Aesth. Plast. Surg. 16:355-363, 1992
Aestheuc _ Plasnc Surgery 9 1992Springe>VerlagNew York inc.
Infracture Technique for the Zygomatic Body and Arch Reduction Doo Byung Yang M.D. and Chul Gyoo Park M.D. Seoul, South Korea
Abstract. In the Orient, prominent malar regions are considered unaesthetic and the majority of women with a prominent malar want to reduce the zygoma. Various operative procedures such as shaving or chiseling the zygomatic body or the zygomatic arch have been used for reducing malar eminence, but the zygomatic arch cannot be reduced sufficiently by these methods. By combining intraoral shaving of the zygomatic body and a new effect arch infracture technique through a temporopreauricular incision, we have obtained very satisfactory results in 19 cases and notable minimal complications over the last three years. Key words: Infracture technique--Prominent zygomatic body and arch--Convexity to concavity
While the first type of prominent zygoma has only a prominent body and the second type has both a prominent body and arch, the third type has a prominent body, arch, and frontal process. For the first type we can easily reduce the malar prominence by shaving through the intraoral route. However, this method alone cannot be similarly applied to the second type because of technical difficulty. We made use of both temporopreauricular and intraoral incisions and successfully reduced the prominent zygomatic arch by the infracture technique. From June 1988 to March 1990, 19 patients underwent reduction of the zygomatic body and arch by this method and the results obtained have proved satisfactory so far.
Materials and Methods The contour of the middle of the face tends to be greatly affected by the shape of the nose and malar eminences. Because of a small nose, the prominent malar eminence of Oriental people makes the nose more shallow and the midface more flat. Since Onizuka [6] first described the reduction malar plasty through intraoral incision and chiseling in 1983, many other methods have been developed and tried for reducing the prominent zygoma. We classified the prominence of the zygoma into three types and defined the operative method according to the type. Moreover, we developed a new operative procedure, called the infracture technique, and applied it to reducing the zygomatic arch.
From clinical examination, photographs, and a basal skull x-ray view, we classified our patients as type 1, 2, or 3: type 1 needs reduction of the zygomatic body (Fig. 1), type 2 needs reduction of the body and arch (Fig. 2), type 3 needs reduction of the body, arch and frontal process. A different operative method was applied to the clinical type: type 1--only malar shaving through the intraoral route, types 2 and 3--intraoral route body shaving and infracture technique through temporopreauricular incision. In the last three years, we performed 67 reduction malar plasties and used the infracture technique for 19 cases of types 2 and 3.
Postoperative Results and Complications Address reprint requests to Doo Byung Yang, M.D., or Chul Gyoo Park, M.D., Jelim Plastic Surgical Clinic, Seoul National University Hospital, Seoul, Korea.
A postoperative basal skull x-ray view and photograph were taken and compared with the preopera-
356
Zygomatic Body and Arch Reduction
Fig. 1. Type l: prominent zygomatic body only, basal skull x-ray view
tire status (Figs. 3-6). Postoperative complications included one case of irregularity of the zygomatic arch (Fig. 3) and one case of transient palsy of the frontal branch of the facial nerve. The latter, which was caused by nerve traction, was fully resolved after 3 months.
