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Archive for the ‘cheek reduction’ Category

Technical Strategies – Transcoronal Posterior Zygomatic Arch Osteotomy

Sunday, August 6th, 2017

 

Cheekbone reduction by osteotomies is the only surgical method for narrowing a wide face. While most commonly performed on Asian patients all around the world, I have done an equal number on other ethnicities as well. By performing a bone cut through the main body of the cheek (zygoma) and at the back end of the zygomatic arch, the widest part of the cheeks can be moved inward. Its effect comes from taking the most convex part of the zygomatic arch and changing its widest point to a lower inward position. Once the bone is moved inward it is usually stabilized in its new position by some form of metal fixation.

The front cheekbone reduction osteotomy is done from an intraoral incision and thus is scar free. Conversely the posterior zygomatic arch osteotomy is usually done from an external skin incision at the back side of the sideburn (male) or preauricular tuft of hair. (female) While this small incision always heals well in my experience, there are alternatives points of access to it.

One approach to the posterior zygomatic arch osteotomy is through the same intraoral incision as the anterior osteotomy. Sliding an osteotome along the underside of the arch it can be fractured in a blinded fashion. Plate stabilization is not possible. This is not a technique that I have done but I know other surgeons that do it.

Another approach to the osteotomy its from above, coming underneath the deep temporalis fascia. This could be done if one is concurrently using a coronal scalp incision for other procedures as well. Thin elevators are placed on both the outside and inside of the posterior zygomatic arch just in front of its temporal attachment. An osteotomy is used to make a complete osteotomy through the thin arch bone. It can then be mobilized and pushed inward. Like the intraoral approach plate fixation is not possible.

Dr. Barry Eppley

Indianapolis, Indiana

Posterior Maxillary Reshaping for Lower Cheek Fullness after Large LeFort I Advancements

Saturday, August 5th, 2017

 

The LeFort I osteotomy is the most common midface bony procedure and has been a staple in orthognathic surgery for over a half decade. With a horizontal osteotomy line above the level of the teeth and across the base of the nose, the upper jaw is mobilized and moved in a variety of dimensional changes with a horizontal movement being the most common. Its amount of forward movement depends on the position of the lower teeth and jaw whether it is being moved or not. The typical Lefort I forward movements are usually in the range of 3 to 7mms in non-syndromic patients.

The need for large maxillary advancements in non-syndromic patients is most commonly done in the treatment of sleep apnea. Moving the upper and lower jaws forward together opens up the oropharyngeal airway as it brings both the base of the tongue and the soft palate forward. Such maxillomandibular movements are often in the range 8 to 10mms.

While typically very effective in improving or curing the patient’s sleep apnea, the appearance of the face often changes with these larger skeletal movements. While bringing the lower jaw and its chin position forward can be perceived as aesthetically advantageous in some patients, the midface changes may not be. As the upper midface is left ‘behind’ (infraorbital rims and cheeks) and the lower midface (maxilla) comes forward, its appearance can become different and may not be an aesthetic improvement.

One midface finding in some sleep apnea surgery patients is that their lower cheek develops a fullness. This is below the cheek bone and corresponds to directly over the maxilla at the level of the base of the nose. This fullness can feel firm rather than soft like fat. This fullness is the result of the back end of maxillary osteotomy now creating a projection or fullness (a step) rather than its natural concavity in this area. This its unique to large maxillary advancements that brings out the back end of the maxilla from underneath the cheekbone.

Correction of this problematic full midface fullness can be done by an intraoral posterior maxillary osteotomy and infracture. Through an intraoral approach and a small vestibular incision over the palpable bony bump, the base of the posterior maxillary protrusion is fractured back into the maxillary sinus. This changes the unnatural bony protrusion back into a more natural concavity and eliminates the external lower cheek fullness.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

Sunday, April 30th, 2017

 

Reduction of prominent cheekbones requires some form of bone reduction. While some may think that shaving or burring can reduce the width of the cheekbones, this is largely an ineffective technique. This is because the only portion of the cheekbone that is accessible for shaving is the most anterior portion right below the eye. This is the anterior or front edge of the zygomatic body which does not have much influence on cheekbone width.

