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22 Secondary Zygoma Reduction
229
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
230
J. Lee
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.
Plast Reconstr Surg. 2004;113:1253–61; discussion
62–3.
6. Mahatumarat C, Rojvachiranonda N. Reduction
malarplasty without external incision: a simple technique. Aesth Plast Surg. 2003;27:167–71.
7. Lee JG, Park YW. Intraoral approach for reduction
malarplasty: a simple method. Plast Reconstr Surg.
2003;111:453–60.
8. Cho BC.Reduction malarplasty using osteotomy and
repositioning of the malar complex: clinical review
and comparison of two techniques. J Craniofac Surg.
2003;14:383–92.
9. Kim YH, Seul JH.Reduction malarplasty through an
intraoral incision: a new method. Plast Reconstr Surg.
2000;106:1514–9.
10. Yang JH, Lee JH, Yang DB, etal. Prevention of complication and management of unfavorable results in
reduction malarplasty. J Korean Soc Plast Reconstr
Surg. 2008;35:465–70.
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
Surg. 2010;63:2018–24.
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.
2012;65:448–55.
Soft Tissue Surgery Combined
withZygoma Reduction
KyungminLee
23
23.1 Pearls
1. While performing malar contouring procedure in Asians, surgeons should pay special
attention to ethnic characteristics of Asians
whose prominent high cheekbone is usually
accompanied by up-slanted eyes as well as
abundant and thick soft tissues.
2. The up-slanted eyes leave a wide margin
below the eyes and emphasize their high
cheekbones, especially when smiling. Also
abundant soft tissues and thick skin frequently
cause cheek drooping and exaggeration of the
nasolabial fold after zygomatic reduction.
These are often the causes of dissatisfaction
after surgery.
3. Lateral canthoplasty is the representative
adjunctive procedures combined with zygoma
reduction. In canthoplasty, reversion of mongoloid slant reduces the wide margin below
the eyes and makes their high cheekbones less
conspicuous.
4. Surgical method of lowering lateral canthoplasty includes a precise oblique canthotomy incision, preseptal dissection, and
securing the lateral end of lower lid toward
K. Lee (*)
Center for Facial Bone Surgery, Department of
Plastic Surgery, ID Hospital, Seoul, South Korea
e-mail: gmsmgood@idhospital.com
inferolateral direction. It is important to
ensure that a new lateral canthal angle is
formed as desired and that the proper contact between the eyeball and palpebral conjunctiva is maintained.
5. Midface lifting procedure using endotine and
mini-lifting with minimal incision is the preferred method for relatively young Asian
patients who underwent facial bonecontouring surgery.
23.2 Introduction
Surgeons often encounter patients seeking reduction malarplasty who remain dissatised with
their facial aesthetics, despite undergoing surgery. A signicant challenge in achieving a satisfactory outcome lies in the structure of the
midface’s soft tissues. Although zygomatic
reduction plays a crucial role in midface contouring, the addition of soft tissue procedures can
greatly enhance the nal aesthetic result, sometimes even more so than the zygomatic reduction
itself.
The interplay between eye characteristics,
such as single eyelids and small palpebral ssures, and the zygoma, requires careful consideration. Surgeons must pay careful attention to the
mongoloid slant of the palpebral ssure and the
soft tissues of the cheeks to achieve successful
midface contouring. The soft tissues covering
© 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_23
231
232
K. Lee
their malar region are often copious and thick [1].
Consequently, some Asian patients with features
like slanted eyes or thicker soft tissues may need
further procedures to rene their facial contours
more precisely (Fig.23.1).
While the prominent high cheekbones, superolateral orientation of the brow, and the mongoloid
slant of the palpebral ssure are considered attractive and youthful by Western beauty standards,
they tend to convey a strong and aggressive
impression in Asian aesthetic preferences. The
periorbital appearance, as mentioned above, such
as the mongoloid slant of the palpebral ssure,
protrusion of the orbital rim, and the soft tissues
of the cheeks may accentuate a wide margin
Fig. 23.1 An example
of unfavorable results
after standard reduction
malarplasty using
L-shaped osteotomy.
