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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5206_Библиотеки_им_академика_М_И_Перельмана
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S. Park
16.3.1.2 Three-Quarter Oblique
Evaluation
Malar eminence is clearest in the oblique view at
approximately 34° from the sagittal plane.
Therefore, several morphologic subcomponents of
45° cheekbone can be identied, which include
convexity (degree and location of protrusion) of the
zygomatic body and arch, innominate semihorizontal groove between orbital rim and malar
prominence (hereafter referred to as “orbito- malar
groove”), and protrusion of inferolateral orbital rim,
location of MMP (maximal malar projection).
The point of maximal malar projection (MMP)
is the point where the outer contour of the zygomatic complex protrudes mostly in three-quarter
view. If the reduction of zygomatic body is per-
formed by shaving, or osteotomy is placed lateral
to MMP, this point stays unchanged while outer
margin of zygomatic body being narrowed, resulting in unnatural, boxy shape cheekbone. As stated
before, the purpose of reduction malarplasty is not
resection of projection; therefore adequate projection and position of maximal malar projection is
the key in postoperative result. The point of maximal malar projection is marked, and the surgeon
decides where to move this point three-dimensionally. The amount of medial repositioning and
ostectomy is closely related to the reduction of
anterior facial width. Ideal position of MMP may
vary in different ethnicities; however, the following lists two simple methods of determining the
ideal position of MMP (Fig.16.3).
Fig. 16.3 Determining the ideal position of the maximal malar projection (MMP). (a) Hinderer analysis. (b) Wilkinson
analysis
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16 The Comprehensive Aesthetic Analysis forMidface
Fig. 16.4 Bony facial morphology at the level of the cheekbone in axial section. Compare the (a) dolichocephalic
Caucasian face and the (b) brachycephalic Asian face
163
Hinderer Analysis
The MMP is determined at the point of intersec-
16.3.1.4 Basic Concept andStrategy
forClassication ofZygoma
tion of two lines, where the rst line connects the
lateral canthus and oral commissure and the second line connects the nasal alar base and the tragus line. The new location is a point placed in
juxtaposition to the crossed lines in the upperouter quadrant [7].
Zygomatic Arch
Bizygomatic distance is determined by lateral
protrusion of arch. It decides the frontal width of
the face in relation with upper and lower facial
width. Surgical variables of zygomatic arch are
amount of arch medialization and shaving quan-
Wilkinson Analysis
tity of posterior area of articular tubercle [9]).
A line is dropped vertically downward from the
lateral canthus to the inferior border of the mandible. The MMP is located at one-third the distance from the lateral canthus to the angle of
mandible [8].
Zygomatic Body
Position and the volume of the zygomatic body
determine the width of anterior midface as well
as facial impression. Zygomatic body can be sub-
divided into upper periorbital, middle body, and
16.3.1.3 Basal Evaluation
In general, Asian faces have a brachyfacial characteristic with a at suborbital area. When viewed
from below, the lack of projection in the subor-
lower maxilla subcomponents. Surgical variables
of zygomatic body are (1) amount of ostectomy,
(2) amount of medialization, (3) amount of set-
back, and (4) superior or inferior positioning.
bital area and protruding zygomatic arch may
form a 90° angle that looks boxy in appearance
(Fig.16.4). In this case, the face appears at and
one-dimensional, which makes the face appear
even wider. Therefore, change in the shape and
position of the zygomatic body is needed to create a midface fullness that appears more threedimensional and youthful. This view helps in
evaluating symmetry and also facilitates evaluation of the zygomatic arch.
