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Extended Zygomatic Reduction
forOrbital Rim Protrusion
SanghoonPark
19
19.1 Pearls
1. Conventional reduction malarplasty primarily
targets the anterolateral zygomatic body and
zygomatic arch, resulting in limited modications to the orbital rim area.
2. For patients with malar prominence near the
orbital rim, a rened approach incorporating a
modied tripod osteotomy technique, combined with burring of the orbital rim, yields
aesthetically pleasing and dependable
outcomes.
3. This specialized procedure is also a viable
option for individuals dissatised with the
results of previous conventional reduction
malarplasty, especially when the concern
involves the proximity to the orbital rim.
4. The modied procedure, including both burring of the orbital rim and tripod osteotomy, is
typically performed through subciliary or
transconjunctival approaches, rather than the
more invasive bicoronal approach.
5. During the surgery, the orbito-malar complex
is osteotomized at strategic points: the zygomatic arch, zygomaticomaxillary suture, and
a location inferior to the typical zygomaticofrontal suture. This is executed using a combi-
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
nation of reciprocating saws and osteotomes.
The repositioned bony segment is then
securely xed at the lateral and inferior orbital
rims and the zygomatic arch. To further rene
the surgical results, particularly in reducing
any bony steps and protrusions along the osteotomy lines, additional burring may be
applied.
6. Throughout the procedure, it’s crucial to safeguard the orbital tissues. This necessitates the
use of appropriate retractors and a deep understanding of the complex three-dimensional
anatomy of the facial structure.
19.2 Introduction
A common issue encountered following zygomatic reduction surgery is undercorrection.
This often stems from either inadequate reduction of the zygomatic body or the prominence’s
proximity to the orbital rim, which complicates
effective osteotomy. Traditional reduction
malarplasty typically focuses on the anterolateral zygomatic body and arch, providing limited improvement in the orbital rim area.
Attempts to perform osteotomy close to the
orbital rim often yield only partial success
(Fig.19.1).
Recognizing that a subset of patients exhibit
combined hypertrophy of the zygoma and orbit
has expanded our perspective on addressing
prominent zygomas. It is crucial to identify infer-
© 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_19
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S. Park
Fig. 19.1 Preoperative (left) and postoperative (right)
views after conventional reduction malarplasty. Note the
lack of reduction at the anterolateral malar protrusion,
olateral orbital rim hypertrophy during the initial
consultation. Once this condition is diagnosed, it
necessitates a more specic and effective
approach than standard reduction malarplasty.
In response to this challenge, we introduce a
modied technique incorporating tripod osteotomy and a burring method applied to the orbitomalar complex. This approach aims to
accomplish a more comprehensive orbito-malar
reduction, thereby addressing the issue of insufcient osteotomy in patients with this specic
anatomical conguration. This technique represents a signicant advancement in the eld,
offering a reliable solution to effectively address
undercorrection in zygoma reduction surgeries,
particularly in cases where the orbital rim is
involved.
especially at the inferolateral orbital rim area after conventional reduction malarplasty procedure
19.3 Patient Assessment
andConsultation
Patients who are dissatised with the outcomes
of their initial conventional reduction malarplasty
often seeking a secondary operation are the good
candidates for surgery. Additionally, primary
patients who express concerns about prominent
cheekbones, especially those classied as type
2B, are also considered suitable candidates for
orbito-malar complex reduction surgeries.
A comprehensive assessment of these patients
is conducted, which involves physical examinations, clinical photography, and radiographic
studies. Radiographic analysis is particularly crucial, utilizing zygomatic arch views and threedimensional computed tomography (3D CT)
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19 Extended Zygomatic Reduction forOrbital Rim Protrusion
193
images to evaluate the extent of anatomical
changes pre- and post-surgery. The diagnosis of
type 2B is conrmed through detailed 3D CT
imaging.
