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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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22 Secondary Zygoma Reduction
22.5 Cases
(A) Undercorrection of Zygoma Arch: Insucient Midfacial Width Reduction
A 27-year-old female who previously underwent reduction malarplasty in other clinic visited
our hospital. The patient complained that the facial width was not reduced. After a new body
osteotomy was performed on medial side of the previous osteotomy, the arch was cut through
sideburns incision. The osteotomized zygoma was impacted medially and xed with plates and
screws (Figs.22.2 and 22.3).
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Fig. 22.2 (Left) Blind osteotomy and no xation of zygoma arch. (Right) Direct osteotomy and rigid xation of
zygoma arch
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Fig. 22.3 (Left) Preoperative frontal view. (Right) Postoperative frontal view
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22 Secondary Zygoma Reduction
(B) Undercorrection of Zygoma Body: Malar Protrusion in Oblique View
A 26-year-old female who underwent reduction malarplasty through infracture technique. The
patient complained that the body was still prominent. We reduced the body size and impacted
zygoma medially with using medial impaction technique.
In infracture technique, greenstick fracture of body cannot effectively reduce the excess protruding body. Postoperative facial depression in the preauricular area was a common problem
because only the posterior portion of arch was impacted medially.
In our technique, complete L-type osteotomy of body can effectively reduce the excess protruding body. And, balanced malar contours are achieved because we can freely control the
degree of body impaction as well as arch impaction (Figs.22.4 and 22.5).
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Fig. 22.4 (Left) Incomplete fracture and no xation of zygoma body. (Right) Complete osteotomy and rigid
xation of zygoma body
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Fig. 22.5 (Left) Preoperative frontal view. (Right) Postoperative frontal view
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22 Secondary Zygoma Reduction
(C) Undercorrection of Zygoma Body and Arch: Total
A 25-year-old female who previously underwent reduction malarplasty complained that the
zygoma was still protruded and the midfacial width was not reduced. The patient wanted secondary zygoma reduction for aesthetic reasons. After a new body osteotomy was performed on
medial side of the previous osteotomy, the arch was cut through sideburn incision. The osteotomized zygoma was impacted medially and xed with plates and screws (Fig.22.6).
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Fig. 22.6 (Above and center, left) Preoperative three-dimensional CT scan. (Above and center, right)
Postoperative three-dimensional CT scan. (Below, left) Preoperative basal skull radiograph. (Below, right)
Postoperative basal skull radiograph
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(D) Asymmetry: Zygoma Malposition
A 29-year-old female patient visited our hospital for malar asymmetry and cheek drooping
after primary reduction malarplasty. Right malar complex was displaced inferiorly by malunion and left zygoma arch was more protruded, resulting cheek drooping and malar asymmetry. After re- osteotomy and trimming at the previous osteotomy site, the right malar complex
was shifted superiorly and medially. Two- point rigid xation was performed with using plates
and screws. More reduction of zygoma body and medial impaction of arch was made in the left
(Fig.22.7).
J. Lee
Fig. 22.7 (Above, left) Preoperative three-dimensional CT scan. (Above, right) Postoperative three-dimensional
CT scan. (Below, left) Preoperative basal skull radiograph. (Below, right) Postoperative basal skull radiograph
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22 Secondary Zygoma Reduction
(E) Conservative Procedures: Plates Removal and Shaving
A 42-year-old female previously underwent two-jaw surgery and concomitant zygoma reduction. The patient complained that the malar area was still prominent, particularly in the oblique
view. The radiologic evaluation showed that the zygoma was sufciently reduced in the rst
surgery. New osteotomy and medio-posterior impaction of the zygoma was concluded to be an
impractical plan. We removed the plates in the zygomatic body and shaved the prominent portion of the zygoma using bur and rasp. (Fig.22.8).
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Fig. 22.8 (Left) Preoperative three-dimensional CT scan. (Right) Postoperative three-dimensional CT scan
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22.6 Complications
andManagement
(Fig. 22.9). Open and irrigation is helpful for
managing severe infection. When inferior orbital
nerve or zygomaticofacial nerve is damaged durMajor complications after zygoma reduction surgery are maxillary sinusitis, nerve injury, and
plate fracture. Maxillary sinus has to be opened
for effective reduction of zygoma body, making
susceptible to infection. CT scan is the best imaging modality for sinusitis. Adequate administra-
ing surgery, numbness of the upper lip or pain of
the temple area can be occurred. This symptom
usually disappear in 6 months. Trauma before
sufcient bone union can break the plates.
