HEAD AND NECK SURGERY

Three-Dimensional Approach to Zygoma Reduction

Review of 221 Patients Over 7 Years
Minbum Kang, MD

focusing on reducing complications while achieving good results have

Background: Zygoma reduction is commonly performed in Asian patients be-
been developed. In the present study, a new surgical technique involving
cause a broad face is considered stubborn in appearance and unattractive. Con-
an L-shaped ostectomy pattern with a 3-dimensional approach to zygoma
sequently, a number of different techniques have been developed for zygoma
reduction was developed. In this surgical technique, the surgeon ap-
reduction, the majority of which involve simple manipulations. However, no con-
proaches the bone via intraoral and preauricular incisions and performs
sensus has been reached on the optimal method. In the present report, we intro-
a small L-shaped ostectomy. The bone segment is moved forward, in-
duce a new method involving ostectomy and fixation that uses a 3-dimensional
ward, and upward, and then fixed with an L-shaped miniplate and screws
approach to zygoma reduction.
(see Video 1, http://links.lww.com/SAP/A140). In the present study, we
Methods: From 2007 to 2013, 221 Korean patients (39 men, 182 women)
assessed the surgical outcomes and complications of this new surgical
underwent zygoma reduction using this technique. The bone was accessed via
technique in 221 Korean patients.
an intraoral and preauricular incision and removed in the body area using a small
L-shaped osteotome through bone cutting in the arch area. The zygoma was
moved anteriorly, medially, and caudally, and then fixed with a miniplate and screws. PATIENTS AND METHODS
Results: All patients were followed up for over 6 months and asked whether they From 2007 to 2013, 221 Korean patients (39 men, 182 women;
were satisfied with the results. Four patients (1.8%) required further reduction age range, 19–62 years) underwent zygoma reduction using this tech-
and underwent a reoperation, but all were eventually satisfied. Two patients nique (Table 1). Of these, 167 patients underwent zygoma reduction
(0.9%) experienced overcorrection with a sunken area around the zygoma, which alone, and 54 patients underwent additional procedures (Table 2). None
was corrected with autologous fat grafting after 6 months. Two patients complained of the patients had a history of trauma, and there were no secondary
of sensory changes around the upper lip, which resolved within 6 months. Two cases. Before surgery, frontal, profile, and lateral view photographs
patients experienced dizziness, temporomandibular joint pain, infection, and/or and cephalometric radiographs (Water's view and submentovertical
cheek drooping. view) were obtained. Then, surgical plans were established based
Conclusions: This new surgical technique causes less frequent and less pro- on evaluation of these radiographs and photographs (see Video 2,
nounced cheek drooping and requires less bone stepping, resulting in greater http://links.lww.com/SAP/A140). All surgeries were performed under
patient satisfaction. general anesthesia. The preauricular incision was accurately planned
Key Words: zygoma reduction, malar reduction, facial contouring, to protect the frontal branch of the facial nerve. After injection of
facial bone reduction 0.25% lidocaine mixed with epinephrine (1:100,000) at the incision
sites, a preauricular incision was made and extended into the perios-
(Ann Plast Surg 2016;76: 51–56) teum using a Mosquito dissector. Complete subperiosteal dissection
was performed from the posterior arch to the body area. After careful
confirmation of complete dissection, an upper labiobuccal vestibular
I n Asia, individuals with a wide and short face (mesocephalic features)
often prefer to have a slender one because a prominent zygomatic
complex is considered to contribute to an unattractive, stubborn, and
incision was made from the bilateral canine fossae to the first molars.
Thereafter, periosteal dissection was performed via this incision medi-
aged appearance. Since Onizuka et al.1 first described a surgical tech- ally up to the inferior orbital nerve and superiorly up to the lateral or-
nique based on chiseling and shaving via an intraoral incision, a number bital rim with the upper portion of the zygoma body (Fig. 1). For the
of different surgical techniques have been developed for reducing malar anterior part of the insertion, the masseter muscle was detached using
bone volume.1–10 Current surgical methods can be divided based on electrocautery. After complete dissection of the zygoma body, the surgi-
the following aspects: (1) type of approach: coronal incision,3 intraoral cal outline was marked with a pencil. Thereafter, parallel osteotomy was
incision,4,6,7,9–11 or a combination of intraoral and preauricular inci- performed using a reciprocating saw (bone segment width, 4–6 mm).
sions5,8; and (2) type of ostectomy: parallel,5 large L-shaped,6,8 or small After 2 oblique osteotomies and 1 vertical osteotomy, the bone segment
L-shaped.11,12 Other aspects include shaving or grinding,7 involvement was removed. Two-point fixations with an L-shaped miniplate and
of a greenstick fracture,4 and type of bone fixation.9,10 Most surgeons screws were performed in the zygoma area. The arch under the
perform zygoma reduction using simple manipulations to avoid scarring, preauricular incision was fully cut and detached using an osteotome.
facial nerve injury, and cheek drooping; thus, a number of techniques Thereafter, the bone segment was moved anteriorly, medially, and cau-
dally, and repositioning was confirmed. In the body area, complete
bony contact was accomplished, and 2 additional screws were fixed
(Fig. 2). Wound closure was performed using 3-0 chromic sutures after
Received November 12, 2014, and accepted for publication, after revision April 14, 2015. saline irrigation. Compressive dressing was applied for 3 days. Most
From the Romian Plastic Surgery Clinic, Seoul, Republic of Korea. patients were discharged 4 or 5 hours postoperatively, but some were
Conflicts of interest and sources of funding: none declared. admitted for 1 day if they experienced pain or bleeding.
Reprints: Minbum Kang, MD, Romian Plastic Surgery, Clinic 8F, Glass
Tower, 406 Gangnam-daero, Gangnam-gu, Seoul 135-080, Republic of
Korea. E-mail: [email protected].
Minbum Kang designed the study, analyzed the data, and wrote the article.
RESULTS
Supplemental digital content is available for this article. Direct URL citations appear in All patients were followed up for over 6 months and asked
the printed text and are provided in the HTML and PDF versions of this article on whether they were satisfied with the results. Four patients (1.8%) re-
the journal's Web site (www.annalsplasticsurgery.com).
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
quired further reduction and underwent a reoperation at 6 months or
ISSN: 0148-7043/16/7601–0051 more after the primary operation. These patients reported subsequent
DOI: 10.1097/SAP.0000000000000548 satisfaction. Two patients (0.9%) experienced overcorrection with a