Significant cheekbone reduction requires  moving the arch portion of the zygoma inward. It is the zygomatic arch, or the connection between the zygomatic body and the temple bone that creates cheek width. This is because it is a curved bone structure even though it is a very thin bone of just a few millimeters in thickness. Its natural convex shape creates the widest part of most people’s face.

As a result of its spanning structure, cheekbone reduction surgery requires cutting the front and back end of the arch and moving it inward. The front bony cut is done from inside the mouth and often includes a portion of the zygomatic body . The back or posterior zygomatic arch cut, however, does not include the temporal bone and is done through a small incision in front of the ear at the back of the sideburn (in men) or the preauricular tuft of hair. (in females)

This direct access allows the posterior zygomatic arch to be fully visualized, cut and repositioned with small plate and screws fixation. The location of the dissection is above the path of the frontal branch of the facial nerve so the risk of injury to it is very low.

The usual amount of inward movement of the posterior arch is 5mm to 6mms which usually matches the front end of the osteotomy cut and inward movement.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Posterior Cheekbone Reduction Osteotomy

Wednesday, February 8th, 2017

 

Cheekbone reduction surgery typically is done by a double osteotomy technique. The anterior cut allows the posterior body of the zygoma (main body of the cheekbone) to move in. The posterior cut is done at the back end of the attached zygomatic arch just in front of the ear. These two cuts allow the whole side of the cheekbone to move inward. This creates the facial narrowing effect.

The anterior cheekbone osteotomy is done from inside the mouth and various design patterns have been described for it. But regardless of the design of the bone cut, it needs to be secured with a plate and screws to prevent inferior migration and sagging cheek soft tissues. Failure to do so is the most common cause of postoperative loss of cheek volume.

Posterior Zygomatic Arch Osteotomy Cut Dr Barry Eppley IndianapolisConversely, the posterior cut through the back end of the zygomatic arch is done externally through a skin incision. By making an incision at the back end of the sideburn hair, direct access can be done right down to the temporal process of the zygomatic arch.  An angled bone cut is then made just before the arch joins the temporal bone. This bone cut, combined with the anterior bone cut, allows the whole cheekbone segment to move inward. With plate and screw fuxation of the anterior, such rigid fixation may not be needed on the posterior cut to hold it in. The angled cut allows the tail of the arch to move inward and being self-locking.

Dr. Barry Eppley

Indianapolis, Indiana

Clinic Snapshots – Posterior Zygomatic Arch Osteotomy Incision

Thursday, January 26th, 2017

 

Cheekbone reduction surgery requires an understanding of the complete bony anatomy of the zygomatic bone. When most people think of the cheekbone ti is perceived as one solid block of bone just underneath the eye. While this area is a major part of the cheekbone, it overlooks the posterior extension of the cheekbone known as the zygomatic arch.

The zygomatic arch connects the main body of the cheekbone (zygoma) to the temporal bone above the ear. It is a thin bridge of bone between these two areas because underneath it passes the large temporalis muscle on its ways to attach to the lower jaw. The zygomatic arch is almost always bowed outward or has a convex shape. This gives width to the side of the midface.

In cheekbone reduction it is rarely a matter of shaving down the bone. Rather the cheekbone is cut and moved inward, this is what make the side of the face more narrow. The bone cuts are done in the front through the main body of the zygoma from an intraoral incision. Conversely the back cut is done where the zygomatic arch meets the temporal bone through an external incision.

Posterior Zygomatic ASrch Incision Healing Dr Barry Eppley IndianapolisThe external incision for the zygomatic arch osteotomy is done through the sideburn hair. It is usually about 1 cm in length and is placed at the junction of the sideburn hair and skin just in front of the ear. Because it is an external incision patients understandably are concerned about how it heals an whether it heals in an inconspicuous manner. Here is a picture of a patient with a posterior zygomatic arch osteotomy incision that was done just over one year ago.

Dr. Barry Eppley

Indianapolis, Indiana

Cheekbone Reduction and Facelift Surgery

Monday, July 25th, 2016

 

Cheekbone reduction is a common facial skeletal procedure done for aesthetic purposes in Asians. It is not done exclusively in Asians, as many different ethnic groups can have wide cheeks, but the vast majority are.

