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Posts Tagged ‘cheek reduction’

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


Zygomatic Osteotomy Patterns in Cheek Reduction Surgery

Thursday, November 10th, 2011

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.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Bone Reduction Surgery

Monday, February 1st, 2010

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.     

Barry L. Eppley, M.D., D.M.D.

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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