy, Faculty of Medicine, Ege University, Izmir, Turkey. Received September 25, 2008, and in revised form October 22, 2008. Accepted for publication November 26, 2008. Address correspondence and reprint requests to Figen Govsa, Ege niversitesi TNp Faku U ltesi Anatomi Anabilim DalN, Izmir 35100, Turkey; E-mail: figen.govsa@ege.edu.tr, fgovsa@yahoo.com Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31819b9f8c

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The Journal of Craniofacial Surgery

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Orbital Restoration Surgery of Nerves

TABLE 1. Related Parameters of ZN, ZFN, and ZTN Distance Orbital opening of the ZTN: the zygomaticofrontal suture Orbital opening of the ZTN: the lateral margin of the orbit Orbital opening of the ZTN: diverging point of the ZN (B-C) Orbital opening of the ZFN: diverging point of the ZN (B-D) Angle between the ZTN and the ZFN (>), degrees ZN: diverging point of ZN (A-B) Orbital opening of the ZFN: the infraorbital margin of the orbit Mean (SD), mm 12.83 (1.91) mm 11.28 (1.04) mm 9.21 (5.18) mm 11.22 (4.25) mm 17.21 (1.24) degrees 5.24 (2.12) mm 13.04 (3.21) mm

FIGURE 1. Branches of the ZN-related parameters that were measured (millimeters) in this study. The ZN (A), diverging point of the ZN (B), orbital opening of the ZTN (C), orbital opening of the ZFN (D), ZN (A to B), ZFN (B to D), ZTN (B to C). > indicates the angle between the zygomaticotemporal and the ZFN. & the distance between the orbital opening of the ZFN and the diverging point of the ZN (BYD), & the distance between the ZN and the diverging point of the ZN (A and B), & the distance between the orbital opening of the ZFN and the infraorbital margin of the orbit, and & the angle between the ZTN and ZFN within the orbit. Differences between the measurements of 2 groups of data specimens were analyzed using the Students t-test. The Pearson correlation test was used in the statistical analysis of the values in the specimens. Results were considered signicant at P 9 0.05.

RESULTS
The zygomaticomaxillary complex was thin and largely roofs the maxillary sinus. Posteriorly, the oor was separated from the lateral wall by the IOF that connects the orbit with the pterygopalatine and the infratemporal fossa. It transmitted the infraorbital and zygomatic branches of the maxillary nerve and the accompanying vessels; orbital branches arise from the pterygopalatine ganglion and form a connection between the inferior ophthalmic vein and pterygoid venous plexus. In the examination of the 36 specimens of 18 cadaveric heads, it was observed that the ZN and infraorbital nerves passed into the orbit through the IOF (Fig. 2). The infraorbital groove in the orbital oor constitutes a bed for the ZN from the IOF (Fig. 3). In all 36 specimens,

the ZN was covered by a thin layer of bone, periosteum, and mucosa, representing the oor of the infraorbital canal (Fig. 2). The ZN can be easily located in the orbital oor, extending from the IOF to the orbital rim anteriorly. The mean (SD) distance from the ZN to the anterior margin of the orbital rim was measured as 39.50 (9.58) mm. The ZN was located close to the base of the lateral wall of the orbit. It soon divided into 2 branches, the ZTN and the ZFN, which run only for a short distance in the orbit through its lateral wall (Figs. 3 and 4). Anteromedially, lateral to the lacrimal hamulus, a small maxillary depression may mark the attachment of the inferior oblique (Fig. 2). The angle between the ZTN and the ZFN within the orbit was approximately 42.21 degrees. The ZTN and the ZFN reached the lateral wall and the oor of the orbit. The ZTN traveled posterior to the greater sphenoid wing of the orbit instead of traversing the IOF. The ZFN traveled along the maxillary portion of the orbit instead of traversing the IOF. The ZTN and the ZFN enter the orbit from separate canals (Fig. 4). The mean (SD) distance between the orbital opening of the ZTN and the meeting point of the ZTN was measured as 9.21 (5.18) mm. The mean (SD) distance between the orbital opening of the ZFN and the meeting point of the ZTN was calculated as 11.22 (4.25) mm. The mean (SD) distance between the orbital opening of the ZFN and the infraorbital margin of the orbit was 13.04 (3.21) mm. The values of the parameters of the ZN, ZFN, and ZTN are given in Table 1.

DISCUSSION
While the zygomaticomaxillary complex represents one of the most exposed anatomic elements of the face, it is mainly responsible for the greatest amount of related maxillofacial trauma, with 97% of motorcycle accident victims.13,14 Periorbital bruising

FIGURE 2. Branches of the ZN in the orbit. 1, ZN; 2, ZTN; 3, ZFN; 4, infraorbital nerve; and 5, inferior oblique muscle. * 2009 Mutaz B. Habal, MD