One of the main risks of cheekbone reduction is sagging of the attached soft tissues. This can be avoided by how the osteotomy is done and with good bone fixation. But in older patients who are already predisposed to loose cheek tissues this risk becomes magnified. It has been suggested that the risk cheek sagging can be prevented by combining a facelift procedure with cheekbone reduction in older patients. This can help create an oval and youthful midface.

In the August 2016 issue of the Annals of Plastic Surgery an article was published entitled ‘Reduction Malarplasty With Face-Lift for Older Asians With Prominent Zygoma’. In this clinical series over 20 older Asian women had a combined cheekbone reduction facelift procedures for their prominent zygomas and aging faces. The cheekbone reduction was done using an L-shaped osteotomy pattern. The facelift was performed in a usual fashion. All of the patients recover successfully with any major complications. The prominence of the cheekbone and sagging midface tissues were improved and the natural midface contour was preserved. Near one hundred percent satisfaction with the improved midface shape as well as rejuvenation of midface was achieved.

The most important aspect of this paper to me is that the performance of a facial skeletal osteotomy and a soft tissue suspension does not work against each other. In other words, the swelling from the cheekbone reduction does not stretch out the facelift result. This would have been my concern and it is good to read that this does not appear to occur.

There was no doubt that the facelift would provide a protective function against any cheek sagging. This is a useful combination of facial procedures to restore the youthful and proportionate facial relationships in older Asian patients. Or for any cheekbone reduction procedure done in an older patient regardless of their ethnicity.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques in Cheekbone Reduction

Saturday, July 9th, 2016

 

cheekbone reduction osteotomies Dr Barry Eppley IndianapolisCheekbone reduction, also known as reductive malarplasty, is a common operation in Asian patients. (although it can and is performed in patients of all ethnicities) There have been numerous cheekbone reduction osteotomy techniques that have been proposed, each with their own merits and proponents. But it is an operation that is not complication free of which the most common problems are cheek soft tissue sagging and non-union of the osteotomy site.

In the June 2016 issue of the Journal of Plastic Reconstructive and Aesthetic Surgery an article on this subject was published entitled ‘Reduction Malarplasty using a Zygomatic Arch-Lifting Technique’. A total of 54 patients underwent this type of cheekbone reduction surgery over an 18 month period.The reduction technique creates an L-shaped osteotomy of the zygomaticomaxillary junction through an intraoral approach. A prefabricated U-shaped microplate and screws was used for arch fixation in the lifted position. The follow-up period ranged from 6 to 18 months and the results were assessed by postoperative CT scans.

The results of this zygomatic arch lifting technique was one of general satisfaction with the aesthetic outcomes. There were no major complications such as buccal branch facial nerve injury or protracted trismus. (difficult with opening) Inadequate bony contact occurred in two patients due to unanticipated trauma with immediate reduction and fixation thereafter. Minor wound infections developed in three patients which resolved with antibiotics.

masseter muscle attachment to zygomatic archRegardless of the osteotomy pattern, techniques in cheekbone reduction must factor in how to stabilize the new position and resist the pull down forces of gravity and the masseter muscle. This requires a stable form of  bone fixation which always consist of some form of plate and screws. The use of such rigid bone fixation overcomes the design of almost any form of osteotomy design. In this arch-lifting technique the zygomatic complex is elevated thus ensuring an adequate bone to bone contact allowing for predictable and accurate aesthetiuc outcomes.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Width Reduction By Zygomatic Arch Reshaping (Malarplasty)

Monday, January 19th, 2015

 

The widest part of the face in most people is controlled by the lateral projection of the zygomatic arch. It is uncommon that the width of the temples or the jawline exceeds that of the zygomatic arches in the midface. The zygomatic body almost always sits inside the maximum width of the convexity of the zygomatic arch.

The only effective method of narrowing midface width is to reposition/reshape the zygomatic arch. This is most commonly done by numerous variations of anterior (zygomatic body) and posterior (temporal attachment of zygomatic arch) osteotomies. This moves the whole curve of the zygomatic arch inward.

All known variations of these cheekbone osteotomies works by moving the existing curve of the arch inward, not by changing the shape of the zygomatic arch. It has always seemed that if the shape of the arch can be changed that would be just as effective as moving the whole arch inward at its ends.