Crucial to the process is a thorough consultation with the surgeon. During these discussions,
patients are given the opportunity to speak their
specic concerns and desired outcomes. The surgeon, in turn, explains the realistic goals and
potential results of the procedure. As the surgery
is quite extensive comparing conventional reduction malarplasty, consultation process should
ensure that patients are well-informed about the
surgical approach and have realistic expectations
regarding the outcomes of their secondary orbitomalar complex reduction surgery.
19.4 Surgical Techniques
All patients are given general anesthesia. At ID
Hospital, orotracheal intubation is preferred, but
nasotracheal intubation can also be utilized.
Intraoral, preauricular and subciliary, or transconjunctival approaches were universally
applied. Intraoral and preauricular incisions are
equal to those of conventional reduction malarplasty described at the previous chapter. Through
these incisions, the soft tissues are elevated superiorly and laterally at the subperiosteal plane to
expose the anteroinferior portion of the maxilla,
zygomatic body, infraorbital foramen, and zygomatic arch with care taken to prevent infraorbital
nerve injury. In contrast with conventional reduction malarplasty, dissection aims at exposing the
zygomaticomaxillary suture as the osteotomy is
performed along this suture line. For the subciliary approach, a skin incision is made inferior to
the lower eyelashes, almost along the full length
of the eyelid. To reach the orbital rim, a skinmuscle ap is elevated inferior to the lower eyelid. Preseptal transconjunctival approach is also
useful especially in patients favoring invisible
scars as possible. Lateral canthotomy can be considered to minimize the risk of periorbital tissue
injuries and secure lateral orbital rim exposure.
After the periosteum is incised, subperiosteal dis-
section was performed to expose the lateral and
inferior aspect of the orbital rim. The extent of
dissection of the lateral orbital rim is narrower
than in conventional tripod osteotomy surgery,
and the usual exposure of the zygomaticofrontal
suture is not mandatory as the level of osteotomy
and burring is inferior to the location of the
suture.
19.4.1 Tripod Osteotomy
In patients with moderate to severe orbital rim
protrusion, tripod osteotomy is a more effective
strategy. The orbito-malar complex is osteotomized at the zygomatic arch, zygomaticomaxillary suture, and about 5mm inferior to the usual
zygomaticofrontal suture by a reciprocating saw
and osteotome (Fig.19.2). The walls of the lateral and inferolateral portion of orbit are osteotomized at about 5 mm from the margin of the
orbital rim, on the inner aspect of the orbital
walls. Osteotomy lines are designed as shown in
Fig. 19.3. The application of the osteotome
around the orbital rim requires gentle osteotomy
Fig. 19.2 Osteotomy lines of orbito-zygomatic
reduction
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Fig. 19.3 Intraoperative photos. Osteotomy design of the orbital rim (left) and osteotomy using reciprocating saw and
osteotome (right)
S. Park
and manipulation to avoid the risk of eyeball
injuries, enophthalmos, and alteration in orbital
volume. After the osteotomies are completed
along the designed lines, the intervening bony
segment is removed, shaved, and repositioned
posteromedially as planned. The repositioning of
the bony segment involved xing with microplates and screws at the lateral orbital rim, inferior orbital rim, and zygomatic arch. Sophisticated
burring is applied to palpable bony steps, if any,
to obtain a smoother and more natural contour.
Wound closure was performed after conrming
bilateral symmetry.
19.4.2 Orbital Rim Shaving
In patients with mild orbital rim protrusion or
localized protrusion, the orbital rim can be shaved
off by burring method. After completion of osteotomy, the channel retractor is inserted to protect
the soft tissue around the orbit and burring the
rim ends leaving enough the cortical bone to x
the plate with resected zygomatic body. Irrigation
of areas leaving no bony dust is critical, and let
the soft tissue redrape naturally around the
region. Quite extensive burring of the orbital rim
is possible and proves to be a very effective and
versatile method for orbito-zygomatic
prominence.
19.5 Key Technical Points
There are two surgical methods described for
improving the prominent inferolateral orbital
rim: one, shaving the orbital rim with a burr
and, the other, mobilizing the orbital rim by tripod osteotomy. The shaving method is less
invasive, but the rasping and burring of the
orbital rim may be traumatic to the periorbital
soft tissue, and the degree of improvement
achieved may be inadequate. The tripod osteotomy, though more invasive, is considered to
be more effective and reliable in achieving the
desired improvement. Surgeons should make a
decision which method is effective and
efcient.
