Background: The most common form of cheek augmentation today is with the use of synthetic fillers. While fillers offer an immediate and non-surgical result their effects are not permanent. Fat is also an injectable option but its results can similarly not be permanent. Cheek implants provide a permanent augmentation effect and can create a wide variety of midface shape effects using either standard or custom implant designs. Bur despite these benefits they are a synthetic material and some patients prefer to avoid having a foreign body in their face.
While injected fat is an autologous cheek augmentation procedure it uses soft tissue volume to create its effects. There is one type of bony autologous cheek augmentation that is the opposite of its more commonly performed cheek reduction surgery. The known but very infrequently performed zygomatic sandwich osteotomy or ZSO is a unique method of cheek augmentation. But cutting and moving out the cheek or zygomatic bone increased cheek width is obtained. The expansion osteotomy causes a gap in the cheekbone which is filled with a graft…just like a sandwich. The anterior osteotomy when expanded acts like a spring in which the graft is held in place by the pressure of the two bone ends which wants to close back down due to the fixed attachment of the posterior zygomatic arch to the temporal bone.
While only an anterior osteotomy in a ZSO procedure is done most of the time, a posterior osteotomy of the arch can also be concurrently performed if the augmentation effect is desired along the whole extent of the cheek. This is done through the same small side burn incision that a posterior arch osteotomy is done for cheekbone reduction.
Case Study: This young male had a natural narrow facial shape and increased facial width was his goal. He did not want a cheek implant and widening of the cheeks was the only dimensional change of the cheeks that was needed.
Under general anesthesia and through an intraoral approach an oblique osteotomy cut was done through the lateral aspect of the main body of the zygoma on both sides. It was expanded out 5mms into which a cut block of corticocancellous cadaveric bone was placed.
The posterior zygomatic arch was approached through a 10mm sideburn incision and the arch cut with an osteotome. A 4mm corticocancellous block was placed to hold the posterior arch out.
The immediate cheek widening effect cold be seen. The cheek widening effect was modest in the change but appropriate for a naturally very thin facial shape.
Case Highlights:
1) The zygomatic sandwich osteotomy (ZSO) is to create a one dimensional autologous cheek widening effect.
2) The most common method of ZSO is an anterior oblique osteotomy through the main body of the cheek bone done through an intraoral approach.The posterior expansion osteotomy can be done if total cheek widening is needed.
3) The ZSO requires the placement of an interpositional graft between the cut ends of the cheekbone of which a cadaveric corticocancellous bone block works well for this purpose.
Dr. Barry Eppley
World-Renowned Plastic Surgeon