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20 The Mini-Zygoma Reduction Surgery
cia and the temporalis muscle facilitates blunt
dissection down to the posterior margin of the
temporal process of the zygomatic body. Using a
periosteal elevator, the posterior side of the periosteum on the temporal process of the zygomatic
body is elevated. Complete osteotomy is performed with the reciprocating saw, under the
careful guidance of palpation from the nondominant hand (Fig.20.1). Notably, the anterior side
of the zygomatic body remains less touched even
after completing the osteotomy (Figs. 20.1 and
20.2) [1].
After completing the osteotomy on the zygo-
matic body, the movability of the zygomatic arch
becomes apparent through the sideburn approach.
The arch is then repositioned inward to align with
the preoperative surgical plan. To ensure a smooth
transition and minimize the palpability of bony
steps, bone shaving is performed at the osteotomy
margins using a surgical burr. This process blunts
any sharp osteotomy edges, contributing to a
more rened surgical outcome. Subsequently, the
zygomatic arch is rigidly xed in place using a
prebent three-hole linear titanium plate and
screws [3]. This xation is crucial as it enables the
osteotomized arch segment to withstand the
downward and rotational forces exerted by the
attached musculature, as depicted in Fig.20.3 [1].
201
Fig. 20.2 Intraoperative photographs of the mini-zygoma
reduction surgery. The zygomatic arch is completely osteotomized through a sideburn incision (above). The zygomatic body is osteotomized through a temporal incision,
while the anterior side of the periosteum of the zygomatic
body is left intact to minimize bone displacement (below).
After all osteotomies are completed, the zygomatic arch is
rigidly xed with metal xtures via the sideburn incision
Intraoral Variation Osteotomy in zygomatic
body can be done with 1cm incision in intraoral
maxillary vestibule. A periosteal elevator is
inserted, and the posterior side of the periosteum
on the temporal process of the zygomatic body is
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elevated, and complete osteotomy is performed
with a reciprocating saw, guided under careful
palpation of the nondominant hand. As it is done
under local anesthesia, osteotomy should be fast
and minimal to reduce the risk of bleeding.
202
S. Park
Fig. 20.3 Comparison on preoperative and postoperative imaging studies. Preoperative and postoperative threedimensional computed tomographic images (above). Preoperative and postoperative zygomatic arch view radiographs
(below)
20.5 Key Technical Points
3. In situations where the protrusion of the zygomatic arch begins posterior to the anterior
1. When accessing the zygomatic arch through a
sideburn incision, it is recommended to
employ blunt dissection through the subcutaneous fatty layer. This approach is preferable
over the use of electrocautery or sharp scissors, as it minimizes the risk of injury to the
frontal branch of the facial nerve.
2. After completing the osteotomy on the zygomatic body, it is crucial to verify the mobility of
the zygomatic arch before withdrawing the saw
from the osteotomy site. If further adjustment
tubercle, additional burring at the posterior
part of the osteotomy site on the arch may
enhance the aesthetic outcome.
4. Postoperatively, patients are typically able to
be discharged on the same day as the surgery.
They are advised to adhere to a soft diet for
the rst 2weeks following the procedure and
to avoid any trauma or direct pressure on the
surgical area for approximately 6 weeks to
ensure proper healing and to maintain the
integrity of the surgical results.
is needed, repositioning the saw accurately at
the initial osteotomy site can be challenging.
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20 The Mini-Zygoma Reduction Surgery
20.6 Case Study
Case 1 (Fig.20.4)
A 28-year-old man with an outward protrusion of the zygomatic arch underwent the minizygoma reduction surgery. A concomitant mandibular reduction was performed. The protrusion
of the zygomatic bone is efciently improved resulting in a reduction of the midface width and
a smooth facial contour (Fig.20.4).
