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18 The Reduction Malarplasty withCoronal Approach
187
18.6 Complications
andManagement
Possible complications are asymmetry, undercorrection, wide scalp scar, hematoma, infection, and facial nerve injury, all of which can be
avoided by thorough surgical planning and
strict adherence to surgical principles and techniques [3].
With the coronal approach, serious complications that might occur are frontal branch of facial
nerve injury and temporal hollowing. Temporal
hollowing can result from dissection through the
temporal fat pad under the supercial layer of the
temporalis fascia to avoid injury to the facial
nerve. To prevent both temporal hollowing and
frontal branch injury, the temporal area is dissected just under the supercial temporal fascia
without entering the supercial temporal fat pad.
This way, the frontal branch, which travels on the
undersurface of the temporoparietal fascia, is
protected. Once reaching the zygomatic arch, the
periosteum is incised on the posterosuperior sur-
face of the arch to expose the lateral facial skeleton (Fig.18.4).
Malunion and cheek ptosis are common complications of reduction malarplasty, although they
are rare with the coronal approach. A major risk
factor for nonunion is insufcient rigid xation at
the superior portion of the malar complex.
Nonunion or malunion can lead to inferior displacement of the malar complex and subsequent
cheek ptosis. To prevent malunion and subsequent cheek ptosis, adequate bone-to-bone contact and rigid xation at the superior part of the
malar complex, rather than the zygomaticomaxillary buttress as in the intraoral approach, is necessary. Two-point xation is preferred over
one-point xation. In cases where malunion or
nonunion has occurred, the revision should be
performed through a coronal approach. The soft
tissue in the bone gap should be completely
removed. The malar complex is repositioned
superomedially and secured rigidly at two sites.
The bony gap at the zygomatic arch can be treated
with a bone graft (Fig.18.5).
Fig. 18.4 Schematic
cross-sectional diagram
of the recommended
dissection path to avoid
facial nerve injury and
temporal hollowing (a,
red line). The integrity
of supercial temporal
fat pad is not violated,
and the periosteum is
incised once reaching
the zygomatic arch (b).
S indicates skull; T
temporalis muscle; Z
zygomatic arch; TF
supercial layer of TF
188
ab
cd
R.-M. Baek and B.-k. Kim
Fig. 18.5 A case showing nonunion after reduction
malarplasty. After dissection, there is a bony gap at the
zygomatic body (a). The malar complex is repositioned
superomedially and secured with plate and screws (b).
18.7 Discussion
Superomedial repositioning leaves a bony gap (black
arrow) at the posterior zygomatic arch (c). This gap is
lled with an interpositional calvarian bone graft, which is
secured in place (d)
The malar bone can be manipulated through
three different incisions: intraoral, coronal, or
When performing malar reduction surgery, the
surgeon should keep in mind that the malar complex must be integrated and be in balance with
the rest of the facial features. Proper management
begins with appropriate patient selection. For
example, in a patient with both prominent malar
bones and mandibular angles, malar reduction
alone may accentuate and attract attention to the
mandibular angles. Such a patient will benet
from malar reduction combined with angle resection (Fig.18.3). Sometimes augmentation genioplasty using the resected bone from the
mandibular angle may further aesthetically
improve the patient’s face by lengthening a short,
square face. It is important to realize that changing the prominence of the malar bone often produces changes in the nose and eyes also [4].
preauricular incision. A major complication of
the intraoral approach is cheek droop, which is
mostly likely due to detachment of bony origins
of the perioral musculature during intraoral dissection. A consequence of cheek droop is an
older appearance to the face after surgery.
Therefore, the intraoral approach is recommended for patients with mostly anteromedial
prominence and those with sparse hair in whom a
coronal incision would leave a noticeable scar.
The advantages of our technique are that accurate osteotomies and resection of the exact
amount of bone are possible because everything
can be done under direct vision. Symmetry and
sufcient reduction can be easily achieved. This
procedure does not alter the natural curvature or
contour of one’s malar bone but simply moves
18 The Reduction Malarplasty withCoronal Approach
189
the entire complex to a location that will result in
a more attractive appearance. It is easy to accomplish symmetric reposition of the mobilized
zygomatic complex and to give rigid and stable
xation under coronal approach. Additionally,
there is no cheek droop after surgery owing to
complete redraping of the facial soft tissue. For
patients who may benet from forehead or subperiosteal face lift, the procedures can be
performed concomitantly with malar reduction
through the coronal approach.
References
1. Onizuka T, Watanabe K, Takasu K, Keyama
A. Reduction malarplasty. Aesth Plast Surg.
1983;7:121–5.
2. Baek S-M, Chung Y-D, Kim S-S. Reduction malar-
plasty. Plast Reconstr Surg. 1991;88:53–61.
3. Baek SM, Oh KS, Baek RM. Skeletal aesthetic sur-
gery: reductions. Facial Plast Surg Clin North Am.
1996;4(1):145–74.
4. Hinderer UT.Malar implants for improvement of the
facial appearance. Plast Reconstr Surg. 1975;56:157.
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
191
192
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)
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
194
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.
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
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,
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
197
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.