Operative Procedure At the beginning of surgery, 1% lidocaine mixed with epinephrine (1 : 100,000) is infiltrated into the upper buccal sulcus. An incision is made in the upper buccal sulcus extending from the canine tooth to the second molar tooth. The mucosa, muscle, and periosteum is detached from the underlying maxilla and zygoma. The infraorbital nerve must be carefully protected. The dissection area is extended over the frontal and temporal process of the zygoma. One important point to keep in mind during this procedure is that the origin of the masseter muscle should not be detached from the maxilla and zygoma. After a complete subperiosteal dissection, the malleable retractor and the Petri intraoral retractor with fiberoptic cable are used to see the inferior orbital rim, zygomatic body, and frontal and temporal processes of the zygoma, all of which make up the malar prominence. Shaving should start from the inferior border of the zygoma and zygomatic process of the maxilla in which the masseter muscle originates (Fig. 7). All of the outer cortex can be carefully shaved while guarding with the retractors. Thus, soft tissue curling and surface irregularities can be avoided. After completing the shaving procedure, we can now see the lateral prominence of the zygomatic arch more clearly and we can continue on to the next step (Fig. 8). The
curvilinear temporopreauricular incision
starts from 5-6 cm above the root of the helix and continues downward along the preauricular skin crease to the upper border of tragus. A strip of temporal and preauricular skin about 5 mm wide should be excised to facilitate the procedure and reduce postoperative skin redundancy (Fig. 9). A dissection plane is created beneath a layer of deep temporal fascia with the dissection proceeding inferiorly to the level of the zygomatic arch. The periosteum of the zygomatic arch is lifted from the posterior part of the arch; thus, we can safely connect the subperiosteal pocket to the anterior side without facial nerve injury (Fig. 10). The outer cortex of the zygomatic arch may also be shaved. Then we determine three cutting points (Fig. 11):
Point A: the junction where the zygomatic body plane meets the zygomatic arch plane. The black A line is applied to a type 2 patient which has a prominent zygomatic body and arch. The red A line is applied to a type 3 patient which has a prominent zygomatic body, arch, and frontal process. Point B: the midpoint between A and C. Point C: a few millilmeters anterior to glenoid fossa. Under the direct vision, we make three greenstick fractures with a pneumatic saw and osteotome on the points A, B, and C and perform infracturing by applying digital pressure. Interosseous fixation procedures were not necessary. The deep fascia should be closed sequentially. After closing the skin, the oral wound is also closed by two layers.
Postoperative Care A liquid diet must be provided for seven days followed by a soft diet for two weeks. Intermaxillary
D.B. Yang and C.G. Park
357
Fig. 2. Type 2: prominent zygomatic body and arch, basal skull x-ray view
fixation is not necessary. The patient should be cautioned to avoid impact injury to the infractured sites for two months.
Discussion
It is well known that there is no general aesthetic standard that is universally accepted. This is true of facial aesthetic plastic surgery. What patients ask of the plastic surgeon may be different in different situations. Many people, especially in Western countries, think that a flat malar curve with loss of relative submalar shallowness, or reversed curve, is not visually pleasing. They think that malar flatness may contribute to premature aging which is exaggerated by downward pooling of degenerated soft tissue and skin; this results in a "drawn down" appearance. As mentioned by Gonzalez-Ulloa [2] and Hinderer [3], patients who have high cheek bones retain their youthful looks in their later years and make them better candidates for rhytidectomy procedures because of the skeletal support provided. Thus, various kinds of malar augmentation methods have been applied [2-5, 7, 8, 10]. Of course, augmented malar features may satisfy Caucasians who have a dolichocephalic face. However, the concept of malar area beauty is different in Orientals who have a mesocephalic face. In the Orient, especially in Korea, most people regard a small, slender face as the ideal shape, but we see many Korean people with a large, square face with increased transverse width or prominent malar areas. Some Korean patients ask the plastic surgeon for a narrower face with an inconspicuous malar area.