In the December 2014 issue of the Aesthetic Surgery Journal, article appeared entitled ‘Zygomatic Arch Reduction and Malarplasty with Multiple Osteotomies: Its Geometric Considerations’. In this paper, a new technique for facial width reduction is presented by making multiple osteotomies and a central bone resection at the middle part of the most protruding part of the zygomatic arch. The amount of bone resection was calculated with a geometrical solution according to the desired reduction rate of the arch height. A 3D CT scan was used to calculate arch height and the length of arch bone that needed to be removed. A central piece of bone was removed from the most protruding point of the zygomatic arch on each side. Greenstick fractures were made at the anterior and posterior roots of the zygomatic arch. The open arches were rotated inwardly until the resected bone met.

Their results in an impressive over 1,000 zygomatic arches were reduced from 3 to 11mms. Amazingly all reduced zygomatic arches healed with solid bony unions. Patient satisfaction with this technique was very high. The success of this cheekbone reduction method is based on changing the shape of the zygomatic arch. Knowing how much bone to remove is the key so that the zygomatic arch ends fall together and meet. That is provided by a simplified geometrical calculation.

Is the central arch resection better than the traditional medial arch displacement technique? In many facial width reduction patients it may not be necessary. But for those with a very convex zygomatic arch shape, changing the shape of the arch is the only way to get a really significant facial width reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Prevention and Treatment of Facial Sagging after Cheek Reduction

Wednesday, April 30th, 2014

 

Cheek Bone Anatomy Dr Barry Eppley IndianapolisOne of the most common concerns about cheekbone reduction surgery is the risk of facial sagging afterwards. The cheek bones play a prominent role in soft tissue support of the face given its prominent skeletal position. There are muscular attachments of the masseter muscle to the underside of the anterior zygomatic body and attachments of the temporalis fascia (not muscle) along the zygomatic arch. There is also the origin of the quadratus labii superioris muscle on the face of the maxilla but this is merely a casualty of the surgical dissection approach from inside the mouth.

What then is the potential cause of facial sagging after cheekbone reduction? As can be seen by the anatomic attachments, this is not primarily due to loss of muscular insertions. Rather it is due to a combination of subperiosteal stripping of the soft tissue from the face of the zygoma and loss of skeletal support due to a cheek deprojection effect. When the front and back end of the zygomatic arch is cut and pushed inward, this bone movement can also inadvertently move the bone and its attached soft tissues downward. This can be other source of facial sagging…deep internal collapse. But any one of these adverse tissue effects alone may not cause facial sagging. It usually every involved factor to create this adverse tissue effect.

Cheek Bone Reduction Osteotomies IndianapolisThus any cheekbone reduction surgery carries the risk of facial sagging but most techniques of zygoma and zygomatic arch reduction surgery will not cause this aesthetic problem. However some reduction methods are more prone to it if the bone is not stabilized by osteotomy design or plate and screw fixation. Downward displacement of the zygoma and the zygomatic arch bone causes tissue prolapse into the submalar and masseteric spaces. This kind of facial sagging is very difficult to correct.

Facial sagging after cheekbone reduction is very different from that of the typical effects of facial aging. Facial skin and the underlying SMAS layer sag due to weakening and stretching of the osteocutaneous ligaments which run between the underside of the skin down to the bone.. This is why jowls and deepening of the nasolabial folds occur. The deep tissues remain intact but the more superficial tissues essentially slide off the face. In facial sagging after skeletal reduction, it is the osteocutaneous ligaments that have lost their attachments. This type of tissue sag is much deeper, down at the bone level, and is not so easily remedied by merely sliding the skin ‘back up into place’.

Restoration of soft tissue sagging after cheekbone reduction is challenging but not impossible. There are two main types of secondary corrective approaches. (tissue repositioning and volume restoration) In some cases, a facelift type approach may be used but this is rarely successful. The direction of skin pull is away from where the tissue is sagging and in the wrong vector. If a skin pull approach is used, it needs to be done more vertically and directed towards the temporal region. This often requires a combined temporal and intraoral (sublabial) approach for tissue resuspension and fixation.