203
Fig. 20.4 Preoperative view of a 28-year-old man who underwent the mini-zygoma reduction surgery (left) and
postoperative view at 4months after the surgery (right)
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204
Case 2 (Fig.20.5)
A 21-year-old woman with lateral prominence in her midface region was planned for the minizygoma reduction surgery. Botulinum toxin injection was done together to treat her masseteric
hypertrophy. The outwardly protruding portion of the zygomatic bone was reduced to result in
a slender and smooth facial contour and to a more feminine appearance (Fig.20.5).
S. Park
Fig. 20.5 Preoperative view of a 21-year-old woman who underwent the mini-zygoma reduction surgery (left)
and postoperative view at 3months after the surgery (right)
20.7 Complications
andManagement
The most common aesthetic concern following
the procedure was undercorrection of the zygomatic body. Approximately 10.6% of patients
According to the ndings from a study conducted
at the authors’ institution, the mini-zygoma
reduction surgery was performed on an outpatient
basis without signicant immediate complications such as unanticipated bleeding or nerve
injuries [1]. None of the patients required hospitalization for postoperative care. Other serious
complications like facial nerve paralysis, hematoma, infection, nonunion, or malunion of the
bone segments were also not observed in the
study.
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expressed dissatisfaction with their results, primarily citing residual prominence in the zygomatic body [1]. Notably, many of these dissatised
patients had initially declined a more extensive
zygoma reduction surgery under general anesthesia, as recommended by their surgeon. Some
patients who were unhappy with their minizygoma reduction outcomes subsequently opted
for conventional zygoma reduction surgery to
achieve more satisfactory results [1]. In a few
instances, the prominence of the zygomatic body
20 The Mini-Zygoma Reduction Surgery
205
became more noticeable postoperatively due to
the reduction of the zygomatic arch, leading to a
relative accentuation of the body. These ndings
underscore the importance of surgeons applying
strict criteria when selecting candidates for minizygoma reduction surgery to prevent the need for
further surgical intervention and to enhance
patient satisfaction.
20.8 Discussion
In comparison to the conventional bi-coronal
approach, the intraoral approach with a pretragal
incision reduces surgical effort and time.
However, this method necessitates general anesthesia to ensure patient safety, as bleeding or
saline used for irrigation can potentially enter the
airway, posing a risk of respiratory complications
[1, 6]. Soft tissue sagging or cheek drooping is a
major concern post-zygoma reduction surgery,
often attributed to extensive dissection during the
intraoral approach. Postoperative care for patients
with intraoral incisions includes dietary precautions to prevent wound contamination.
Zygomatic protrusion can manifest as either a
protruding zygomatic body or arch, or occasionally both [1, 3, 7, 8]. Traditional malar reduction
techniques target both the zygomatic body and
arch [9–14]. However, not all patients with a
wide midface have signicant zygomatic body
protrusion. Approximately 10% of patients seen
at the authors’ institute presented with isolated
zygomatic arch protrusion, without notable zygomatic body prominence.
For patients with only zygomatic arch protrusion, an intraoral approach is unnecessary and a
simpler surgical method can be employed without general anesthesia. This approach reduces the
risk of complications typically associated with
intraoral procedures.
Minimally invasive zygoma reduction techniques previously introduced often do not utilize
rigid xation [6, 15]. This can lead to complications like downward displacement, malunion, or
nonunion of the osteotomized zygomatic bone
segment. Our mini-zygoma reduction surgery
addresses this by implementing rigid xation
through a sideburn incision [1]. Rigid xation
counters the downward and rotational forces
exerted by the masseter muscle, ensuring longterm stability. Utilization of a prebent titanium
plate allows for precise repositioning of the zygomatic arch and correction of asymmetry [1, 2].
In patients with mild hypertrophy of the zygomatic body, the approach to zygomatic osteotomy
needs to be carefully considered. When a surgeon
attempts to make an osteotomy line deeper into the
zygomatic body in this limited exposure, it can
present several challenges. Firstly, this approach
can make the osteotomy more complex and technically demanding. Secondly, and more importantly, it increases the risk of bleeding, which is a
signicant concern in this surgical procedure.