16.3.1.5 Classication ofZygomatic
Prominence (Fig.16.5)
Type 1. Increased zygomatic arch width
Type 2. Protrusion of zygomatic body and arch
2A. Prominent zygomatic body without
orbital rim protrusion
2B. Prominent zygomatic body with orbital
rim protrusion
Type 3. Flat square zygoma
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164
S. Park
Fig. 16.5 Classication of the cheekbone and its prevalence
Type 1. Increased zygomatic arch width
Patient in type 1 has normal zygomatic body with
increased zygomatic width. This patient presents a wide face if upper and lower faces are
also wide or present localized zygomatic arch
prominence in front of ear. This type 1 has
5.6% incidence.
t.me/Dr_Mouayyad_AlbtousH
Type 2A. Prominent zygomatic body without
orbital rim protrusion
Patient in type 2A has prominent zygoma with
increased arch width, which presents as strong
impression. Type 2A patients have relatively
localized protrusion. Hypertrophy conned to
lower lateral to the orbital rim is relatively
16 The Comprehensive Aesthetic Analysis forMidface
165
easy to correct because there is enough space
to put the osteotomy medial to projection and
to change the position of MMP.Type 2A has
incidence of 66.2%.
Type 2B.Prominent zygomatic body with orbital
rim protrusion
Patient in type 2B has orbital hypertrophy, which
is very difcult to correct with conventional
zygomatic reduction. Patient should be consulted with limitation of postoperative result
and need for more extensive surgery. Type 2B
has incidence of 20.4%.
Type 3. Flat square zygoma
Patient with type 3 has at or retruded zygomatic
body with widening of posteror body and
zygomatic arch. In basal view, this patient
demonstrates a retruded maxilla. This patient
presents with square face if lower face is also
wide. Type 2C has incidence of 7.8%.
Patients’ cheekbone is classied into one of
the four types, and then their appropriate surgical
technique is determined by considering abovementioned key variables of the zygomatic body
and arch (Fig.16.6).
16.3.1.6 Surgical Strategy andDetails
(Fig.16.6)
Type 1. Mini-zygoma reduction
Type 2A.High L-shaped osteotomy (I-, L-shaped
osteotomy if applicable)
Type 2B.High L-shaped osteotomy with orbital
rim shaving or tripod osteotomy
Type 3. L-shaped osteotomy with anterior aug-
mentation (with minimal arch medialization)
Once the classication of zygomatic prominence is determined, surgical plan is established
with all the surgical variables decided. Variables
of zygomatic body are (1) amount of ostectomy,
(2) amount of medialization, (3) amount of setback, and (4) superior or inferior positioning.
Variables of zygomatic arch are amount of arch
medialization and shaving quantity of posterior
area of articular tubercle [9]. Detailed surgical
techniques will be discussed in the corresponding
chapter [10–12].
Detailed precaution should be addressed to
have best results. The posterior basal portion of
the arch, which is posterior to the osteotomy, cannot be medialized and should be carefully shaved
to prevent visible step. Too much arch reduction
with the remaining zygomatic body will result in
a at boxy face. In order to avoid this outcome
and create full midface.
16.3.2 Additional Considering Points
16.3.2.1 Soft Tissue Contribution
Facial soft tissue is a critical aesthetic factor in
zygoma reduction surgeries. For patients with
thin, fair skin and minimal cheek fat, the outcomes of bone surgery tend to be more pronounced, and the likelihood of soft tissue
drooping is lower, making them ideal candidates
for zygoma reduction. However, in such cases,
surgeons must be meticulous in ensuring smooth
transitions at bony osteotomy sites to avoid visible steps or palpable plates through thin skin.
Conversely, patients with abundant cheek soft tis-
a
Fig. 16.6 Illustration for applied surgical techniques
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b
166
Fig. 16.7 Evaluation of
facial harmony. Facial
harmony should be
considered between
midfacial width (Zy–Zy)
and lower facial width
(Go–Go) and between
midfacial width and
upper facial width (Ft–
Ft). The ratio between
the height (Tr–Me’) and
the width of the face
should be in proportion
S. Park
sue or thicker skin face a higher risk of cheek
drooping post-surgery. These patients should be
informed about this risk and potential adjunct
procedures like liposuction or lifting. In cases
with a prominent zygomatic area due to muscular
and adipose tissue, overcorrection is often recommended to compensate for this prominence
and big bony step is allowed as it does not make
any problems. In patients over 35, the decrease in
facial soft tissue and skin elasticity can accentuate the malar eminence, contributing to an aged
and tired appearance. Zygomatic reduction can
be particularly benecial for middle-aged women
aiming for a more youthful, soft, and feminine
facial contour.
