Successful ORIF Surgery for Complex Mid-Facial and Zygomaticomaxillary Fracture in a 28 Y.O. Male

Chief Complaints

A 28-year-old male patient with a body mass index (BMI) of 21 presented to the Plastic and Reconstructive Surgery Department at PACE Hospitals, Hitech City, Hyderabad, with a history of a road traffic accident (bike vs pedestrian). The patient reported oral and nasal bleeding following the accident. There was no history of loss of consciousness, vomiting, seizures, or ear bleeding. The patient subsequently presented to the hospital and was admitted for further evaluation and management of his injuries.

The patient had no known history of systemic illnesses such as Diabetes Mellitus or Hypertension and no other significant chronic medical conditions. He also had no history of previous surgeries, major trauma, long-term medication use, allergies, or bleeding disorders.

On general examination, the patient was conscious, coherent, and cooperative, with a GCS of E2V5M6 with stable vital parameters. Neurological assessment was within normal limits. Extraoral examination revealed abnormal facial asymmetry in the right upper and middle third of the face due to edema. Eye movements were normal with no evidence of diplopia (double vision).

On palpation, tenderness was present over the upper and middle third of the face with an abnormal step deformity in the right infraorbital region and depression in the right cheek region. Intraoral examination showed slightly abnormal occlusion with deviation toward the left side and an abnormal laceration over the right upper lip, while the rest of the oral cavity findings were normal.

Following the clinical examination, the Oral and Maxillofacial Surgery team conducted a thorough assessment, including a detailed review of the patient’s medical history and a focused evaluation of his facial injuries.

To confirm the diagnosis and determine the extent of bone and soft tissue damage, the patient underwent detailed clinical and radiological evaluations. These included a CT scan of the face, CT brain (plain), 3D CT face reconstruction, X-ray of the paranasal sinuses, X-ray chest PA view, 2D echocardiography, complete blood picture, liver and kidney function tests, electrolytes, random blood glucose, coagulation profile including prothrombin time, activated partial thromboplastin time, bleeding and clotting time, viral screening for HIV, HCV, and HBV, urine examination, and blood grouping with Rh typing. The imaging revealed fractures involving the right zygomaticomaxillary complex, including the lateral and floor of the right orbit with herniation of inferior orbital fat, the anterior, medial, and posterolateral walls of the right maxillary sinus, the medial and lateral pterygoid plates, the lesser wing of the sphenoid, and the right zygomatic arch.

Associated soft tissue edema and an upper lip laceration were also noted. All other investigations, including CT brain, chest X-ray, echocardiography, and laboratory reports, were within normal limits. These findings confirmed the presence of complex facial trauma requiring surgical intervention.

Based on the confirmed diagnosis, the patient was advised to undergo Facial bone fracture treatment along with Lip Laceration treatment in Hyderabad, India, under the care of the Oral and Maxillofacial Surgery team, to restore both function and facial aesthetics.

After a detailed consultation with Dr. B Arvind, Consultant Oral and Maxillofacial Surgeon, a comprehensive evaluation was performed to determine the most appropriate diagnostic and therapeutic approach. Considering the patient’s history of a road traffic accident, clinical presentation with pain, swelling, facial asymmetry, step deformity in the right infraorbital region, deranged occlusion, and an upper lip laceration, a focused local examination and extensive imaging studies were undertaken to formulate an optimal treatment strategy.

Based on the clinical and radiological findings, which confirmed a right zygomaticomaxillary complex fracture involving the lateral and floor of the right orbit with herniation of inferior orbital fat, the anterior, medial, and posterolateral walls of the right maxillary sinus, the medial and lateral pterygoid plates, the lesser wing of the sphenoid, and the right zygomatic arch, it was determined that open reduction and internal fixation of the facial fractures along with suturing of the upper lip laceration was identified as the most suitable surgical intervention. This approach aimed to restore facial symmetry, preserve ocular function, repair soft tissue injuries, relieve pain, prevent further complications, and optimize functional and aesthetic recovery.

The patient and his family members were thoroughly counselled regarding the severity of the injury, the necessity of surgery, the surgical procedure, the associated risks, and the expected postoperative recovery and rehabilitation process.

Following the decision, the patient was scheduled to undergo ORIF Surgery for facial fracture, in Hyderabad at PACE Hospitals, along with Suturing of Upper Lip Laceration under the supervision of the expert Oral and Maxillofacial Surgery team.

The following steps were carried out during the procedure:

• Preoperative Preparation and Anesthesia: The patient underwent a thorough preoperative evaluation, including a complete pre-anesthetic checkup and neurosurgical clearance due to the involvement of facial bones and proximity to the orbit. Standard aseptic preparation of the face was performed, and the patient was induced under general anesthesia, with continuous monitoring of vital signs throughout the procedure.

• Intermaxillary Fixation (IMF): To achieve proper occlusion and maintain stability of the maxilla and mandible during surgery, intermaxillary fixation screws were placed. This step ensured precise alignment of the dental arches and facilitated accurate reduction of the zygomaticomaxillary complex fractures.

• Exposure of Fracture Sites: The fracture sites were accessed using a right vestibular incision for exposure of the zygomaticomaxillary buttress and lateral maxillary wall, and a right subciliary incision for access to the infraorbital rim and orbital floor. Soft tissues were carefully dissected to avoid injury to the infraorbital nerve, orbital contents, and surrounding vasculature, allowing clear visualization of the fracture segments.

• Reduction and Internal Fixation: The fractures of the right zygomaticomaxillary complex, including the infraorbital rim, orbital floor, zygomatic arch, and maxillary walls, were anatomically reduced. Rigid internal fixation was achieved with a 1.5 mm orbital plate with gap over the infraorbital rim, secured with four 1.5 × 6 mm screws, and a 2.0 mm × 4-hole straight plate with gap over the zygomaticomaxillary buttress, fixed with three 2.0 × 8 mm screws. This restored facial symmetry, orbital contour, and midface skeletal stability.

• Closure and Postoperative Care: After achieving meticulous hemostasis, the surgical sites were closed in layers, using 3-0 vicryl sutures for deep tissue and 4-0 prolene sutures for the skin. The patient was safely extubated and shifted to the ICU for close postoperative monitoring. 
  

The post-operative period was uneventful, and the patient remained hemodynamically stable. During his hospital stay, he received the necessary medication as advised. He was subsequently discharged with medications, dietary instructions, and advice for follow-up and suture care.

Upon discharge, the patient was prescribed medications for infection prevention, pain and inflammation control, and gastrointestinal protection. Anti-nausea and antacid therapy were provided to manage potential postoperative vomiting and gastric discomfort. Supplements and vitamins were advised to support overall healing and immunity. Local care included nasal drops, eye drops, antiseptic mouthwash, and topical ointment over the sutured area, and instructions for steam inhalation to aid mucosal recovery and maintain hygiene.

The patient was advised to adhere to a soft diet for one month to facilitate proper healing and minimize strain on the operated facial structures.

The patient was informed to contact the emergency ward at PACE Hospitals in the event of any emergency or the development of symptoms such as fever, vomiting, swelling, pain at the surgical site, or signs of allergic reaction.

This case highlights the effective management of a complex zygomaticomaxillary fracture with associated soft tissue injury using open reduction and internal fixation. The surgery was completed successfully without complications, and stable fracture fixation was achieved. The post-operative period was uneventful, and the patient was discharged with appropriate care instructions for optimal recovery.