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15 Soft Tissue Surgery Combined withtheMandible Contouring Surgery
155
interstices resembles ligament characteristics,
contributing to its long-term stability [30].
Secondly, the inherent elasticity of the thread
ensures a more natural lifting effect, both in
resting and dynamic facial expressions. It’s
crucial to avoid overtightening the thread during knotting, as this allows for a more natural
immediate postoperative appearance, unlike
the rigidity often observed with barbed suture
lifting. Thirdly, the elastic thread is designed to
be impalpable. Its consistency closely matches
that of the surrounding soft tissues, and its
smooth, non-barbed surface further minimizes
palpability, enhancing patient comfort.
Fourthly, the ease of removal is a notable
advantage. The core of the nonabsorbable
thread, made of silicone, does not adhere
strongly to surrounding tissues, facilitating its
removal if necessary.
However, there are limitations to consider
with elastic lifting. Some patients express apprehension about having nonabsorbable materials
placed in their faces. Additionally, mastering the
technique requires time and experience, particularly in aspects like insertion layers and traction
force control. Lastly, compared to the barbed
thread lift, there is comparatively less long-term
data available regarding the efcacy and potential
complications of the elastic lift. Despite these
limitations, the elastic lift remains a valuable and
effective option in facial rejuvenation, particularly for patients seeking a more natural and
long-lasting result.
References
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Plast Surg. 2010;16:1–8.
2. 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.
2012;65(4):448–55.
3. Jin H. Reduction malarplasty using an L-shaped
osteotomy through intraoral and sideburns incisions.
Aesth Plast Surg. 2011;35(2):242–4.
4. Villa MT, White LE, Alam M, Yoo SS, Walton
RL.Barbed sutures: a review of the literature. Plast
Reconstr Surg. 2008;121(3):102e–8e.
5. Sulamanidze MA, Fournier PF, Paikidze TG,
Sulamanidze GM. Removal of facial soft tissue
ptosis with special threads. Dermatologic Surg.
2002;28(5):367–71.
6. Sulamanidze MA, Paikidze TG, Sulamanidze GM,
Neigel JM.Facial lifting with “APTOS” threads: featherlift. Otolaryngol Clin N Am. 2005;38(5):1109–17.
7. Lee S, Isse N.Barbed polypropylene sutures for midface elevation: early results. Arch Facial Plast Surg.
2005;7(1):55–61.
8. Horne DF, Kaminer MS.Reduction of face and neck
laxity with anchored, barbed polypropylene sutures
(contour threads). Skin Ther Lett. 2006;11(1):5–7.
9. Kaminer MS, Bogart M, Choi C, Wee SA.Long-term
efcacy of anchored barbed sutures in the face and
neck. Dermatologic Surg. 2008;34(8):1041–7.
10. Sulamanidze M, Sulamanidze G.APTOS suture lifting methods: 10 years of experience. Clin Plast Surg.
2009;36(2):281–306.
11. Bisaccia E, Kadry R, Rogachefsky A, Saap L,
Scarborough DA. Midface lift using a minimally
invasive technique and a novel absorbable suture.
Dermatologic Surg. 2009;35(7):1073–8.
12. Garvey PB, Ricciardelli EJ, Gampper T. Outcomes
in thread lift for facial rejuvenation. Ann Plast Surg.
2009;62(5):482–5.
13. Abraham RF, DeFatta RJ, Williams EF III.Threadlift for facial rejuvenation: assessment of long-term
results. Arch Facial Plast Surg. 2009;11(3):178–83.
14. Rachel JD, Lack EB, Larson B.Incidence of complications and early recurrence in 29 patients after facial
rejuvenation with barbed suture lifting. Dermatologic
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15. Apfelberg DB, Rosenthal S, Hunstad JP, Achauer
B, Fodor PB. Progress report on multicenter study
of laser-assisted liposuction. Aesth Plast Surg.
1994;18(3):259–64.
16. Goldman A, Wollina U, de Mundstock EC.Evaluation
of tissue tightening by the subdermal Nd: YAG laserassisted liposuction versus liposuction alone. J Cutan
Aesthet Surg. 2011;4(2):122–8.
17. Kim JH, Min KH, Heo CY, Baek RM, Park HJ, Youn
SW, Kim EH.Histological evaluation of dermal tissue
remodeling with the 1444-nm neodymium:yttriumaluminum- garnet laser in invivo model. J Dermatol.