Given these considerations, this approach is generally not recommended for such cases [16, 17].
In summary, patient evaluation for zygoma
reduction surgery must carefully determine the
need for reducing the zygomatic body. In cases of
isolated zygomatic arch protrusion, the minizygoma reduction technique offers a simpler and
effective solution for midface aesthetic improvement, suitable for outpatient procedures.
References
1. Park S, Kim DH, Kim T, Lee TS. The minizygoma reduction surgery: a simple and reliable
approach for mid-face narrowing. J Craniofac Surg.
2016;27:1298–301.
2. Yang DB, Park HS, Park CG.Technical renements
of infracture for the zygomatic body and arch reduction. Aesth Plast Surg. 1998;22:380–90.
3. Lee TS.Standardization of surgical techniques used
in facial bone contouring. J Plast Reconstr Aesthet
Surg. 2015;68:1694–700.
4. Experience in East Asian MX. Facial recontouring:
reduction malarplasty and mandibular reshaping.
Arch Facial Plast Surg. 2010;12:222–9.
5. Morris DE, Moaveni Z, Lo LJ.Aesthetic facial skeletal contouring in the Asian patient. Clin Plast Surg.
2007;34:547–56.
6. Rhee DY, Kim SH, Shin DH, Uhm KI, Song WC, Koh
KS, Choi HG.Lateral facial contouring via a single
preauricular incision. J Plast Reconstr Aesthet Surg.
2012;65:e205–12.
7. Yang DB, Chung JY.Infracture technique for reduction malarplasty with a short preauricular incision.
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S. Park
Plast Reconstr Surg. 2004;113:1253–61; discussion
1262–1253.
8. Nagasao T, Nakanishi Y, Shimizu Y, Hatano A,
Miyamoto J, Fukuta K, Kishi K.An anatomical study
on the position of the summit of the zygoma: theoretical bases for reduction malarplasty. Plast Reconstr
Surg. 2011;128:1127–38.
9. Wang T, Gui L, Tang X, Liu J, Yu D, Peng Z, Song
B, Song T, Niu F, Yu B.Reduction malarplasty with
a new L-shaped osteotomy through an intraoral
approach: retrospective study of 418 cases. Plast
Reconstr Surg. 2009;124:1245–53.
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. Ma YQ, Zhu SS, Li JH, Luo E, Feng G, Liu Y, Hu
J. Reduction malarplasty using an L-shaped osteotomy through intraoral and sideburns incisions. Aesth
Plast Surg. 2011;35:237–41.
12. Kim YH, Seul JH.Reduction malarplasty through an
intraoral incision: a new method. Plast Reconstr Surg.
2000;106:1514–9.
13. Hong SE, Liu SY, Kim JT, Lee JH.Intraoral zygoma
reduction using L-shaped osteotomy. J Craniofac
Surg. 2014;25:758–61.
14. Qiu S, Gui L, Wang M, Chen Y, Niu F, Liu J, Liu W,
Zhang Y.Biomechanical analysis of reduction malarplasty with L-shaped osteotomy. J Craniofac Surg.
2012;23:749–54.
15. Lee JS, Kang S, Kim YW. Endoscopically assisted
malarplasty: one incision and two dissection planes.
Plast Reconstr Surg. 2003;111:461–7; discussion 468.
16. Onizuka T, Watanabe K, Takasu K, Keyama
A. Reduction malar plasty. Aesth Plast Surg.
1983;7:121–5.
17. Lee TS. The importance of shaving the zygomatic
process during reduction malarplasty. Int J Oral
Maxillofac Surg. 2016;45:1002–5.
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Alloplastic Modication
oftheMidface
SanghoonPark
21
21.1 Pearls
1. Augmentation in the midface region can
enhance volume and balance in Asian facial
aesthetics, providing a more harmonious and
proportionate appearance. Augmentation in
the malar eminence, which is popular in
Western countries, is less common, reecting
the region’s unique cultural perspectives on
facial beauty.