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Kang Annals of Plastic Surgery • Volume 76, Number 1, January 2016

Current surgical methods can be divided according to approach,

TABLE 1. Patient Classification Based on Age and Sex (n) osteotomy sites, fixation sites, and materials used.
The use of 3 approaches has been reported: coronal, intraoral,
Age, y Male Female Total and a combination of intraoral and external. Coronal approaches2 offer
<20 0 4 4 the advantage of reduction of the upper part of the zygoma and wide
21–30 23 84 107 exposure.11 If needed, a forehead lift can be performed concomitantly.
31–40 11 60 71 However, a coronal approach cannot be used to manage the inferior part
of the zygoma and may potentially result in a scalp scar. Kim and Seul6
41–50 4 25 29
and Gui et al11 reduced the zygoma body via an intraoral approach
51–60 0 9 9 alone, but the part of the body that was ostectomized differed. Kim
>60 1 0 1 and Seul5 included the inferior part of the maxilla, which can provide
Total 39 182 221 the maxillary sinus opening, but has fixation problems due to the thin
anterior wall. Gui et al11 removed the bone in the upper part of the
maxilla and zygoma body, and performed an osteotomy with 1 oblique
sunken area around the zygoma area, which was corrected with auto- osteotomy line and 2 vertical osteotomy lines. Our method is similar to
logous fat grafting at 6 months after surgery. One patient had pain in this previous study with respect to the part of bone that is ostectomized.
the temporomandibular joint area for 7 months, which resolved with However, we also removed the more posterior part after 2 oblique
mouth-opening exercises. Two patients experienced dizziness, were osteotomy lines and 1 vertical osteotomy line. Moreover, we used a
transferred to the ear, nose, and throat clinic, and were confirmed to preauricular incision for cutting the posterior part of the arch (Fig. 2).
have tinnitus. One patient developed an infection in an oral wound The anterior part of the masseter muscle detachment is essential for
and received intravenous ceftriaxone treatment for 1 week. Two patients providing an area for fixation. Many other surgeons have reported
experienced a sensory deficit around the upper lip, which resolved after methods using intraoral and preauricular incisions.4,5,8,12 Parallel
6 months. One patient complained of cheek drooping, but no other pro- ostectomy5 or shaving4 has been performed using an intraoral incision.
cedure was required (Table 3). Yang and Chung4 introduced a technique using a greenstick fracture
and preauricular fixation with miniplates and screws. Risk of facial
nerve injury is increased with this method; however, limitations with
CASE REPORTS respect to reduction are present, particularly with the body area. Lee
et al9 introduced a blind technique with rasping and sawing. Yang and
Case 1 Chung4 and Lee et al9 both reported use of a greenstick fracture in
A 25-year-old woman complained of a broad face that resulted in the body area. These techniques did not include fixation after bone
a masculine appearance. She underwent angle resection and tubercles cutting or the need for a greenstick fracture, but are associated with
excision concomitant with zygoma reduction. She was satisfied with the following issues: (1) nonunion or malunion can occur after bone
the results (Figs. 3, 4). cutting; (2) greenstick fracture is difficult to accurately perform until
the surgeon has acquired considerable experience with the technique;
Case 2 and (3) evidence of worsened sensory problems and nerve damage
from the fixation materials has been observed.
A 32-year-old woman complained of a prominent zygoma and The concept of malar reduction has changed from rasping and
facial angle, an antimongolian slant and epicanthus, and a flat forehead. rotation4,7,10 to body repositioning.11–13 Wide periosteal elevation is
She underwent mandible angle resection with tubercles excision, lateral thought to be a cause of cheek drooping. However, in the present study,
and medial canthoplasty, and autologous fat grafting of the forehead the zygoma was moved upward, forward, and inward after full periosteal
and nose. She was satisfied with the results (Figs. 5, 6). elevation, suggesting that wide periosteal elevation can be performed
without a high incidence of this complication. Gui et al11 reported min-
Case 3 imal periosteal dissection, short operating time, and wearing elastic fa-
A 22-year-old woman complained of a prominent zygoma and cial dressing as 3 factors to help avoid cheek drooping. However, face
flat nose. She underwent zygoma reduction and augmentation rhino-
plasty with a silicone implant. She was satisfied with the results (Fig. 7).