Additional xation is considered in revisional
surgery (Fig.22.10).
tion of antibiotics is the rst choice for treatment
Fig. 22.9 A 37-year-old female patient had sinusitis after
zygoma reduction. (Left) Computed tomography (CT)
demonstrating acute sinusitis with air bubbles within uid
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density, indicating purulence in the right maxillary sinus.
(Right) CT demonstrating normal maxillary sinus after
antibiotic treatment
22 Secondary Zygoma Reduction
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Fig. 22.10 A 24-year-old male patient had reivision surgery for changing plates and screws. (Left) Panoramic radio-
graph and 3D CT demonstrating plate fracture on left zygoma. (Right) Panoramic radiograph and 3D CT demonstrating
xation reinforcement with additional plate
22.7 Discussion
14].Nonunion of the osteotomy site may result in
clicking sound, pain, and relapse. Major source
Surgical techniques for reduction malarplasty
can be classied by three factors: approach, osteotomy, and xation. Bicoronal approach was
adopted in secondary cases because it provided
denite manipulation under direct vision. But
young patients do not prefer coronal approaches
because of long scars [2]. In authors’ experience
intraoral approach can expose enough space even
in most of secondary cases. Absolute indication
for coronal approach is multiple-segmented
zygoma which cannot be controlled. In case of
delayed nonunion or malunion, strong muscle
pull and stiff soft tissue make the reposition of
the zygoma impossible. In these cases, wide
exposure and release of all the attaching soft tissue may be necessary via coronal approach [12,
of nonunion is insecure xation; however, inade-
quate immobilization by mastication and trauma
may be the sources as well. Vague, dull, sustain-
ing pain around the maxilla and eye is a source of
suspicion. However, accurate diagnosis is not
easy. Diagnostic and imperative surgical inter-
vention may be necessary in case of clinical
impression. Complete resection of scar tissue
between osteotomy, exposing fresh bony margin,
is critical. If there should be bony gap, proper
bone graft is necessary. So preparation of bony
donor site and discussion with patient on the
necessity of bone graft is important.
Soft tissue depression along the osteotomy
site is rare but happens in patient with thin skin.
Bony gap or bony step may be reconstructed with
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either bone graft or alloplastic materials such as
Medpor. In most cases with mild depression, an
easier way is fat injection or ller injection as a
camouage.
References
1. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg. 1991;88:53–61.
2. Wang T, Gui L, Tang X, etal. Reduction malarplasty
with a new L-shaped osteotomy through an intraoral
approach: retrospective study of 418 cases. Plast
Reconstr Surg. 2009;124:1245–53.
3. Yang X, Mu X, Yu Z, etal. Compared study of Asian
reduction malarplasty: wedge-section osteotomy
versus conventional procedures. J Craniofac Surg.
2009;20(Suppl 2):1856–61.
4. Lee KC, Ha SU, Park JM, et al. Reduction malarplasty by 3-mm percutaneous osteotomy. Aesth Plast
Surg. 2006;30:333–41.
5. Yang DB, Chung JY.Infracture technique for reduction malarplasty with a short preauricular incision.
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10. Yang JH, Lee JH, Yang DB, etal. Prevention of complication and management of unfavorable results in
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11. Lee YH, Lee SW.Zygomatic non-union after reduction malarplasty. J Craniofac Surg. 2009;20:849–52.
12. Baek RM, Kim J, Lee SW.Revision reduction malarplasty with coronal approach. J Plast Reconstr Aesthet
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13. Yuji N, Tomohisa N, Yusuke S, etal. The boomerang
osteotomy– a new method of reduction malarplasty. J
Plast Reconstr Aesthet Surg. 2012;65:e111–20.
14. Baek RM, Kim J, Kim BK. Three-dimensional
assessment of zygomatic malunion using computed
tomography in patients with cheek ptosis caused by
reduction malarplasty. J Plast Reconstr Aesthet Surg.
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