16.3.2.2 Asymmetry andFacial Balance
When considering overall facial shape, including
mandible prominence and facial length, it’s
important to evaluate the potential impact of
zygoma reduction (Fig.16.7). Zygoma reduction
can be undertaken either as a standalone procedure or in conjunction with mandible reduction.
In cases where the patient exhibits prominent
mandibular features, a reduction malarplasty
alone might not sufce to achieve a balanced
facial width between the bigonial and bizygomatic areas. In such instances, a combined mandible reduction is often recommended. For
patients with long faces and pronounced cheekbones, reducing the bizygomatic distance without other adjustments can lead to a long and
narrow facial appearance, sometimes referred to
as a “cucumber face.” Therefore, in these cases,
the surgeon should be deliberate in reduction of
width. Additionally, in cases of facial asymmetry,
meticulous control over the amount of bony
resection, the extent of setback, and the vertical
movement of the osteotomized lateral segment is
crucial for achieving a symmetrical and harmonious outcome.
16.4 Discussion
The importance of considering the orbital rim in
zygomatic reduction is a novel aspect highlighted
in our study. For instances where the external
orbital rim is protruding, reducing this protrusion
via a transconjunctival or subciliary approach
becomes crucial. If neglected, the remaining
inferolateral orbital rim protrusion could become
t.me/Dr_Mouayyad_AlbtousH
16 The Comprehensive Aesthetic Analysis forMidface
167
a point of dissatisfaction for patients, as exemplied in Fig.16.1 of our series.
In some patients, the orbito-malar groove may
not be prominent, yet the extent and distribution
of hypertrophy can be accurately documented,
facilitating the selection of the optimal osteotomy
position. Our classication system, while
acknowledging the potential overlap between
types due to the complexity of clear discrimination, proves instrumental in aiding plastic surgeons to evaluate zygoma shape and formulate
tailored surgical plans based on individual patient
needs and preferences.
The surgeon’s prociency in various surgical techniques, particularly in the placement of
osteotomies, is pivotal. For instance, high
L-osteotomy, where the medial osteotomy is
typically positioned 4–7mm from the external
orbital rim, is more appropriate for patients
classied as type 2B. This technique offers a
more effective reduction of the upper part of
the zygoma, especially noticeable in the threequarter oblique view. Techniques like tripod
osteotomy or orbital rim shaving demand surgical expertise due to their proximity to adjacent functional systems and critical anatomical
structures. Therefore, a thorough understanding and skillful application of these advanced
techniques are essential for achieving desired
aesthetic outcomes while ensuring patient
safety.
References
1. Kim TY, et al. Reduction malarplasty according to esthetic facial unit analysis: retrospective
clinical study of 23 cases. J Oral Maxillofac Surg.
2014;72(8):1565–78.
2. Onizuka T, Watanabe K, Takasu K, Keyama
A. Reduction malarplasty. Aesth Plast Surg.
1983;7:121–5.
3. Yang DB, Park CG.Infracture technique for the zygomatic body and arch reduction. Aesth Plast Surg.
1992;16:355–63.
4. Cho BC.Reduction malarplasty using osteotomy and
repositioning of the malar complex: clinical review
and comparison of two techniques. J Craniofac Surg.
2003;14:383–92.
5. Kim YH, Seul JH.Reduction malarplasty through an
intraoral incision: a new method. Plast Reconstr Surg.
2000;106:1514–9.
6. Bettens RM, Mommaerts MY, Sykes JM. Esthetic
malar recontouring: the zygomatic sandwich
osteotomy. Facial Plast Surg Clin North Am.
2002;10(3):265–77.
7. Hinderer UT. Malar implants for improvement
of the facial appearance. Plast Reconstr Surg.