DISCUSSION
In Asia, reduction malarplasty has been performed increasingly
over the past decade. The aim of this procedure is to obtain softer and
rounder facial contours. Since Onizuka et al.1 reported bone shaving
via an intraoral incision, many other methods have been introduced.

TABLE 2. Patient Classification According to Surgeries Performed

Concomitantly With Zygoma Reduction (n)

No concomitant surgeries 167

Angle resection, tubercles excision 6
Angle resection 14
Rhinoplasty 33
Angle resection, rhinoplasty 1 FIGURE 1. The periosteal dissection area, marked using a blue
pencil, is noted during zygoma reduction.

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Annals of Plastic Surgery • Volume 76, Number 1, January 2016 Zygoma Reduction for Facial Contouring

FIGURE 2. Three-dimensional aspects of the operative procedure for zygoma reduction. A, Ostectomy of the malar area with 2 vertical
lines and an oblique line. B, Fixation of a small L-shaped miniplate before preauricular osteotomy. C, Fixation with screws after
preauricular osteotomy. D, Movement of the zygoma anteriorly, medially, and caudally.
lifting was required in 5.3% of patients in this previous study. Only incision. The present technique used a preauricular incision for full dis-
1 patient (0.45%) in the present study underwent face lifting despite un- section of the outer periosteum and accurate oblique bone cutting. An-
dergoing full periosteal dissection. This difference could be the result other option for avoiding cheek drooping is removal of buccal fat.
of differing direction of bone interventions between studies. In particu- In summary, this new technique has several essential features:
lar, Gui et al11 moved the bone downward, and used only an intraoral (1) full elevation of the outer periosteum of the zygoma; (2) masseter

FIGURE 3. (above) Preoperative views of a 25-year-old patient who complained of a broad face that resulted in a masculine impression.
She underwent a combination of zygoma reduction and angle resection with tubercles excision. (Below) Six-month postoperative
view. Smooth facial lines were achieved without any complaints.

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Kang Annals of Plastic Surgery • Volume 76, Number 1, January 2016

FIGURE 4. (Left) Preoperative and postoperative submental view. (Right) Preoperative and postoperative Water's view.

FIGURE 5. (Above) Preoperative views of a 32-year-old patient who complained of a prominent zygoma and facial angle, an
antimongolian slant and epicanthus, and a flat forehead. She underwent angle resection of the mandible with tubercles excision,
lateral and medial canthoplasty, and autologous fat grafting of the forehead and nose. She was satisfied with the results. (Below)
One-year postoperative views.

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Annals of Plastic Surgery • Volume 76, Number 1, January 2016 Zygoma Reduction for Facial Contouring

FIGURE 6. (Left) Preoperative and postoperative submental view. (Right) Preoperative and postoperative Water's view.

FIGURE 7. (Above) Preoperative views of a 22-year-old patient who complained of a prominent zygoma and flat nose. She underwent
zygoma reduction and augmentation rhinoplasty with a silicone implant. She was satisfied with the results. (Below) One-year
postoperative views.

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Kang Annals of Plastic Surgery • Volume 76, Number 1, January 2016

ACKNOWLEDGMENT
TABLE 3. Complications During the Postoperative Period Informed consent was received for publication of the figures in
this article.
Complication (<6 mo) No. Patients Treatment
Bleeding 0 Admission for 1 day REFERENCES
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