Modified Gillies Approach for Zygomatic Arch Fracture Reduction in the Setting of Bicoronal Exposure Edward Swanson, BAS,* Christian Vercler, MD,* Michael J. Yaremchuk, MD,* and Chad R. Gordon, DO*Þ Abstract: Zygomatic arch fractures are common injuries, occur- ring in isolation in 5% of all patients with facial fractures and in 10% of patients with any fracture to the zygomaticomaxillary com- plex. Isolated noncomminuted depressed zygomatic arch fractures are easily treated with the minimally invasive Gillies approach, which most often provides long-term stability. However, zygomatic arch fractures often occur in conjunction with zygomaticomaxillary com- plex, Le Fort, calvarial, and naso-orbitoethmoid fractures. In situa- tions requiring a bicoronal incision to address concomitant injuries, zygomatic arch fractures are frequently treated with wide dissection and rigid fixation. Using principles obtained from isolated arch frac- tures, we present for the first time to our knowledge the use of a modified Gillies approach to noncomminuted zygomatic arch frac- tures in a case requiring a bicoronal incision. With the deep temporal fascia exposed from the reflected bicoronal flap, a 1-cm horizontal incision is made within the deep temporal fascia allowing a Gillies elevator to easily reduce the arch fracture in a plane between the deep layer of the deep temporal fascia and the temporalis muscle. This technique exploits the advantages of the traditional Gillies approach, preserving fascial attachments, avoiding neurovascular injury, and obviating the need for rigid fixation. Moreover, this method saves time and money and decreases morbidity. Our modified Gillies approach to zygomatic arch fractures in the setting of a bicoronal incision can be applied to a wide range of cases because of the frequency with which arch fractures occur with concomitant craniomaxillofacial in- juries requiring wide exposure. Key Words: Craniofacial surgery, Gillies approach, closed zygoma reduction, zygomatic arch, craniomaxillofacial trauma, facial reconstruction (J Craniofac Surg 2012;23: 859Y862) The advantages of this [my] reduction technique are self evident: (1) The incision is made in a region where the resultant scar is negli- gible. (2) The wound is far enough removed from the bruised and swollen parts for infection to be avoided. (3) The field is free from important nerves that might be injured during the operation. (4) The lines of force to be exerted in levering the bony mass into position are more easily obtained through this approach than any other. VSir Harold Gillies 1 (1927) In 1927, Sir Harold Gillies identified the importance of malar projection and described a closed approach for the reduction of zygoma fractures. 1 Using a small, oblique incision within the temporal hairline, he placed an elevator strategically between the deep temporal fascia and temporalis muscle to lever the fracture(s) into place. In fact, the last paragraph from his article (shown above) demonstrates how he astutely recognized the accompanying advan- tages, including preservation of soft tissue attachments and avoidance of the facial nerve (ie, frontal branch). This in turn allowed Sir Gillies to effortlessly treat arch fractures with a low recurrence rate. Although the Gillies approach was originally described for all zygomaticomaxillary complex (ZMC) fractures, today it is primarily reserved for depressed arch fractures. Fractures of the zygomatico- frontal region, zygomaticomaxillary buttress, and infraorbital rim are more often fixated with miniplates through a combination of supra- tarsal, intraoral, and transconjunctival approaches. Furthermore, arch fractures may be associated with calvarial, supraorbital rim, and naso- orbitoethmoid fractures necessitating a bicoronal incision for ade- quate exposure. In this particular instance, most craniomaxillofacial surgeons dissect the arch free from surrounding tissues in an effort to reduce and fixate the depressed segments. Here, we present a novel modification of the Gillies approach in the setting of a necessitated bicoronal incision. With the flap reflected anteriorly, an incision can be made simply within the deep temporal fascia (analogous to the Gillies incision) located underneath the temporal hairline area, thereby allowing similar reduction with an elevator (Fig. 1). This technique therefore preserves all soft tissue attachments, avoids similarly the frontal nerve, and may in fact reduce both time and cost in the operating room. CLINICAL REPORT The patient is a 48-year-old man who sustained a significant head injury with multiple craniofacial fractures after being injured by a public transit bus. The patient was exiting the large vehicle when he mistakenly tripped on a sidewalk step and fell toward the rear of the bus landing his head within the rear wheel well. Once stabilized at the Massachusetts General Hospital trauma center, he was evaluated by the Plastic Surgery Service and found to have sig- nificant periorbital edema and ecchymosis (Fig. 2). A complete trauma workup revealed a subdural hematoma, C3 vertebral body TECHNICAL STRATEGY The Journal of Craniofacial Surgery & Volume 23, Number 3, May 2012 859 From the *Division of Plastic & Reconstructive Surgery, Department of Sur- gery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; and †Department of Plastic & Reconstructive Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland. Received August 24, 2011. Accepted for publication November 20, 2011. Address correspondence and reprint requests to Chad R. Gordon, DO, Department of Plastic & Reconstructive Surgery, Johns Hopkins University School of Medicine, JHOC #8152F, 601 N Caroline St, Baltimore, MD 21287; E-mail: cgordon@jhmi.edu The authors report no conflicts of interest. Copyright * 2012 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31824dd5c3 Copyright © 2012 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.