This patient with
prominent cheekbones
and up-slanted eyes
underwent reduction
malarplasty using
standard L-shaped
osteotomy. Although
malar prominence was
effectively reduced from
the three-quarter oblique
view, she complained
that she still had a wide
margin below the eyes
from the front view.
Thus, she wanted to
have a further surgery, a
lowering lateral
canthoplasty, to attain a
softer image as a
separate procedure
below the eyes, particularly noticeable among
those with high cheekbones when smiling. To
achieve a softer and more attractive midfacial
contour, lowering lateral canthoplasty is increasingly performed alongside reduction malarplasty
within the Asian population. The integration of
eye procedure with zygoma reduction presents
several benets. Correcting the mongoloid slant
can diminish the wide margin below the eyes,
making the high cheekbones appear less prominent (Fig. 23.2). Furthermore, periorbital
approach for canthoplasty allows for the reduction of the remaining protruding inferolateral
orbital rim, enhancing the periorbital region’s
contour, including the upper zygomatic body.
23 Soft Tissue Surgery Combined withZygoma Reduction
233
a
Fig. 23.2 Simulating the lowering lateral canthoplasty
after reduction malarplasty. This simulation can demonstrate how vertical lowering and horizontal expanding of
the lateral canthus make the high cheek bone less conspicuous by reducing the surface below eyes. 9.2% of
b
The presence of ample soft tissue and thicker
skin often leads to cheek drooping and pronounced nasolabial folds, with the descent of
midcheek fat and skin contributing to the formation of jowls [2–4]. A spectrum of corrective procedures exists, ranging from minimally invasive
laser rejuvenation to extensive traditional facelift
surgeries. However, the demographic typically
opting for reduction malarplasty tends to be
younger, prompting a preference for thread lifting using elastic threads, whether absorbable or
nonabsorbable, owing to its procedural simplicity. There are certain limitations. Thread lifting
offers a temporary effect lasting between
1–3years. Thread lifting potentially leads to an
emphasized 45° highlight point and a broader
midface. It may leave dimples occasionally
emerging at the thread insertion points [5–7].
The demand for a simplied midface lifting
method has grown in conjunction with the popularity of reduction malarplasty. Traditionally,
midface lifting employing endotine devices
required transconjunctival or subciliary incisions,
yet these can now be conveniently placed through
intraoral incisions used in malarplasty techniques. Alternatively, mini-lifting, involving a
minimal incision within the temporal hairline,
presents another viable option for individuals
seeking midface rejuvenation after reduction
malarplasty.
c
malar surface area (a-b-c) is decreased more than that of
reduction malarplasty alone (a-b-c). Through virtual plastic surgery, we can verify the effectiveness of the combination of zyR and LLC. Also it shows the patients the
potential changes that might occur
23.3 Patient Consultation
andAssessment
23.3.1 Preoperative Evaluation
Standard photographic documentation and radiologic examination are routinely obtained. A comprehensive evaluation of the midface, including
the malar prominence, infraorbital rim protrusion, the relationship between the globe and
orbital rim, lateral canthal angle, and the overlying soft tissues, is vital to plan the requisite combination of procedures.
Preoperatively, the patient’s periorbital
appearance including lateral canthal slant and
inferolateral orbital rim projection is thoroughly
examined and discussed in sitting position and in
order to determine how much lower the lateral
canthus vertically and lengthen the palpebral ssure horizontally.
The lower lid itself should also be examined
for laxity. A preoperative snap-back test and measuring intraoperative lid distraction are useful
indicators of lower lid tone. This information can
then be used to determine if a canthopexy vs.
canthoplasty would be benecial in restoring
lower lid support and preventing postoperative
complications related to lid malposition.
