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Fig. 2.5 Buccal fat pad.
The buccal fat pad
consists of a main body
and four extensions:
buccal, pterygoid,
supercial, and deep
temporal. The body is
centrally positioned. The
buccal extension lies
supercially within the
cheek, and the pterygoid
and temporal extensions
are situated more deeply
S. Park
ment following an anterior vestibular approach is
crucial; improper positioning during surgical closure can result in a drooping chin and sagging
lower lip, altering the facial appearance.
2.5.2 Buccinator Muscle (Fig.2.4)
The buccinator muscle, located below the mucogingival junction opposite the molars and ascending along the oblique line of the ascending ramus,
plays a vital role in the mimetic muscle system.
Innervated by the motor buccal branch of the
facial nerve, this muscle facilitates movements
akin to peristaltic motion. Disruption of the buccinator muscle can impair bolus transport, affecting oral functionality.
2.6 Fat
2.6.1 Buccal Fat Pad (Fig.2.5)
The buccal fat pad, an essential anatomical feature in facial contouring, is composed of a central
main body and four extensions: buccal, pterygoid, supercial, and deep temporal (Fig. 2.5).
The main body is centrally located and extends
above the parotid duct along the masseter’s anterior border, then coursing medially to overlay the
posterior maxilla’s periosteum. In this region, it
covers the buccinator muscle’s upper bers,
extending forward over the maxillary second
molar and wrapping around the maxilla to the
pterygomaxillary ssure, where it closely associates with branches of the internal maxillary artery
and the maxillary division of the trigeminal
nerve.
The buccal extension, the most supercial part
of the fat pad, contributes signicantly to the
cheek’s fullness. It lies below the parotid duct,
extending along the masseter’s anterior border
into the mandibular retromolar area, and is anterior to the ramus. Intraorally, its caudal extension
aligns with the occlusal surface of the mandibular
third molar, with its anterior boundary marked by
the facial vessels. The parotid duct traverses
supercially over the fat pad before penetrating
the buccinator muscle, while the masseteric fascia limits and denes the buccal extension’s
space.
2.7 Conclusion
A comprehensive understanding of the critical
anatomical structures, including nerves, vessels,
muscles, and fat, is indispensable for performing
facial bone contouring surgery. This chapter
offers an overview of these vital structures,
underscoring their importance in surgical planning and execution. Surgeons engaged in facial
bone contouring must diligently respect these
anatomical components to avoid potential dam-
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2 Anatomic Basis forFacial Bone Contouring Surgery
13
age, ensuring both the safety and effectiveness of
their procedures. The information provided here
serves as a foundational guide, enabling surgeons
to approach facial bone contouring surgeries with
a well-informed perspective.
References
1. Pitanguy I, Ramos AS.The frontal branch of the facial
nerve: the importance of its variations in face lifting.
Plast Reconstr Surg. 1966;38:352.
2. Standring S, editor. Gray’s anatomy. 40th ed.
Edinburgh: Churchill Livingstone; 2008.
3. Hwang K, Lee W, et al. Vulnerability of the inferior
alveolar nerve and mental nerve during genioplasty:
an anatomic study. J Craniofac Surg. 2005;16:10–4.
4. Ellis E 3rd, Zide MF, editors. Surgical approaches to
the facial skeleton. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.
5. Al-Kayat A, Bramley P. A modied pre-auricular
approach to the temporomandibular joint and malar
arch. Br J Oral Maxillofac Surg. 1979;17:91.
6. Drake R. Gray’s anatomy of students. Philadelphia:
Churchill Livingstone; 2010. p.855–66.
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t.me/Dr_Mouayyad_AlbtousH
Basic Approaches forFacial Bone
Contouring Surgery
SungJaeAhn
3
3.1 Pearls
1. Before making facial incisions, it is imperative to consider facial aesthetics, the preservation of facial expression muscles, branches of
the facial nerve, and sensory nerves to ensure
optimal surgical outcomes and patient
satisfaction.
