Cheek augmentation can be achieved through several methods—most commonly, injectable fillers, fat grafting, and cheek implants. Each option serves a role in enhancing facial aesthetics. However, when it comes to consistent shape, defined size, long-term permanency, and potential reversibility, cheek implants remain the gold standard.
Yet, not all patients are comfortable with the idea of implants. For those who seek an alternative—and in carefully selected cases—a bone-based method exists. Similar in concept to the sliding genioplasty used for chin enhancement, the Zygomatic Sandwich Osteotomy (ZSO) allows for modification of the cheekbone itself.
Understanding the Zygomatic Sandwich Osteotomy
The ZSO is performed through an intraoral approach, where an oblique osteotomy (bone cut) is made in the zygomatic (cheek) bone. The outer segment of the cheekbone is then mobilized and pushed outward, creating a physical gap. This space is filled with a bone graft and secured in place using a small plate and screws. The result is a lateral projection or widening of the midface—producing a noticeable cheek augmentation effect.
It’s important to note that ZSO does not provide true three-dimensional (3D) augmentation like implants might, but in properly chosen patients, it can offer a satisfying and cheek widening enhancement.
What If the Patient Changes Their Mind?
As with all facial augmentation procedures, patient satisfaction over time may evolve. If a patient later decides that the outcome is no longer desirable, the question arises—can the ZSO be reversed? The answer is yes.
A 3D CT scan will typically reveal the modified contour of the cheekbone, often marked by a visible bony “step-off” at the graft site. (blue line) To reverse the ZSO, the grafted bone can be carefully removed (red marked areas) using angled cuts on either side of the graft. Once the graft is excised, the outer cheekbone segment naturally collapses back into place, closing the gap and restoring the original width. The area is then stabilized with a new plate and screws to ensure proper healing.
Reversibility and Bone Healing Expectations
A secondary ZSO reversal closely resembles a standard cheekbone reduction procedure. The prior bone graft creates a clearly visible surgical landmark, simplifying the location for removal. In every ZSO case I have encountered, the bone graft had fully integrated, forming a solid union. Likewise, in cases where the graft is later removed, one can reasonably expect the bones to reunite and heal properly.
Dr. Barry Eppley
World-Renowned Plastic Surgeon