2013;40(9):706–10.
18. Woodhall KE, Saluja R, Khoury J, Goldman MP. A
comparison of three separate clinical studies evaluating the safety and efcacy of laser-assisted
lipolysis using 1,064, 1,320 nm, and a combined
1,064/1,320nm multiplex device. Lasers Surg Med.
2009;41(10):774–8.
19. Badin AZ, Moraes LM, Gondek L, Chiaratti MG,
Canta L. Laser lipolysis: accidity under control.
Aesth Plast Surg. 2002;26(5):335–9.
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DA, Barone F. Laser-assisted lipolysis: a review.
Dermatologic Surg. 2012;38(2):155–69.
21. Jacono AA, Bryant LM.Extended deep plane facelift incorporating facial retaining ligament release
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jawline and neck rejuvenation. Clin Plast Surg.
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effect of the 1,444 nm Nd:YAG laser: comparison
with the 1,064nm Nd:YAG laser. Lasers Surg Med.
2009;41(10):721–7.
23. Youn JI, Holcomb JD.Ablation efciency and relative thermal connement measurements using wavelengths 1,064, 1,320, and 1,444nm for laser-assisted
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24. Sasaki GH. Early clinical experience with the
1440-nm wavelength internal pulsed laser in facial
rejuvenation: two-year follow-up. Clin Plast Surg.
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ned 1444-nm Nd-YAG laser: a new paradigm for
facial sculpting and rejuvenation. Facial Plast Surg.
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facial and body contouring and tissue tightening:
a 2-year experience with 75 consecutive patients.
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closure with barbed sutures. Clin Plast Surg.
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Part III
Midface
The Comprehensive Aesthetic
Analysis forMidface
SanghoonPark
16
16.1 Pearls
1. The assessment of zygomatic prominence
involves objectively examining key elements
such as the position and volume of the zygomatic body, arch width, and its balance with
other facial structures.
2. A comprehensive evaluation includes clinical
consultation, photographic documentation,
and both radiologic and 3D imaging
analyses.
3. Our classication system categorizes prominent zygoma into four distinct types, each
dened by unique morphological characteristics of various subcomponents.
4. Corresponding to these classications, four
different surgical principles are applied.
Surgical techniques employed I-, L-, and high
L-osteotomies, orbital rim shaving, and tripod
osteotomy.
5. This classication system’s efcacy is validated by improved results, emphasizing the
importance of recognizing individual differences and avoiding common surgical pitfalls.
6. The thickness of the overlying soft tissues,
including skin, subcutaneous fat, muscles,
and buccal fat, is a critical consideration.
S. Park (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: spark@idhospital.com
Patients with thin skin and minimal cheek fat
tend to exhibit more pronounced operative
results and a lower risk of postoperative soft
tissue drooping. Conversely, those with
thicker skin and abundant fat may experience
less noticeable effects and a higher likelihood
of cheek drooping. It’s essential to inform
such patients about the potential for cheek
drooping and to discuss possible adjunctive
measures.
7. Factors identied as high risks for skin and
soft tissue sagging after zygomatic reduction
include being over 40 years of age, having
abundant cheek fat, possessing thin skin with
laxity, presenting with a class II mandible or
ill-dened mandible-neck line, and exhibiting
a deep nasolabial fold or jowls. These considerations are crucial in surgical planning and
patient counseling to ensure optimal outcomes and patient satisfaction.
16.2 Introduction
The zygoma, a pivotal structure in the midface,
possesses a complex three-dimensional character
that poses challenges for quantitative description
and analysis. While Hinderer made signicant
strides in effectively describing the zygoma, the
objectivity and practical applicability of these
descriptions are still not fully assured. Our team
has pioneered in developing an objective classication of the zygoma and the subdivision of the
© 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_16
159
160
S. Park
Fig. 16.1 An example of unfavorable results after standard reduction malarplasty. A 27-year-old male showing
under-corrected prominent cheekbone, which was treated
zygomatic body, a crucial advancement given the
historical lack of detailed description of the
zygoma’s subcomponents and their aesthetic
implications. Until recently, these subcomponents were not distinctly identied, and their
roles in achieving aesthetic results were not
clearly understood. Consequently, the recent
surge in the popularity of zygomatic surgeries
has led to a number of suboptimal outcomes
(Fig.16.1). An objective diagnosis of zygomatic
prominence, grounded in a thorough anatomical
understanding, is key to achieving superior
results.