2. The intraoral approach is predominantly used
in facial bone contouring surgeries. This
approach provides extensive exposure to most
of the facial skeleton while leaving scars completely concealed within the oral cavity.
3. The bicoronal approach offers versatile access
to the upper and middle facial skeleton,
including the zygomatic arch. This approach
effectively hides scars within the hairline and
ensures excellent surgical access.
4. Transcutaneous incisions, such as the Gillies’
approach and sideburn incisions, are employed
for accessing the zygoma. Scars from the
Gillies’ approach can be concealed within the
hairline, while sideburn incisions provide
direct access to the posterior portion of the
zygomatic arch.
5. Surgical approaches through the lower eyelid,
including the subciliary and transconjunctival
incisions, offer signicant exposure to the
inferior orbital rim, the lower part of the lateral orbital rim, and the upper region of the
zygoma body. The transconjunctival approach,
in particular, ensures that scars remain hidden
within the conjunctiva, maintaining the aesthetic integrity of the eye area.
3.2 Introduction
Successful facial bone contouring surgeries hinge
on adequate access and exposure of the facial
skeleton. Selecting an appropriate surgical
approach involves multiple considerations.
Firstly, incision sites should prioritize facial aesthetics along with surgical convenience, placing
incisions in less noticeable areas, even if distant
from the skeletal site of operation. Secondly, care
must be taken to prevent damage to muscles and
nerves responsible for facial expressions, as
facial paralysis could result in signicant cosmetic and functional decits. Lastly, surgeons
must be aware of numerous sensory nerves exiting the facial skeleton to avoid postoperative
hypesthesia, combining technical precision with
anatomical knowledge [1–3].
S. J. Ahn (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: sjahn0220@idhospital.com
© 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_3
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S. J. Ahn
3.3 Surgical Approaches
3.3.1 Intraoral Approach
3.3.1.1 Maxillary Vestibular Approach
For malar reduction surgery, the zygomatic bone’s
body is accessible via an intraoral incision.
Preoperative administration of a vasoconstrictor
along the incision line reduces bleeding. The incision, made about 5 mm above the mucogingival
junction, can extend posteriorly as needed, typically to the rst molar. This incision sequentially
cuts through mucosa, submucosa, muscle, and
periosteum. Using periosteal elevators, the tissues
are elevated subperiosteally. The infraorbital nerve
is located by dissecting superomedially toward the
infraorbital foramen. Dissection continues superiorly to the lateral edge of the infraorbital rim and
posteriorly behind the zygomaticomaxillary buttress. Closure involves a simple absorbable suture
through the mucosa, submucosa, musculature, and
periosteum (Fig.3.1) [1–4].
3.3.1.2 Mandibular Vestibular
Approach
This is the standard approach for mandibular contouring surgeries. After vasoconstrictor injection,
the mucosa from canine to canine is incised, either
curvilinearly or in a V-shape, sparing the frenulum
and extending anteriorly. The incision reveals the
mentalis muscle, with care taken to avoid the mental nerve. When approaching the mandible’s body
and ramus, the incision is placed about 5mm below
the mucogingival junction. Sparing the mucosa
near mental foramen helps to protect the mental
nerve and also prevents the nerve from being overly
pulled. The mentalis muscle is subperiosteally
stripped from the mandible, with careful periosteal
detachment around the mental foramen. Dissection
proceeds posteriorly along the mandibular body
and ramus, staying within the periosteal layer to
prevent vascular damage. Subperiosteal dissection
near the mandibular angle causes the masseter
muscle to retract upward. For wound closure in the
posterior region, a single-layer suture sufces,
while the anterior region necessitates a two-layer
closure to rmly reattach the mentalis muscle.
Three absorbable sutures reapproximate the mentalis muscle, followed by mucosal closure with
absorbable sutures (Fig.3.2) [1–3, 5–7].
3.3.2 Bicoronal Approach
The bicoronal approach is utilized for exposing
the skeleton of the upper and middle face in facial
bone contouring surgeries, including procedures
like malar reduction or forehead contouring.