2. The procedures commonly performed for
midface augmentation include paranasal and
suborbital augmentation, addressing specic
areas to achieve desired aesthetic outcomes.
3. Alloplastic materials used in these procedures
typically consist of implants such as silicone
or porous polyethylene. While autogenous fat
grafting is an alternative, it has limitations in
the amount of augmentation achievable and
unpredictability related to cell survival after
transplantation. The use of autogenous bone
grafts for midface augmentation is infrequent,
mainly due to issues with bone resorption
over time, which can compromise the longterm stability and effectiveness of the
augmentation.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
4. Screw xation of implants in midface augmentation is crucial, as it not only prevents
implant movement but also eliminates gaps
between the implant and the underlying skeletal structure. This technique ensures a snug
t of the implant, reducing the risk of postoperative complications like hematoma or
seroma formation and contributing to a more
predictable augmentation result.
21.2 Introduction
Midface hypoplasia, while less frequently a subject of patient complaints and consultations compared to a wide midface, still requires
comprehensive consideration, especially in the
context of Asian facial structures where increased
width relative to anteroposterior (AP) length is
common. When the ultimate goal is to achieve a
slimmer-looking yet volumetric face, augmentation of the midface can be a straightforward and
cost-effective approach. The midface is anatomically divided into several subunits, including the
cheek, paranasal area, and suborbital area, with
the latter two being the most commonly targeted
areas for augmentation [1, 2].
A simple and rapid method for midface augmentation is the use of free fat grafting with a
small cannula. For moderate augmentation, typically 10–20cc of centrifuged fat is required for
each side, taking into account the potential for
© 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_21
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208
S. Park
later resorption. In cases of severe hypoplasia
with Class III deformity, orthognathic surgery
may be necessary to achieve the desired
correction.
This chapter will focus primarily on the use of
alloplastic implants for maxillary augmentation,
exploring the techniques, considerations, and
outcomes associated with this specic approach
to midface enhancement.
21.3 Patient Assessment
andConsultation
Physical examination is indeed a fundamental
component of preoperative assessment and planning in aesthetic augmentation procedures.
Reviewing photographs with the patient is a valuable practice as it aids in discussing aesthetic
concerns and goals. It provides a visual reference
that can help both the patient and the surgeon to
align their expectations and objectives for the
procedure.
In most cases, especially involving a surgically altered or traumatically deformed skeleton,
imaging techniques such as cephalometric
X-rays and computed tomographic (CT) scans
are essential. These imaging modalities provide
a detailed view of the skeleton in different planes
and in three dimensions, which is crucial for
accurate preoperative planning and successful
surgical outcomes. They are particularly valuable in complex cases where standard physical
examination and photographic assessments may
not sufce. The decision to omit radiologic
assessments is typically based on the procedure’s
nature and the specic anatomical area involved.
In such cases, the size and position of the implant
are determined based on the surgeon’s aesthetic
judgment, guided by their experience and the
patient’s physical examination.
In patients requiring midface augmentation, it
is common to nd that their intermaxillary skeletal relationships and occlusion are within the
normal range. However, some patients may
exhibit a Class III relationship with hypoplastic
maxilla. The use of alloplastic implants in the
paranasal area can simulate the effects of a LeFort
I osteotomy.
Patients seeking midface augmentation often
have simple and limited midface hypoplasia and
are looking to add volume and restore facial balance. A depressed paranasal area can accentuate
the nasolabial fold, giving an aged appearance.
This condition is associated with various degrees
of Binder syndrome. Flat suborbital area is frequently accompanied with prominent malar eminence and may give at and square impression.
Additionally, a at and sunken suborbital rim can
give the illusion of proptosis (bulging eyes).
Augmentation of the pyriform aperture can effectively increase the projection of the nasal base
and open the nasolabial angle. This technique
also helps to lessen the depth of the nasolabial
fold by smoothing it out from below. Previous
zygomatic reduction also may alter the orbitalmalar relationship and worsens the look of
depressed maxilla.