But volume restoration also can have an important role to play in restoring midface tissue sagging. Reprojecting the anterior cheek (not the width) by the intraoral placement of an implant is the simplest and most effective soft tissue lifting method. But understandingly most patients are reticent to consider the placement of a synthetic material. Fat injections can also be used and, while natural, does not offer much of a push to lift tissues. In very rare cases, the cheek bones themselves can be repositioned but this is very difficult and no guarantee of lifting prolapsed soft tissues. An implant should trump an attempt at osteotomy reversal.

In summary facial sagging after cheekbone reduction is a problem best avoided. Choosing a favorable osteotomy pattern and proper and careful execution will avoid it most of the time. If it occurs early intervention is advised, ideally no earlier than three months before but no later than six months after the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

 

Asian Facial Reshaping by Cheek Narrowing and Jaw Angle Reduction

Sunday, August 4th, 2013

 

Reflecting different facial characteristics from distant parts of the world is the difference between Eastern Asian and Caucasian facial bone structures. Prominent cheekbones and a strong jaw angle are common Asian features that are often asked to be reduced as they create a face that is perceived to be wide, square and relatively flat. In the Western world, however, these facial features are highly valued and requests for aesthetic augmentation of the cheeks and jaw angles are common.

Surgical reduction of the cheek and jawline can be done by employing craniofacial bone contouring techniques. But there are limitations as to how much bone reduction can be obtained and the facial changes that will result. Not every Asian face can be made more round, oval or more narrow in width. The thickness of the overlying soft tissues will affect how much reduction of the bone on the outside is seen. In addition it is important for the surgeon to realize that Asians seeking bone contouring surgery are not trying to achieve a Western look but a better shaped face that preserves their ethnicity.

Cheek bone reduction surgery has evolved over the years. Initially simple burring was done on the anterolateral face of the cheekbone through an intraoral approach. This is not only largely ineffective but also can lead to soft tissue sagging from complete periosteal detachment. It is now recognized that an infracture of the zygomatic arch is the only effective method of facial width reduction. (the arch is the culprit not the cheek bone prominence per se) While this can be done very effectively from above under direct vision through a coronal scalp incision, that is a more invasive approach than is necessary. The zygomatic arch can be repositioned by performing a bone cut at the attachment of the front part of the arch to the cheekbone body (zygoma) as well as a second bone cut at the back end of the arch where it attaches to the temporal bone. This moves the convex arch inward, reducing facial width by about 4 to 6mm per side.

Some Asian faces are wider in the upper face not because of the zygomatic arch convexity alone. The width of the temporal area above (bitemporal width) may also be significant and even when zygomatic narrowing is done the results do not make much of a facial change. Bitemporal facial width, contrary to popular perception, is not due to bone but the thickness of the temporalis muscle.  The temporal bone is a very concave bone whose thickness has little influence on the facial width at the side of the eye into the hair-bearing temporal scalp region. This muscle can be reduced by either Botox injections or temporal muscle release and resection through a vertical scalp incision.

Asian faces often have a wider lower face due to a large flare to the jaw angle and thick overlying masseter muscles. To get the best narrowing effect, both muscle and bone must be treated. Resection of the masseter muscle is not a good option and any consideration of that has now been replaced by Botox injections. This requires a series of Botox injections done over a year to produce a sustained muscle shrinking effect.

Contouring of the prominent jaw angle is done from an intraoral approach using several techniques. The traditional approach of a complete amputation of the angle, while , effective, often leaves a high and ill-defined bone shape that may also cause loss of soft tissue support and the development of jowls. The goal is jaw angle narrowing not necessarily jaw angle removal. Burring of the prominent angle, saw reduction in the sagittal plane or an outer cortical bone removal are all better reduction techniques that amputation. Narrowing of the jawline in front of the jaw angle towards the chin can also be done and may be necessary to really show the effects of any jaw angle (bigonial) reduction.

It is very valuable before doing either cheek or jaw angle reduction that presurgical x-rays are obtained. At the minimum panorex and submental digital x-rays are needed. But the drop in cost of 3D facial CT scans and the easy accessibility of them at any outpatient CT center makes their use preferred.

Whether reducing the Asian jaw angle/jawline or the cheek width, it is important to look at how one affects the other. Reduction of a prominent jaw angle can make the cheek prominence look wider and vice versa. This is somewhat similar to the relationship between the nose and the chin. This is why the best Asian facial narrowing effect comes from simultaneous reduction of both cheek and jaw angles in many patients.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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