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
Indianapolis, Indiana