1975;56:157–65.
8. Wilkinson TS.Complications in aesthetic malar augmentation. Plast Reconstr Surg. 1983;71:643–7.
9. Kang JS.Plastic surgery. 3rd ed. Seoul: Koonja; 2004.
10. Kook MS, Jung S, Park HJ, Ryu SY, Oh HK.Reduction
malarplasty using modied L-shaped osteotomy. J
Oral Maxillofac Surg. 2012;70:e87–91.
11. Hong SE, Liu SY, Kim JT, Lee JH.Intraoral zygoma
reduction using L-shaped osteotomy. J Craniofac
Surg. 2014;25:758–61.
12. Lee TS.Standardization of surgical techniques used
in facial bone contouring. J Plast Reconstr Aesthet
Surg. 2015;68(12):1694–700.
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t.me/Dr_Mouayyad_AlbtousH
Standard Zygoma Reduction
withIntraoral Approach
SanghoonPark
17
17.1 Pearls
1. The primary objective of reduction malarplasty is to diminish the width of the cheekbones. Nonetheless, surgeons are encouraged
to broaden their focus beyond mere reduction.
A pivotal aspect of this procedure involves
transforming a boxy and at facial contour
into a more rened three-dimensional shape.
The ultimate goal should be to sculpt the
facial line into a smoother, more feminine
contour, thereby enhancing the overall aesthetic appeal and balance of the face. This
holistic approach not only addresses the width
of the cheekbones but also signicantly contributes to the harmonization and femininity
of the facial features.
2. The key variables to be evaluated are bizygomatic width, volume, and position of the
zygomatic body. The amount of ostectomy is
determined considering volume of zygomatic
body.
3. The zygomatic body and arch are usually moved
medially, posteriorly, and sometimes superiorly
or inferiorly during the surgery; the point of
maximal malar projection (MMP) is marked
and its new ideal position is carefully planned.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
4. Overall facial shape including mandibular
prominence and facial length should be considered in planning reduction malarplasty.
Particular care should be taken for patients
with a long face, as excessive reduction has
risk of making the face to appear longer after
the surgery.
5. Reduction malarplasty can be performed
solely or in combination with other facial
bone contouring surgeries such as mandible
reduction, genioplasty, or forehead
augmentation.
6. Soft tissue has a great effect on the results in
reduction malarplasty. In patients with abundant cheek fat and sagging skin, the slimming
effect might be less obvious and cheek drooping is more probable.
7. The following ve factors are considered high
risks for skin and soft tissue sagging generally: (1) age over 40years, (2) abundant cheek
fat, (3) thin skin and skin laxity, (4) class II
mandible or ill-dened mandible-neck line,
and (5) deep nasolabial fold or jowl.
17.2 Introduction
The prominence of the malar complex, a characteristic feature of the Mongoloid or brachycephalic face (as depicted in Fig. 17.1), is often
viewed as less desirable in many Asian countries.
This perception is inuenced by the evolving
beauty standards, which, historically, have varied
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. Park (ed.), Facial Bone Contouring Surgery, https://doi.org/10.1007/978-981-97-4992-8_17
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169
170
ab
Fig. 17.1 Bony facial
morphology at the level
of the cheekbone in
axial section. Compare
the (a) dolichocephalic
Caucasian face and the
(b) brachycephalic
Asian face
S. Park
signicantly across cultures and ethnicities. In
17.2.1 Reduction ofFacial Width
recent times, there has been a noticeable shift in
the aesthetic preferences of East Asians, moving
toward a more slim ideal. This new ideal favors a
slimmer, more three-dimensional facial appearance, diverging from traditional Asian beauty
norms.
This shift in aesthetic standards has sparked a
growing interest in altering facial contours to
align with these new ideals. Consequently, facial
contouring surgery has gained considerable popularity in East Asia and is now a frequently performed procedure. The trend is not just conned
to Asia; it is also increasingly prevalent among
The main objective of reduction malarplasty is to
make facial contour more slender and narrow.
