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.
Conversely, 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.
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.
The 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.
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.
Cheekbone 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.
Regardless 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
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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.
One 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.
Thus 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.
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.
The shape of the face obviously changes in different geographic regions and cultures. This is certainly true in facial aesthetics between Western and Asian cultures. One of the facial features that is really different between these two cultures is the cheek region. In the Western face a high or protruding cheek is regarded as both youthful and aesthetically pleasing. In contrast, high or prominent cheekbones is regarded as unaesthetic in the Asian face. In a face that is generally smaller overall, prominent cheekbones can look really big in an Asian face.
Because of the desire to not have protruding cheeks in an Asian face, cheek reduction or reduction malarplasty is a very common operation in Eastern Asian countries. It is an extremely uncommon facial operation in Caucasians although I have seen and done a few such cheek reductions over the years in my Indianapolis plastic surgery practice.
Most cheek reductions use both an anterior and posterior osteotomy. The anterior osteotomy goes somewhere through the body of the cheek or zygoma while the posterior osteotomy cuts the attachment of the zygomatic arch to the temporal bone. The posterior osteotomy has very little variation in performing it. But the anterior osteotomy cut has some variation in placement and design due to the different sizes and shapes of the zygomatic bone. How it is cut and how much bone is removed determines how much volume reduction is achieved and whether the area of maximum cheek protrusion is effectively reduced.
The easiest anterior approach to cheek reduction is to separate the front edge of the zygomatic arch where it attaches to the posterior body of the zygoma. This junction is certainly easy to see intraoperatively from the intraoral approach. While easily cut, however, shifting of the zygomatic arch medially can leave the protrusion point of the cheek bone in some patients unchanged. This can be remedied by burring the body of the zygoma down to be even with the repositioned zygomatic arch. However, it can be hard to get the junction between the bone edges smooth and it may also be structurally unstable.
When the protrusion point of the zygoma is more anterior than the junction, a different osteotomy pattern is used. An L pattern osteotomy design is used with two pairs of osteotomy cuts on the anterior surface of the zygoma. When it is cut this way and a sagittal section of bone removed, the zygoma and the attached zygomatic body are moved inward as a unit. This will ensure that a smooth zygoma will result and it will be more stable.
In an interesting paper published in the November 2011 issue of Plastic and Reconstructive Surgery, plastic surgeons from Tokyo studied the position of the ‘summit’ of the zygoma. The summit is just another name for the maximal point of cheek protrusion. Knowing where it is located in any patient is obviously important when planning the cheek reduction operation. Their study showed that the summit of the zygoma is located medial to the junction of the frontal process and the zygomatic arch. The bone incision line in cheek reductions, therefore, should be placed medial to the posterior edge of the frontal process to get effective reduction of the protrusion. Not surprisingly, the zygomatic summit is higher in men than women due to a bigger cheekbone and then so should the bone incision be placed also.
Prior to cheek bone reduction surgery, I like to get a simple submental facial x-ray to locate the the point of maximal bony cheek protrusion which can be easily seen on the film. This helps to determine the best cheek osteotomy type.
Changing one’s bony prominences is the primary method for altering the shape of the face. The face is composed of a variety of bones which have convex and concave contours. The external appearance of the face is highly influenced by the convex bone contours. From the brow bone down to the long curvilinear shape of the mandible, there are numerous key bony projection points. (e.g., cheeks, chin, jaw angles)
Most commonly, a variety of plastic surgery operations exist to enhance or increase their projections. Chin, nose, cheek and jaw angle implants are prime examples. It is almost always easier to increase facial bone projection by adding to the bone rather than actually moving the bone. There are also, however, operations that work in reverse…to reduce or deproject these very same prominences.
Facial bone reductions are not as well known and are less commonly done. Unlike augmentations, facial reduction procedures require modification or shortening of the bony prominences. While some can be shaved down, others require actual cutting off or out of bone sections to change the amount of bony projection.
Brow bone reduction is requested when the brows have a very prominent or ‘Neanderthal’ appearance. Mainly this procedure is done in men and in male to female conversions. (facial feminization surgery) This must almost always be done through a frontal hairline or scalp incision. In some cases, the brow bone may be simply burred down but this is unusual. The underlying frontal sinus occupies much of the width of the brow bone so the overlying bone is quite thin. Only if one is modifying the tail of the brow can it be just burred down. The outer table of the frontal sinus must be removed, reshaped, and then put back with tiny plates and screws. The scar from the incisional approach is the key decision in deciding to undergo this operation.