Consideration of the patient’s hairline is crucial
when designing the incision line, which typically
Fig. 3.1 Maxillary Vestibular Approach: This approach
allows easy access to the zygomatic bone through an
intraoral incision, providing excellent visualization without external scarring. Dissection encompasses areas
t.me/Dr_Mouayyad_AlbtousH
superomedial to the infraorbital neurovascular bundle and
superolateral to the infraorbital rim, extending laterally
behind the zygomaticomaxillary buttress
3 Basic Approaches forFacial Bone Contouring Surgery
17
curves anteriorly near the vertex, remaining
about 5cm within the hairline. Zigzag-designed
bicoronal incisions are preferred to minimize
scar visibility. This incision can extend inferiorly
to the earlobe level, connecting with a preauricular incision, thus providing direct exposure to the
zygomatic arch and infraorbital rims.
To reduce bleeding, vasoconstrictors are
injected along the proposed incision line. The
incision, made with a scalpel, extends from one
superior temporal line to the other, cutting
through skin, subcutaneous tissue, and galea to
reveal the subgaleal plane. The ap is then lifted
and dissected above the pericranium. Below the
Fig. 3.2 Mandibular Vestibular Approach: This intraoral
incision offers superior visualization and access for mandible contouring surgeries without external scars, preserving facial motor and sensory nerves
superior temporal line, the incision extends to the
supercial layer of the temporalis fascia.
Hemostatic measures include applying Raney
clips or electrocauterizing bleeding vessels. Care
is taken to avoid extensive cauterization at the incision edges to prevent alopecia. The ap is elevated
above the pericranium, typically using manual nger dissection and blunt periosteal elevators. The
dissection plane, just supercial to the thick temporalis fascia, continues anteriorly and inferiorly,
eventually allowing the ap to evert. At frontal
area, the dissection proceeds anteriorly over periosteum, and the periosteum is incised at the level
about 2cm from the supraorbital ridges to protect
the supratrochlear and supraorbital nerves. Then
subperiosteal dissection proceeds to the supraorbital ridges. Lateral portion of the ap is dissected
above the temporalis fascia. As dissection nears
the ear, the supercial layer of the temporalis fascia is incised at the zygomatic arch root. The dissection remains supercial to the temporalis fascia,
safeguarding the temporal branch of the facial
nerve. Once the zygomatic arch’s superior surface
is visible, a periosteal incision is made along this
surface, extending to the orbital rim and meeting
the cross-forehead incision. This subperiosteal
elevation exposes the lateral surfaces of the zygomatic arch, body, and lateral orbital rim.
Closure of the bicoronal incision involves
suture resuspension of soft tissues, periosteum
suturing around the orbital rims, and a two-layer
scalp closure using absorbable and nonabsorbable sutures or staples (Fig.3.3).
Fig. 3.3 Bicoronal
approach: This approach
is integral for directly
exposing the upper and
midface skeleton,
particularly enabling full
access to the zygomatic
body, arch, and lateral
and inferior orbital rims.
Subgaleal dissection is
changed to subperiosteal
dissection at the level
about 2cm from the
supraorbital ridges
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18
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S. J. Ahn
3.3.3 Transcutaneous Approach
3.3.3.1 Sideburn Approach
For direct access to the zygomatic arch’s posterior portion, an incision is made within the sideburn area. An 8–10mm incision is made with a
scalpel at the zygomatic arch level, midline to the
sideburn. Given the proximity to the frontal
branch of the facial nerve, careful blunt dissection is recommended. Following subcutaneous
dissection, a sharp incision is made on the periosteum, and subperiosteal dissection exposes the
osteotomy and xation site. Wound closure
involves two absorbable sutures for the subcuta-
Fig. 3.4 Sideburn approach: This approach offers direct
access to the zygomatic arch’s posterior portion via a
sideburn- level incision, necessitating caution due to the
proximity of the frontal branch of the facial nerve
neous layer, followed by simple nonabsorbable
sutures for the skin (Fig.3.4).
