Bleeding Control in Zygomatic Aneurysmal Bone Cysts: Intraoperative Ligation as an Alternative to Preoperative Embolization

OBJECTIVES: Zygomatic aneurysmal bone cysts (ABCs) are rare lesions that may lead to significant intraoperative bleeding. Although preoperative selective arterial embolization (SAE) is often recommended for hemorrhage control, it may not always be feasible. This report explores intraoperative external carotid artery (ECA) ligation as a potential alternative. METHODS: A 30-year-old female with a 4×3×3 cm hypervascular ABC of the zygomatic arch underwent surgical excision under general anesthesia. Intraoperative proximal ECA ligation was performed to control bleeding. A review of the literature was conducted for comparison. RESULTS: ECA ligation enabled near-bloodless resection with no major complications. Facial nerve weakness resolved within 3 months. No recurrence was observed at the 4-month follow-up. Among the 10 published zygomatic ABC cases, only 2 featured lesions ≥4 cm with documented hypervascularity, and both underwent preoperative embolization. No prior case involved intraoperative ligation. CONCLUSIONS: Intraoperative ECA ligation may be a safe and effective alternative to selective arterial embolization in selected craniofacial ABCs, mainly where embolization is unavailable.