Usually, facial width is determined by bizygomatic distance which connects the articular
tubercles on bilateral sides. Hence, reduction or
transposition of the zygomatic arch is an effective
method to narrow facial width. As zygomatic
body is hypertrophied concurrently in most of
these cases, reducing only zygomatic arch may
not be able to correct boxy appearance; thus,
combined and harmonious reduction of zygo-
matic arch and body is essential [1].
Asians residing in Western countries, further
indicating a global inuence on beauty perceptions and preferences. Surgeons should under-
17.2.2 Change aBoxy Facial Contour
stand that simply reducing the width of face
cannot sufce the patients’ need and should make
their face beautiful in terms of their altered
beauty standards.
Surgeons should understand that simply
reducing the width of face cannot sufce the
patient’s need and should make their face beautiful in terms of their altered beauty standards
on the basis of their anatomic characteristics.
The goals of reduction malarplasty are as
follows:
Prominent zygoma combined with the protruding mandible angle creates a boxy face. When
viewed from below, the at midface and wide
cheekbones also create a boxy and at appearance. Changing in the shape and position of the
zygomatic body can create a midface fullness
that appears more three-dimensional and
youthful.
into aThree-Dimensional
Contour
t.me/Dr_Mouayyad_AlbtousH
17 Standard Zygoma Reduction withIntraoral Approach
necessary, as is radiologic examination including
frontal view, submentovertex view, and Waters’
view. A computed tomography (CT) scan with
3D reconstruction is also helpful to evaluate the
shape of the zygomatic complex. The key variables to consider are the volume and position of
the zygomatic body and the bizygomatic width.
17.4 Zygomatic Body Analysis
The amount of ostectomy required during the
surgery is determined according to the volume of
the zygomatic body. A wider resection of the
zygomatic body should be planned when the volume is large. However, excessive reduction may
cause a at or decient look. Therefore, maintaining an adequate volume of the zygomatic
body in the anteroposterior dimension and transverse plane after the surgery is essential.
Fig. 17.2 Anterior and posterior facial contour lines. The
anterior facial contour line connects the temple, zygomatic body, cheek, and mandible body (red line), while
the posterior facial contour line connects the temple,
zygomatic arch, mandible angle, and chin (blue line). If
the anterior contour line is too convoluted, the patient
gives a “strong,” “offensive,” “old,” “tired,” “masculine”
impression. The posterior contour line reects the facial
width and facial size
17.2.3 Attain aSmooth Facial Line
An individual having smooth facial line looks
more feminine and young. In cases of protruded
cheekbones in outward direction, the facial line
connecting the temple-zygoma-cheekmandibular angle constitutes a very rough and
uneven line (Fig.17.2). Zygomatic reduction is a
good option for the patients who desire a youthful, soft, and feminine facial contour.
eral margin of zygoma should be trimmed or
moved medially. A critical factor in this process
is the identication and management of the maximal malar projection (MMP) point, which is the
most protruded portion of the outer contour of the
zygomatic complex when viewed from a basal
three-quarter angle.
otomy line is positioned lateral to this point, the
MMP remains unchanged, which can result in an
inadequate reduction and an irregular facial
appearance. Therefore, reduction of zygomatic
body together with MMP moving to ideal position is the key for desirable postoperative result.
The ideal MMP point may vary among different
ethnicities and subjective favors; however, the
following are two simple methods of determining
the ideal position of the MMP (Fig.17.3).
171
To make the midfacial width narrow, the lat-
If the MMP is located anteriorly and the oste-
17.3 Patient Assessment
andConsultation
Direct physical examination is the most important process to evaluate the patient’s problems
and establish a surgical plan. Clinical photos are
t.me/Dr_Mouayyad_AlbtousH
17.4.1 Hinderer Analysis
The MMP is determined at the point of intersection of two lines. One imaginary line connects
the lateral canthus and the oral commissure, and
another line connects the nasal alar base and the
tragus. The new location of MMP is a point
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