3.3.3.2 Gillies’ Approach
This approach involves a temporal incision made
2.5cm superior and anterior to the helix, within
the hairline. A 2cm incision is made, avoiding
the supercial temporal artery, and dissection
continues through subcutaneous tissue and supercial temporal fascia to the deep portion of the
deep temporal fascia. Incising this fascia exposes
the temporalis muscle. A periosteal elevator,
inserted deep to the temporalis fascia and supercial to the temporalis muscle, advances to the
zygomatic body’s posterior portion. Scalp closure is typically achieved with staples (Fig.3.5).
3.3.4 Periorbital Approach
3.3.4.1 Subciliary Incision
The subciliary approach is utilized to access the
lateral and inferior orbital rim and the upper part
of the zygomatic body and maxilla. Protecting the
cornea is vital, and the use of a temporary tarsorrhaphy or corneal shield can minimize ocular
injuries. The incision, about 2mm below the eyelashes and potentially extending laterally past the
lateral canthus, should be inltrated with a vasoconstrictor to facilitate hemostasis and tissue separation. The initial incision is through the skin,
with subsequent sharp dissection to the inferior
Fig. 3.5 Gillies’ approach: Utilizing a plane between the deep temporal fascia and the temporalis muscle, this approach
allows access to the zygomatic body’s posterior portion for osteotomy
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3 Basic Approaches forFacial Bone Contouring Surgery
19
orbital rim. The orbicularis oculi muscle is
incised, and a skin-muscle ap is elevated for
access. The periosteum is incised below the
orbital rim, taking care to avoid the infraorbital
neurovascular bundle. Periosteal elevation reveals
the anterior surfaces of the maxilla and zygoma.
Closure involves suturing the periosteum and
skin, typically without the need to suture the orbicularis oculi muscle (Fig.3.6) [1–3, 8–11].
After placing a corneal shield, a vasoconstrictor
is injected under the conjunctiva. The lower eyelid is everted, and traction sutures are placed. If a
lateral canthotomy is needed, it begins the incision, followed by cutting through the conjunctiva
toward the infraorbital rim. The incision through
the conjunctiva and lower eyelid retractors is
midway between the tarsal plate and the conjunctival fornix, avoiding the lacrimal sac. Periosteum
is sharply incised below the orbital rim, and ele-
3.3.4.2 Transconjunctival Incision
This approach, similar to the subciliary incision,
allows exposure of the lateral and inferior orbital
rim and the upper zygomatic body and maxilla.
vation exposes the maxilla and zygoma. Inferior
canthopexy and conjunctival suturing nalize the
procedure, with subcutaneous and skin sutures at
the canthotomy site (Fig.3.7) [1–3, 9, 11, 12].
ab
Fig. 3.6 Subciliary approach: This approach involves an incision just below the eyelashes, extending laterally, and
allows for direct access to the orbital rim and zygomatic body, minimizing visible scarring
ab
Fig. 3.7 Transconjunctival approach: Initial incisions are made through the conjunctiva, enabling access to the orbital
rim and zygomatic body without external scarring
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S. J. Ahn
3.4 Key Technical Points
1. In maxillary or mandibular vestibular
approaches, the incision should be placed
about 5mm from the mucogingival junction
for easier closure.
2. During intraoral approaches, careful subperiosteal dissection is necessary to avoid damaging the infraorbital and mental nerves.
3. Using electrocautery in a bicoronal approach
can cause irreversible damage to hair follicles,
leading to alopecia, which may be aesthetically problematic.
4. Shaving hair before a bicoronal incision is not
medically necessary, and preserving hair
helps in minimizing damage to follicles.
5. In subciliary approaches, it’s crucial to tend
the lower lid tissues upward during dissection
to prevent skin dehiscence.
References
1. Ellis E 3rd, Zide MF, editors. Surgical approaches to
the facial skeleton. 2nd ed. Philadelphia: Lippincott
Williams & Wilkins; 2006.
2. Martou G, Antonyshyn OM. Advances in surgical
approaches to the upper facial skeleton. Curr Opin
Otolaryngol Head Neck Surg. 2011;19:242–7.
