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Dr. Barry Eppley

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Posts Tagged ‘cheek bone reduction’

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


Different Methods to Narrow the Cheek Bones

Tuesday, September 30th, 2008

The need to reduce or narrow wide cheeks is a far less frequent request than making them bigger. Most commonly, cheek reduction surgery is requested by Asian cultures, notably Eastern Asians. East Asian cultures value a small face, and wide cheekbones appear to make the face bigger. In rare cases, a patient may have developed a wide cheek(s) due to a facial bone fracture from an injury or may simply have a more flat face appearance which makes the face look wide.

Cheek reduction can be done by two methods, Through an incision from inside the mouth, the prominence of the cheek bone can be burred down or a piece of cheek bone can be removed allowing it to become narrower. Burring down the cheek bone is rarely a good idea. It takes a lot of bone reduction to make a visible external difference and the soft tissues of the cheek may sag after if they do not heal back down to the bone. Taking  a vertical wedge of cheek bone out where it attaches to the main bone of the upper jaw, allows the entire cheek bone complex to fall in, narrowing the width of the face. I usually place a very small plate and screws to make sure the outer part of the cheek bone stays in the newly narrowed position permanently. The back end of the cheek bone, where it attaches to the skull (temple) , can also be cut as well as the front end. When both are done together, the face is further narrowed.

While cutting and removing a piece of cheek bone sounds like a complex procedure, it is really quite simple and quick to perform. It is similar to a chin osteotomy but it is easier on the patient as this part of the upper jaw is not responsible for jaw movement even though there are some muscles attached to it. It is far more effective than burring of the cheek prominence and poses no risk of the soft tissues of the cheek sagging after surgery.

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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