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19 Extended Zygomatic Reduction forOrbital Rim Protrusion
19.6 Case Study
Case 1
A 34-year-old woman complained of prominent zygoma and wide midface (Fig.19.4, left). We
recommended orbito- zygomatic reduction for this patient as she had concurrent protrusion of
her orbital rim and zygomatic body and arch. Osteotomy was performed to achieve a 5-mm
reduction of each zygoma in order to reduce the protrusion of her zygoma. The posterior part of
the zygomatic arch was divided by performing a complete osteotomy. The osteotomized orbito-
malar complex was shifted medially (by 5mm) and posteriorly (by 3mm) and xed by using
microplates and screws. The prominence of orbital rim and zygoma markedly improved as seen
at 6months postoperatively (Fig.19.4, right).
195
Fig. 19.4 Preoperative view of a 34-year-old woman
who underwent the orbito-zygomatic reduction sur-
gery (left) and postoperative view at 6months after the
t.me/Dr_Mouayyad_AlbtousH
surgery (right). The protrusion of the inferolateral
orbital rim is efciently improved resulting in a
smooth contour of the midface
196
Case 2
A 37-year-old woman had history of zygoma reduction surgery at another hospital 6years prior
to her consultation with us. She complained of prominence of the malar area, especially at the
inferolateral aspect of the orbital rim (Fig.19.5, left). Osteotomy was performed to achieve a
3-mm reduction of each zygoma in order to reduce the protrusion of her zygoma. The osteoto-
mized orbito-malar complex was shifted medially (by 3mm) and posteriorly (by 3 mm) and
xed by using mini-plates and screws. The prominence of the orbital rim and zygoma markedly
improved as seen at 6months postoperatively (Fig.19.5, right).
S. Park
Fig. 19.5 Preoperative view of a 37-year-old woman
who underwent the orbito-zygomatic reduction sur-
gery (left) and postoperative view at 6months after the
19.7 Complications
andManagement
Complications include postoperative swelling,
mild bruising, edema of sclera, and conjunctival
congestion or irritation. Hematoma requiring surgical intervention, wound-related problems, unexpected fractures, diplopia, surgical site infection,
t.me/Dr_Mouayyad_AlbtousH
surgery (right). The protrusion of the inferolateral
orbital rim is efciently improved resulting in a
smooth contour of the midface
permanent neurosensory decit, facial paralysis, or
facial asymmetry can occur [1–3]. Above all,
avoiding injury to the eyeball and periorbital tissue
is most important. If inadvertent injury to the
orbital tissue occurs such as lacrimal duct system
injury and retrobulbar hematoma that is known as
ophthalmologic emergency, delicate ophthalmologic examination should be considered.
19 Extended Zygomatic Reduction forOrbital Rim Protrusion
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19.8 Discussion
The majority of studies focusing on reduction
malarplasty primarily address the reduction of
the anterolateral zygomatic body and/or arch.
However, there’s a notable gap in the literature
when it comes to handling cases involving the
protrusion of the inferolateral orbital rim, with
or without accompanying zygomatic prominence. In such specic scenarios, conventional
osteotomy techniques, even when executed close
to the orbital rim, often yield limited improvement. This can lead to patient dissatisfaction,
prompting them to seek additional consultations
and potential corrective surgeries. A unique
challenge arises in certain cases where the surgical reduction of the zygomatic body can inadvertently accentuate the orbital rim. This can create
an aesthetic outcome resembling the facial characteristics associated with Treacher Collins syndrome, where there is a notable prominence of
the orbital rim and decient zygoma. To address
these specic cases more effectively, the orbitozygomatic reduction technique has been developed. This approach offers a more comprehensive
solution, targeting both the zygomatic body and
the orbital rim to achieve a more harmonious and
balanced facial contour. It is a signicant
advancement in the eld of facial contouring
surgery, providing a tailored solution for cases
that previously had limited options for
improvement.