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FIGURE 3. AYD, Dissection of the oor and lateral margin of the orbit. 1, Lower eyelid; 2, infraorbital margin; 3, ZFN; 4, infraorbital canal; 5, orbital opening of the ZFN; 6, ZTN; and 7, orbital opening ZTN. and edema, orbital or malar deformity, intraorbital anesthesia, trismus, diplopia, and epistaxis were seen together with the problems of eye mobility, pupil level differences, and enophthalmus.15 The intraorbital nerves are often involved in zygomaticomaxillary complex fracture lines that include the infraorbital groove in 95% of cases.15,16 The neurologic symptoms arise from the fact that the fracture line runs through or in the immediate vicinity of the infraorbital canal and foramen and damages these nerves.17Y20 This results in dysaesthesia of the skin of the lower eyelid, cheek, and nose and of the skin and mucosa of the upper lip, gingiva, and teeth on the affected side. According to previous authors, infraorbital nerve involvement alone with minimal or no displacement of the zygoma is not an indication for surgical intervention because full regression of neurologic symptoms in undisplaced fractures may occur spontaneously, although decompression of the infraorbital nerve, even in markedly displaced fractures, may damage it.16Y20 They also concluded that comminuted fractures are associated with the high incidence of infraorbital dysaesthesia probably because of the lack of stability of the bony fragments around the infraorbital canal and foramen; therefore, the pressure on the nerve continues despite treatment. The purpose in treating zygomaticomaxillary fractures is to restore the premorbid malar and orbital conguration while avoiding the complications such as facial asymmetry, visual disturbances, enophthalmus and exophthalmus, diplopia, orbital dystopia, enophthalmus, and infraorbital paresthesia.21Y24 A variety of etiologies may result in functional and aesthetic deciencies requiring orbital reconstruction. Loss of vision, diplopia, extraocular muscle dysfunction, and ocular misalignment can interfere with a patients ability to perform the simplest tasks.9 The treatment of zygomaticomaxillary fractures varies depending on the surgeons, and the cosmetic and functional results are frequently less than optimal.13Y16 The emphasis is placed on the indications for closed and open reductions, consistent methods of three-dimensional alignment and xation, and the management of concomitant intraorbital rim and orbital oor fractures. The results of cosmetic and functional analysis of the surgical intervention

FIGURE 4. A and B, Lateral wall of the orbit. 1, Infraorbital margin; 2, ZN; 3, ZTN; 4, orbital opening of the ZFN; 5, ZFN; and 6, zygomaticofrontal suture.

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included ophthalmic and otolaryngologic evaluations, along with the antropometric measurements for facial symmetry.20Y23 Insufcient orbital oor reconstruction and atrophy of traumatized periorbital fatty tissues were mainly related to entropin, ectropion, and corneal abrasion. The postoperative complications involving the infraorbital nerve such as malar asymmetry, visual disturbances, diplopia, orbital dystopia, enophthalmus, and sensory decits have been reported by various authors.23 The orbital extension of the zygoma constitutes most of the lateral orbital wall and also forms part of the orbital oor lateral to the infraorbital groove. Therefore, a displaced zygomatic fracture, by denition, is also an orbital oor fracture. The failure in repositioning the lateral orbital complex accurately, as well as insufcient repair of the orbital oor, can therefore be a major factor in the development of posttraumatic visual disturbances.23 When literature is analyzed, it was seen that there is not much detailed data concerning the ZTN and the ZFN. Hwang et al18 has a study on the course of ZTN in the orbit. Hwang et al found that the mean (SD) distance from the emerging point of the ZTN to the zygomaticofrontal suture is 13.93 (2.81) mm, and the mean (SD) distance from the emerging point of the ZTN to the lateral margin of the orbit is 10.48 (2.04) mm.18 They reported that the angles between the ZTN and the ZFN within the IOF and within the orbit are approximately 16 and 36 degrees, respectively.18 Many surgeons are tempted to use miniplates in the infraorbital area for ease of reconstruction and sometimes to join them with the bone grafts for comminuted fractures where it is impossible to apply a screw owing to the small fragment size.4 In principle, miniplate osteosynthesis is limited to certain vertical and horizontal buttresses; therefore, areas such as the zygomatic arch, infraorbital rim, orbital oor, and anterior wall of the maxilla should be avoided. We aimed to determine some anatomic points as a sign of quick determinants of the ZFN and ZTN location in orbit. Kazkayashi et al dened the approximate place of the IOF,10 and the results of our measurements are close to the ndings of these authors. Incidentally, we could not nd any study in the literature that included the cephalometric analysis of the skull to assess the exact location of the IOF. Our cadaver studies have revealed that the orbital oor, the ZN, ZFN, and ZTN, could easily be visualized. This study has provided measured objective criteria for the zygomaticomaxillary complex and their relationship with different anatomic landmarks, which are crucial during surgery. Findings about the landmarks and side symmetry are to be carefully considered. No differences at a signicance level of P 9 0.01 were observed in the right-left side comparison of the data about all the parameters. We had difculty in comparing our ndings because the previous studies did not include detailed parameters. The lateral wall and oor of the orbit contain important nerves that are to be taken care of for nailing. On the oor of the orbit, the distances between the hole of the ZFN and the anterior margin of the orbit and, on the orbital lateral wall, between the hole of the ZTN and the lateral margin of the orbit are important.16Y20 Evaluating these measurements, it should be kept in mind that the nerves may get damaged. Many craniofacial techniques that involve some form of zygomaticomaxillary approaches have been described.21 To improve the management of these fractures, it is necessary to determine the location of the fracture line and know the anatomy of this region. An inadequate technique can cause extensive nerve damages that will signicantly reduce the chances of success for further reconstruction.21,24 The surgery of access should have minimal morbidity, and its use should introduce minimal additional operating time. Reconstruction is faster and less costly because fewer miniplates are used, and cosmetic results are also better. * 2009 Mutaz B. Habal, MD

As a result, anatomic landmarks of the ZTN and ZFN may affect the diagnostic and surgical procedures involving the orbital oor. Care must be taken to avoid placing the screws close to the ZTN and ZFN. It is an indisputable fact that the success in surgical strategy and planning mainly relies on the surgeons knowledge of the landmarks of the orbital oor, on gaining the right orientation even at the initial stages of surgery, on preventing a wide incision, on providing a shorter surgery time, and on avoiding serious complications such as facial asymmetry, visual disturbances, diplopia, orbital dystopia, enophthalmus, and infraorbital paresthesia. The aim of this study was to provide information about the anatomic orientation of the orbital reconstruction that has been widely used in craniofacial surgical practice.

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