3. Villwock JA, Suryadevara AC.Update on approaches
to the craniomaxillofacial skeleton. Curr Opin
Otolaryngol Head Neck Surg. 2014;22:326–31.
4. 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.
5. Park S, Lee TS. Aesthetic osseous genioplasty. In:
Pu LL, editor. Aesthetic plastic surgery in Asians:
principle & techniques, vol. II. Boca Raton: CRC
Press; 2015. p.703–28.
6. Lee TS, Kim HY, Kim T, Lee JH, Park S.Importance
of the chin in achieving a feminine lower face: narrowing the chin by the “mini V-line” surgery. J
Craniofac Surg. 2014;25:2180–3.
7. Lee TS, Kim HY, Kim TH, Lee JH, Park S.Contouring
of the lower face by a novel method of narrowing
and lengthening genioplasty. Plast Reconstr Surg.
2014;133:274e–82e.
8. Werther JR.Cutaneous approaches to the lower lid
and orbit. J Oral Maxillofac Surg. 1998;56:60–5.
9. Subramanian B, Krishnamurthy S, Suresh Kumar
P, Saravanan B, Padhmanabhan M. Comparison
of various approaches for exposure of infraorbital
rim fractures of zygoma. J Maxillofac Oral Surg.
2009;8:99–102.
10. Wilson S, Ellis E 3rd. Surgical approaches to the infraorbital rim and orbital oor: the case for the subtarsal
approach. J Oral Maxillofac Surg. 2006;64:104–7.
11. Giraddi GB, Syed MK. Preseptal transconjunctival vs. subciliary approach in treatment of infraorbital rim and oor fractures. Ann Maxillofac Surg.
2012;2:136–40.
12. Uemura T, Watanabe H, Masumoto K, Chuman
T, Satake Y, Yanai T, Harada Y, Ishihara Y, Kikuchi
M.Transconjunctival approach for zygomatic fracture:
a single surgeon’s experience of more than 20 years.
Plast Reconstr Surg Glob Open. 2016;4:e757–61.
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Customized Instruments forFacial
Bone Contouring Surgery
SanghoonPark
4
4.1 Pearls
1. Adopting standardized instruments during
surgical procedures can signicantly decrease
complication rates and lead to more predictable surgical outcomes. This not only
improves the procedural efciency but also
enhances patient satisfaction due to the
increased likelihood of achieving desired
results.
2. The utilization of double-bladed saws and
pre-bent plates in reduction malarplasty plays
a crucial role in minimizing the risk of postoperative asymmetry or errors in the correction of zygoma contours. These tools help
prevent technical faults, thereby ensuring
more accurate surgical outcomes.
3. Employing a guarded saw in mandible reduction is instrumental in reducing the incidence
of inferior alveolar nerve injury. It also aids in
achieving a more symmetrical and regular
jawline after surgery, addressing one of the
key concerns in mandibular contouring
procedures.
4. In genioplasty, using pre-bent plates allows
for the accurate placement of the chin in line
with preoperative analyses, ensuring that the
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
nal outcome aligns with the planned adjustments. Additionally, the use of a doublebladed saw during osteotomies enhances
procedural accuracy, leading to more consistent and desirable surgical results.
5. A surgeon’s careful efforts to avoid unintentional errors are paramount in achieving satisfactory surgical results. This attention to detail
and adherence to standardized procedures signicantly contribute to reducing the incidence
of complications and ensuring patient
satisfaction.
4.2 Introduction
Recent years have seen a surge in the popularity
of facial bone contouring surgery, accompanied
by signicant improvements in surgical techniques and patient outcomes. Achieving satisfactory results in cosmetic surgery hinges not only
on meeting each individual’s aesthetic expectations but also on minimizing the risk of complications. An essential aspect of this is the
standardization of surgical methods used in
facial bone contouring surgery. The aim is to
simplify the procedure for the surgeon, ensuring
awless execution, and ultimately leading to the
patient’s satisfaction with their aesthetic results.
In this context, this chapter introduces several
standardized surgical instruments that are commonly utilized in facial bone contouring
surgery.
© 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_4
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