With the evolution of craniofacial surgery, surgeons now have a more extensive array of techniques for zygoma reduction. These techniques
vary in invasiveness and include the less invasive
mini-zygoma reduction (performed via intraoral or
Gillies’ approaches, with or without a preauricular
approach), standard zygoma reduction (employing
both intraoral and preauricular approaches), and
the more aggressive coronal approach [1–5]. The
careful selection and application of these options,
tailored to the specic classication of zygomatic
prominence and the patient’s individual needs, are
crucial for optimal results.
In this article, we provide a detailed description of the subtypes of zygomatic prominence
by conventional L-shaped osteotomy technique. (Left)
Preoperative view, (Right) 3months after reoperation
and the corresponding surgical techniques, offering insights into the nuanced approaches required
for effective aesthetic enhancement of the zygomatic area.
16.3 Patient Consultation
andAssessment
Preoperative assessment should include a history
of previous malar contouring procedures, including autologous fat injection, ller injection, or
alloplastic implant placement such as silicone or
Medpor®. Especially, patients with prior history
of fat or ller injection are more likely to have
greater chance of cheek drooping. In addition,
special care should be taken not to neglect the
inammatory conditions such as sinusitis or
periodontal disease. This is because such conditions can be exacerbated by surgery and are
therefore best treated prior to surgery. The degree
of eye prominence should also be examined
prior to surgery, as this can inuence the optimal
reduction of protruding inferolateral orbital rim.
In particular, patients with enopthalmic eyeballs
are at risk for undercorrection and should be
considered for sufcient reduction of external
orbital rim.
16 The Comprehensive Aesthetic Analysis forMidface
16.3.1 Preoperative Analysis
The evaluation of the malar area is somewhat
hindered by a lack of anthropometric or
cephalometric landmarks along its complex
three- dimensional curvature [6]. The point zygion (Fig.16.4, point Zy), which denes the maximum interzygomatic distance (zygion-zygion),
does not correspond to the area of maximum
malar prominence (MMP). Malar contouring
involves not only the zygomatic region but also
the periorbital region. Pitfalls can be avoided if
one is conscious about these relationships.
Evaluation should include the three basic views:
frontal, three-quarter oblique, and basal. Direct
physical examination is the key process to evaluate the patient’s problems and establish a surgical
plan. Clinical photos are necessary as is radiologic examination including frontal view, lateral
view, submentovertex view, and Waters’ view.
CT scan with 3D view is also essential to evaluate
the shape of the zygomatic complex.
161
16.3.1.1 Frontal Evaluation
The frontal evaluation can be simplied by visualizing an anterior and posterior facial plane
(Fig.16.2). The anterior facial plane is dened by
the superior temporal line, lateral border of the lateral orbital rim, malar prominence, midface, and
mentum (Fig.16.2, blue line). The posterior facial
plane is circumscribed by the contour line of the
head (Fig.16.2, red line). A combination of variable forms of these two planes denes a variety of
facial shapes. In the case where the cheekbones
protrude outwardly, the facial line connecting the
temple-zygoma-cheek-mandible angle constitutes
a very convoluted line (Fig. 16.2). Volume and
position of zygomatic body and bizygomatic
width are key variables to be considered. The volume of zygomatic body determines the amount of
ostectomy during the surgery. If the volume of
zygomatic body is large, wider resection of zygomatic body is planned. However, overzealous
reduction results in at or decient look. Therefore,
keeping the adequate volume of zygomatic body
in anteroposterior dimension and transverse plane
Fig. 16.2 Anterior and posterior facial contour lines. The
anterior facial contour line connects the temple, zygomatic body, cheek, and mandible body (blue line), while
the posterior facial contour line connects the temple,
zygomatic arch, mandible angle, and chin (red 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
is essential. The position of zygomatic body is
measured in both, its most lateral margin and in its
maximal projection. Outer margin of zygomatic
body is observed in conjunction with temple and
cheek. To narrow the anterior midfacial width, lateral margin of cheekbone should be trimmed or
moved inward. If the outer margin of cheekbone is
placed wide, the amount of narrowing and medialization should be maximized, and ostectomy
should be combined.
162
ab
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
ab
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
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.
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
b