The tripod osteotomy technique for reduction
malarplasty was rst introduced by Satoh and
colleagues in 1993 [4]. This method involved a
coronal incision to access the malar bone in the
subperiosteal plane and required full detachment
of the lateral canthal ligament for exposing the
lateral orbital rim. The osteotomy was performed
in three key areas: anteriorly at the frontozygomatic suture, laterally along the maxillozygomatic suture, and posteriorly at the
temporozygomatic suture. The repositioned
zygoma was then stabilized with interosseous
wiring at the frontozygomatic and temporozygo-
matic sutures. Despite its effective outcomes, this
technique wasn’t widely adopted due to its invasiveness and associated complications. In contemporary practice, the intraoral approach has
become the standard for performing orbitozygomatic reduction. This approach offers several advantages over the traditional coronal
incision technique. Notably, the lateral canthal
osteotomy performed in our method is situated
below the zygomaticofrontal suture, which
allows for the preservation of the lateral canthal
ligament. This preservation signicantly reduces
the risk of alterations in the shape and appearance
of the eyes. Additionally, the intraoral approach
offers benets such as smaller scars, reduced
operation time, less bleeding, and a lower risk of
facial nerve injury. These improvements make
the procedure more patient-friendly while still
achieving comparable surgical results to the earlier method.
The technique of tripod osteotomy for correcting malar protrusion, while possibly perceived as
too aggressive from a Western aesthetic standpoint, aligns well with the preferences of East
Asian patients who often desire a smoother facial
prole with minimal malar protrusion. Our
orbito-zygomatic reduction procedure has
yielded satisfying results for these patients.
However, for those who seek only minor improvements to the inferolateral orbital rim protrusion
and are hesitant about extensive surgery, we have
explored the option of intraoral shaving.
Unfortunately, this approach typically leads to
less satisfactory outcomes.
Ideal candidates for orbito-zygomatic reduction surgery are those with pronounced protrusion in the upper third of the zygomatic body
and/or the inferolateral orbital rim. When selecting patients with precision and considering their
specic anatomical features, we nd that orbitozygomatic reduction offers an effective solution.
This technique not only addresses the prominent
zygoma but also effectively corrects associated
inferolateral orbital rim protrusion, catering to
the aesthetic goals of the patient.
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198
S. Park
References
1. Lee YH, Lee SW.Zygomatic nonunion after reduction malarplasty. J Craniofac Surg. 2009;20:849–52.
2. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg. 1991;88:53–61.
3. Kim T, Baek SH, Choi JY. Reduction malarplasty
according to esthetic facial unit analysis: retrospective clinical study of 23 cases. J Oral Maxillofac Surg.
2014;72:1565–78.
4. Satoh K, Watanabe K.Correction of prominent zygomata by tripod osteotomy of the malar bone. Ann
Plast Surg. 1993;31:462–6.
t.me/Dr_Mouayyad_AlbtousH
The Mini-Zygoma Reduction
Surgery
SanghoonPark
20
20.1 Pearls
1. There is a growing trend in facial bone contouring surgery toward addressing mild or borderline problems with minimally invasive
methods. This shift reects patient preferences
for less intensive procedures, quicker recovery
times, and reduced postoperative discomfort.
2. Traditional full-scale reduction malarplasty
often requires general anesthesia and can be
more invasive. While previously introduced
minimally invasive techniques offered a less
invasive approach, they sometimes lacked
surgical stability and reliability, raising concerns about their effectiveness. Thess procedures fail to survive because of unpredictability
of outcome and complications due to lack of
adeqaute xation.
3. The mini-zygoma reduction surgery is particularly indicated for patients who desire
minimal invasiveness combined with surgical
reliability. It’s most suitable for those with a
chief complaint of wide midface width due to
isolated zygomatic arch protrusion, without
signicant prominence of the zygomatic
body. In patients with borderline hypertrophy
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
of the zygomatic body, there is a concern of
postoperative complaint of under-correction,
choice of mini-zygoma reduction surgery
should be carefully consulted.