Similarly, the degree of eye proptosis should also
234
K. Lee
be examined prior to surgery, as this can inuence optimal placement of the canthal anchoring
suture. In particular, in patients with slightly protruding eyes, lateral canthal suture should be
placed superiorly to prevent for scleral show.
23.3.2 Patient Selection
23.3.2.1 Lowering Lateral Canthoplasty (LLC)
The criteria for inclusion primarily encompassed
individuals exhibiting zygomatic prominence
coupled with an upward slant of the eyes.
Exclusion criteria were delineated to include
patients with either acute or chronic sinus infections or demonstrated obstruction of the osteomeatal complex. Additionally, enophthalmic
patients with a robust orbital rim characterized by
a diminutive eyeball ensconced within a prominently developed lateral orbital rim were expected
to diminished efcacy of the lowering lateral
canthopexy (LLC) procedure. Exophthalmic
patients with pronounced eye protrusion were
excluded to mitigate the risk of postoperative
scleral show. Simultaneous reduction of inferolateral orbital rim may be indicated in selected
patients [1].
23.3.2.2 Midface Lifting Procedure
After assessment of the patients’ age, volume
of fat and skin elasticity in an upright sitting
position, the high-risk groups for skin and soft
tissue sagging are selected as follows: (1) age
over 40, (2) abundant cheek fat, (3) thin skin
and skin laxity and (4) prominent smile line
with already drooped cheek. This is evaluated
before the surgery because once the patient lies
on a bed, soft tissue distribution is changed.
Then, fat removal area, soft tissue sagging area,
and lifting design are marked on the patient’s
face.
23.4 Surgical Technique
23.4.1 Lowering Lateral
Canthoplasty Combined
withZygomatic Reduction
Under general anesthesia, with the patient in
neck-extended supine position, the patient’s
zygomatic contour was designed. Either subciliary approach or transconjunctival approach can
be used. When excision of the lower eyelid skin
is required or when ectropion is anticipated after
LLC, the subciliary incision is useful. The transconjunctival approach allows for better scar camouage. A precise oblique canthotomy incision,
extending laterally and inferiorly from the lateral
canthus in alignment with the upper eyelid’s lateral part and the lateral canthus, is typically
3–4mm in length. Dissection proceeds through
the preseptal space towards the infraorbital rim
(Figs.23.3 and 23.4).
Reduction malarplasty follows a similar
approach, with subperiosteal dissection liberating lower lid and midface soft tissue, ensuring
Fig. 23.3 Overview of complimentary procedure 1: lowering lateral canthoplasty combined with zygomatic
reduction. After all contouring procedure is nished, the
detached lateral end of lower lid tarsus is secured toward
inferolateral direction onto the periosteum of the lateral
orbital rim (a lowering lateral canthoplasty). Canthopexy
with section of the canthal ligament and low neo-canthal
positioning alter the tilt of the eyelids
23 Soft Tissue Surgery Combined withZygoma Reduction
235
Fig. 23.4 Clinical photographs show a step-by-step
description of the LLC-Zy contouring technique. The process of lowering lateral canthopexy is divided up into
these stages after the completion of the inferolateral
safe transition zones of dissection to prevent periorbital soft tissue damage. When integrated with
LLC procedures, high-L osteotomy is favored, as
its oblique osteotomy line is positioned closer to
the external orbital rims compared to the traditional L-shaped osteotomy, implementing the
greater effect of LLC.