Paranasal pyriform aperture augmentation
increases the projection of the nasal base and
opens the nasolabial angle. It also tends to lessen
the depth of the nasolabial fold by effacing it from
below. This procedure makes people look younger
and richer and this is the reason of its Korean
nickname, “nobility surgery”.
21.4 Surgical Techniques
1. Alloplastic augmentation of the midface can
be performed under either local anesthesia
with sedation or general anesthesia. When
implants are placed through intraoral
approaches, general anesthesia with endotracheal intubation assures protection of the airway in case of bleeding.
2. Intraoral sulcus incisions are used likewise
other facial bone contouring surgery. These
incisions should be made with a sufcient
labial cuff to allow watertight mucosal repair.
Because the implant is a foreign body, watertight closure is important to prevent possible
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21 Alloplastic Modication oftheMidface
209
contamination and inammation around the
implant (Fig. 21.1).
3. The medial extent of the incision is made just
lateral to the pyriform aperture not to place
incisions directly over the implant. Suborbital
augmentation is done through an intraoral
incision from the canine to the second premolar about 1cm above the upper gingivolabial sulcus.
4. Subperiosteal dissection exposes the area to
be augmented. In paranasal augmentation,
the infraorbital nerve usually does not need
to be exposed or identied. The extent of dissection should t to the size of implant.
Overly wide dissection can cause unnecessary large dead space which may cause
seroma collection and infection, while too
narrow dissection can cause distortion of
implant.
5. The choice of appropriate size and thickness
of implant is the most important factor for
successful augmentation. It is helpful to
place temporary implants over the skin surface to check the size and contour (Figs. 21.1
and 21.2).
6. Final adjustments to the implant are crucial.
Using a scalpel or scissors, the implants are
precisely carved to t the augmentation area.
They are then thoroughly cleaned with
Betadine solution before being placed
through the intraoral incision. This process
ensures the implant is tailored to the specic
contours of the surgical site, enhancing both
the t and the aesthetic result.
7. The positioning of the implant is critical,
particularly in paranasal augmentation. If the
medial border of the implant is too distant
from the pyriform aperture, the augmentation effect may be insufcient, potentially
leading to unnatural demarcation.
Conversely, placing the implant over the pyriform aperture can negatively impact the
nasal airway and alter nostril shape.
Therefore, achieving a balance in implant
placement is key to both functional and aesthetic success.
8. In suborbital augmentation, the implant
placement requires careful consideration to
avoid the infraorbital nerve and to ensure
adequate augmentation. The placement must
be high enough to achieve the desired aesthetic effect but should avoid impinging on
the infraorbital nerve to maintain midface
sensation (Figs. 21.3 and 21.4).
9. Before securing the implant with screws, it’s
advisable to manually check the effect of
augmentation and symmetry by both visual
inspection and palpation. Generally, a minimum of two-point xation with screws is
recommended. This prevents implant rotation and ensures predictable outcomes. Care
should be taken to avoid the root of the
canine during screw placement.
10. Meticulous attention to hemostasis is necessary, as even a small amount of hematoma
can lead to infection around the implants.
Extensive irrigation with Betadine and saline
solution is recommended to minimize this
risk. Finally, the wound should be closed in a
watertight manner using 4-0 Vicryl sutures to
prevent potential complications and promote
optimal healing.
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210
a b
ab
S. Park
Fig. 21.1 Paranasal augmentation. Note that intraoral
incision is made about 1cm above the upper gingivolabial
sulcus. Subperiosteal dissection exposes the area to be
augmented. The infraorbital nerve should be preserved.
Fig. 21.2 Implants for paranasal augmentation. The
implants used in ID hospital are shown. It is made of silicon, triangular shape with concave medial side to t to
Two points xation with screws are recommended to prevent rotation of implant. The root of the canine should be
avoided when the implant is immobilized with screws
pyriform aperture. The thickness of implants ranges from
2 to 6mm
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