4. Despite the minimally invasive nature of the
procedure, rigid xation is crucial to ensure
stable and reproducible aesthetic results. This
aspect of the surgery helps in maintaining the
position of the osteotomized segments and
preventing postoperative complications.
5. The surgery involves complete osteotomy of
the zygomatic body and arch, performed
through both temporal and sideburn incisions
under local anesthesia. Following the inward
repositioning of the osteotomized zygoma
segment, rigid xation is achieved on the
zygomatic arch using metal xtures. This
approach minimizes invasiveness while ensuring stability.
6. Patients undergoing mini-zygoma reduction
surgery typically experience fast recovery and
minimal postoperative swelling. The technique ensures stability of the bony segments,
preventing displacement and aiding in quicker
healing.
7. The mini-zygoma reduction surgery is a viable option for patients with minimal zygomatic arch prominence who seek a minimally
invasive procedure. Its predictability and reliability are ensured through rigid xation,
making it a preferred choice for specic
patient groups.
© 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_20
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S. Park
20.2 Introduction
The reduction malarplasty is popular especially
among the Asian population which is widely performed for patients with prominent cheekbones
with a wide facial contour [1–5]. For patients who
have a wide facial appearance resulting from the
lateral protrusion of the zygomatic arch even
without any excessive zygomatic body prominence, a conventional reduction malarplasty may
be improper and overly invasive.
Typically, reduction malarplasty procedures
are conducted under general anesthesia to ensure
patient safety and airway protection during the
surgery. In recent times, there’s been a growing
demand for simpler, less invasive methods to
enhance facial contours. In response, some
studies have explored reduction malarplasty via
alternative approaches such as the Gillies temporal method or small preauricular incisions, eliminating the need for intraoral incisions. Despite
being minimally invasive, these techniques often
lack rigid xation, leading to unpredictable outcomes and potential risks like bony nonunion [1].
To address these limitations, our clinic has developed the “mini-zygoma reduction surgery,” an
compromizing approach that maintains the minimally invasive nature of the procedure while
incorporating necessary xation techniques. This
modication ensures more reliable and consistent
results, aligning with the evolving preferences of
patients seeking facial contour improvements [1].
20.4 Surgical Technique
Operations are usaully conducted under local
anesthesia, complemented by intravenous sedation. The process begins with inltrating a solution
containing 1% lidocaine and 1:100,000 epinephrine into the proposed incision lines. An initial
incision is made in the sideburn area, granting
access to the posterior portion of the zygomatic
arch (Fig. 20.1. Special care is taken during this
step due to the proximity of the frontal branch of
the facial nerve. Upon reaching the periosteal layer
of the zygomatic arch, a precise incision on the
periosteum was executed. This allows for subperiosteal dissection to expose the osteotomy and xation site, and a reciprocating saw is then used to
perform a complete osteotomy just in front of the
anterior tubercle of the zygomatic arch [1].
Additionally, a 2cm incision is made in the
temporal area, situated approximately 2cm posterior to the temporal hairline and 5cm above the
helical root of the ear. The incision is deepened to
expose the temporalis muscle. The surgical pathway between the deep layer of deep temporal fas-
20.3 Patient Assessment
Patients must thoroughly analyzed by physical
examination together with imaging studies
including clinical photographs, cephalometric
and panoramic radiographs, and threedimensional computed tomography. Preoperative
status of any degree of facial nerve weakness or
abnormality of the temporomandibular joint
should also be identied preoperatively. Patients
with isolated zygomatic arch protrusion without
any hypertrophy in the zygomatic body region is
the proper indication for the mini- zygoma reduction surgery.
t.me/Dr_Mouayyad_AlbtousH
Fig. 20.1 Illustration of the mini-zygoma reduction surgery. First, osteotomy of the zygomatic arch is performed
through a sideburn incision using a reciprocating saw.
Then, osteotomy on the zygomatic body is done through a
temporal incision with a J-shaped reciprocating saw
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