The detached lateral end of lower lid tarsus is
secured toward inferolateral direction (usually at
the level of lower pupil margin) using nonabsorbable 5-0 nylon suture onto the periosteum of the
lateral orbital rim. It is important to ensure that a
new lateral canthal angle is formed as desired and
that the proper contact between the eyeball and
palpebral conjunctiva is maintained. The surgeon
should pull the end of conjunctival ap and suture
it to the skin of the lateral corner. The wound is
closed while removing the dog-ear skin surrounding the lateral canthus with minimal
incision.
orbital rim reduction through lower lid. A Senn retractor
and a malleable retractor are used to retract the lower lid
and the orbital contents
23.4.2 Endotine Midface Lifting
Combined withZygomatic
Reduction
The endotine lifting itself can be performed under
intravenous sedation with subciliary or transconjunctival incision in isolated cases and under general anesthesia in cases with facial
bone-contouring surgeries with intraoral incision. The most important point of endotine midface lifting is where to put the endotine. Sagginess
usually appears on the front cheek so the endotine must grab and hold the saggy soft tissues
around front cheek. After nishing malarplasty,
there are plates and screws for xation of the
bone segments, and it is not easy to nd an adequate bony surface to put endotine. So, endotine
can be placed on the surface of those plates
(Fig. 23.5). Protrusion block in the endotine,
designed to place them into the skulls should be
236
K. Lee
removed. Endotine is put in the desired area and
xed with 2 points in order not to rotate. Because
of the thickness of the endotine, xation screws
longer than 8 mm are usually used (Fig. 23.6).
Copious irrigation and meticulous hemostasis
with electrocautery are recommended to ensure
minimal bleeding and contamination. Finally,
surgeons lift overlying soft tissue (front cheek)
slightly upward and push gently on endotine that
endotine can hold the sagging soft tissues. Check
the adequacy of soft tissue lifting. Palpability of
endotine is usually not the problem and, if any,
improves with dissolution of the implant.
23.4.3 Mini-lifting Combined
withZygomatic Reduction
Mini-lifting procedure is preferred to classic fullface lifting as patients are young and do not want
long scar. The basic surgical technique of minilifting after zygoma reduction is similar to standalone procedure. Skin incision is made from
inside the temporal hair to retrotragal area and is
undermined approximately 1 cm (Fig. 23.7).
Incision for mini-lifting and pre-tragal incision
should be separate and care are taken for the skin
in-between. Sharp SMAS dissection starts with
knife and then extends with scissors out to the
extent of releasing the zygomatic ligament.
Deep-plane SMAS ap is secured to adequately
redrape the sagging tissue into natural and
dynamic position [8]. Finally the skin incisions
are sutured using 4-0 vicryl and 5-0 and 6-0
nylon.
Fig. 23.5 Position of endotine insertion after
malarplasty
Fig. 23.6 Clinical photographs showing endotine
inserted upon the plates and screws of malarplasty.
Protrusion block in endotine was removed before inserted.
8mm screw was used to x endotine
Fig. 23.7 Incision design of mini-lifting with zygomatic
reduction. Incision starts from inside the temporal hair to
posterior border of sideburn (preauricular area)
23 Soft Tissue Surgery Combined withZygoma Reduction
23.5 Cases
Case 1
Preoperative views of a 22-year-old female patient presented with a prominence cheek bone and
up-slanted eyes. In anterior view, she showed a facial asymmetry and small lateral scleral triangle because of steep mongoloid slant. From the oblique view, a severely projected 45° zygomatic body and abundant soft tissues over malar area were noted. After reduction malarplasty
using high L-shaped osteotomy (body resection 5/6mm, setback 3/4, arch medialization 4/5,
posterior arch shaving on both sides), mongoloid slant lowering was completed with downward
movement of 2mm and lateral extension of 3mm on both sides. Five months postoperatively,
the protruding cheek bone was reduced, mongoloid slant became less steep, and the lateral
scleral triangle was enlarged (Fig.23.8).
237
238
Fig. 23.8 Preoperative
views of a 22-year-old
female patient in Case 1
(left column).
Postoperative views
after zygoma reduction
combined with lowering
lateral canthoplasty
(right column). Six
months postoperative
views showed that the
contour of midfacial
margin was smooth. And
the slope of palpebral
ssure became less
steep. The lateral
canthus was extended
laterally and inferiorly
exposing more sclera
which gives a softer
image, especially, while
smiling
K. Lee