Cheek reduction is about modifiying the front edge of the cheek bone and its arched form back to where it attaches to the temporal bone. Most patients that want cheek reduction are often Asians in an effort to improve their wider face appearances. A vertical bone cut is made through the body of the malar bone and a wedge of bone is removed. The reduced cheek bone is then attached to the maxilla with a four-hole plate and screws. To get the more posterior part of the arch to move inward, the thin attachment of the posterior part of the zygomatic arch is cut with an osteotome and allowed to move inward (by muscle pull) without the need to secure it.
Nasal reduction is achieved by conventional rhinoplasty techniques. A significant part of a nasal hump is actually cartilage and not bone. The key in reductive rhinoplasty is not to overdo it, creating a saddle nose or pinched upper and middle vault appearance. This can result in nasal airway breathing difficulties. When it comes to helping a face look less wide and more sculpted, the nasal dorsum often is better elevated and not reduced.
Chin reduction is done by burring down the genial prominence. While this bone area is simple to get to through a submental incision, chin reductions are notoriously prone to cause soft tissue problems if not done correctly. This is the only facial bony prominence where the soft tissue does not just ‘snap back’ over the bone. If the excess skin and muscle is not removed and readapted back to the reshaped bone, it will sag resulting in the classic ‘witch’s chin deformity. Also, unlike chin bone advancements which can be brought forward 10 to 12 mms or more, retropositioning of the chinbone can not be done as dramatic and is more in the range of 4 to 6mms at best. Going back further than that can have adverse effects on the neck causing undesired fullness.
Jaw angle reduction is most commonly done in Asians like cheek reduction. Through an incision inside the mouth, the angle of the jaw is blunted by an oblique bone cut removing the prominent tip. How much of the tip or angle area is removed is a matter of intraoperative judgment. There is a fine balance between removing too little and completely having no angle at all. A nearly straight line from below the ear to the chin is not desireable either. This is the most uncomfortable of all the facial bony prominences to reduce because the large master muscle must be raised, causing considerable swelling after also.
The cheek bone (zygoma) is a very valuable part of one’s appearance as it provides a prominent highlight and a width dimension to the face. It also provides support to the eyeball and serves as an attachment point to the tendons of the upper and lower eyelids.
Some people have naturally broad or narrow cheek widths, of which one component is caused by the development and shape of the dimensionally complex zygoma. The curvature of the zygomatic body and attached arch bone is responsible for some of this width.
The normal position of the zygoma cam also be altered through injury, with cheek or ‘tripod’ fractures being frequent. When the bone is fractured, it almost always is displaced downward and inward into the maxillary sinus cavity. As the pillar or support of it is lost, it can only fall in this direction. Technically, it rotates (tilts, not just falls) and the cheek prominence is lost and the corner of the eye may be pulled down slightly also. While most of these zygoma fractures are repaired immediately, some never get fixed for a variety of reasons creating a secondary zygomatic deformity marked by a flatter cheek.
Zygomatic osteotomies are one potential method to improve these bone malpositions. Depending on the facial objective, the type of zygomatic osteotomy can differ which also influences the incisional approach.
In a purely cosmetic application, the zygomatic body (not arch) can have a wedge of bone removed for reduction or can be cut and expanded. (with or without grafting) By so doing, one can moderately help change the width of the face in this area. Because it is usually done on both sides of the face for cosmetic change, the total amount of change (by bone measurement) may be as much as 10 to 15 mms. Almost all cosmetic zygomatic osteotomies are done through an intraoral approach.
For reconstructive purposes, most zygomatic osteotomies are usually done on one side only. The objective being to match the opposite uninjured side. Deoending on how the bone must change position will determine what incisions are used. Usually the intraoral approach alone is not adequate as the zygomatic complex must be freed and rotated, not just changing one dimension of the zygomatic body. Thus two incisions are used, most commonly intraoral and lower eyelid. (blepharoplasty) Extensive three-dimensional complex movements may need a coronal (scalp) incision as well to fully mobilize the bone at each pillar of support. In my Indianapolis plastic surgery practice, I usually try to avoid the scalp approach as this is undesired by most patients and is reserved for those few patients who have had a more significant midface ‘crush-type- injury.
Zygomatic osteotomies will need bone fixation, using very small titanium plates and screws. These almost never need to be removed later and they rarely cause any problems.
When contemplating reconstructive zygomatic osteotmies, there is often an orbital component to the deformity that may require orbital floor reconstruction and repositioning of the lateral canthus to change the level of the corner of the eye as well.
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.