Remarkable developments have occurred in correcting facial deformities, but reduction of the malar prominence remains a challenge. Onizuka [6] was the first to describe the method of chiseling and shaving of the zygomatic body and arch through the intraoral approach. In his photographs, the anterior malar eminence was reduced to a certain degree, but lateral bulging still remained. Another approach was attempted by Whitaker [9] who described zygomatic shaving through a bicoronal incision which provides excellent exposure. However, shaving can reduce the malar prominence to a certain degree, but it has little effect on lateral bulging of the zygomatic arch. To narrow the width of the face, including lateral bulging of the zygomatic arch, Edgerton [1] proposed a more radical procedure that included resection of the zygomatic arch. This procedure is quite radical. It is difficult to control lateral irregularities. We also have experience with using the malar shaving procedure in many cases and we are convinced that lateral prominence of the zygomatic arch is still present even after aggressive shaving. In order to solve this problem, we have devised the infracture technique which makes three greenstick fractures on the zygomatic arch and converts the prominent convex arch into a smooth concave one. We prefer the dual approach through an intraoral incision and a temporopreauricular incision because the intraoral approach alone cannot provide direct vision of the zygomatic arch; only through the dual approach can we expose the entire malar eminence including the zygomatic arch and frontal process of the zygoma. None of the 19 cases in which we used the combined intraoral and temporopreauricular approaches needed a blood transfusion. We can safely perform
358
Zygomatic Body and Arch Reduction
Fig. 3. (A-C) Preoperative and postoperative views and (D) basal skull x-ray view, (Right) Slight irregularity remains. For the broad and short face, a deep concave arch infracture is made
D.B. Yang and C.G. Park
359
4. ( A - C ) Preoperative and postrative views and (D) basal skull y view. For the broad and short ,, a deep concave arch infracture lade
360
Zygomatic Body and Arch Reduction
Fig. 5. ( A - C ) Preoperative and postoperative views and (D) basal skull x-ray view. For the long face, a slight concave arch infracture is made
D.B. Yang and C.G. Park
361
Fig. 6. (A-C) Preoperative and postoperative views and (D) basal skull x-ray view. For the asymmetric face, the infracture is made in the zygomatic arch on the left side only
Fig. 7. Intraoral operative view
Fig. 10. The zygomatic arch is exposed beneath the deep temporal fascia and periosteum
Fig. 8. After completing the intraoral shaving procedure, the left prominent zygomatic body is reduced
Fig. 11. Markings of points A, B, and C and concave right side zygomatic arch after infracture Fig. 9. The temporopreauricular incision, for a 5-mmwide excision of skin, is marked the infracture technique without use of interosseous wiring because (1) the remaining medial periosteum can maintain the continuity of the zygomatic arch,
(2) the underlying temporalis muscle provides additional support that prevents displacement of the fractured zygomatic arch and prevents its impinging on the coronoid process of the mandible, (3) the fracture line A to C remains in the state of greenstick fraction.
D.B. Yang and C.G. Park
It is hard to expect good healing of the bone graft which m a y occur after wiring procedure. The m a s s e t e r muscle should not be detached from the z y g o m a and zygomatic process of the maxilla because this m a y lead to an hourglass deformity of face. Also, the shape of the face is an important factor in determining the degree of fracture. For a broad and short face, a deep concave arch infracture is needed to m a k e the face look long (Figs. 3, 4). F o r a long face, a slight c o n c a v e arch infracture is necessary to produce smooth face look. (Fig. 5). Conclusions
We have p e r f o r m e d the reduction malar plasty in 19 cases using a technique that combines shaving and infracture. This led us to the following conclusions: (1) Our operative method is safe and effective. (2) The dual a p p r o a c h through intraoral and temporopreauricular incisions can sufficiently expose the zygomatic b o d y and arch. (3) This operative method is the only one that effectively changes the c o n v e x arch to a c o n c a v e one. (4) We can safely p e r f o r m the infracture technique without using interosseous wiring. (5) The shape of the face is an important factor in determining the degree of infracture.
363 References
1. Edgerton MT et al: Patients seeking symmetrical recontouring for "perceived" deformities in the width of the face and skull. Aesth Plast Surg 14(I):59, 1990 2. Gonzalez-Ulloa M: Building out the malar prominences as an addition to rhytidectomy. Plast Reconstr Surg 53:293, 1974 3. Hinderer U: E1 injerto oseo herterologo de Kiel en perfiloplasties y depresiones faciales (indicasiones y experiencia). Rev Latinoam Cir Plat 11:156, 1967 4. Hinderer U: Malar implants for improvement of the facial appearance. Plat Reconst Surg 56:157, 1975 5. Hinderer U: Malar implants to improve facial proportions and aging. In: Stark RB (ed): Plastic Surgery of the Head and Neck. New York: Churchill, 1987, pp. 1097-1107 6. Onizuka T et al: Reduction malar plasty. Aesth Plast Surg 7:121, 1983 7. Spadafora A, de los Rios E, Toledo Rios R: Pomulos planos (platizigion), endoprotesis de polietileno insertadas por vis subperiostica del arco cigomatico. Prensa Med Argent 58:1946, 1971 8. Whitaker LA: Aesthetic augmentation of the malar-midface structures. Plast Reconstr Surg 80:337, 1987 9. Whitaker LA et al: Aesthetic surgery of the facial skeleton. Persp Plast Surg 1:23, 1988 10. Wilkinson TS: Complications in aesthetic malar augmentation. Plast Reconstr Surg "/1:643, 1983
Aestheuc _ Plasnc Surgery 9 1992Springe>VerlagNew York inc.
Infracture Technique for the Zygomatic Body and Arch Reduction Doo Byung Yang M.D. and Chul Gyoo Park M.D. Seoul, South Korea
Abstract. In the Orient, prominent malar regions are considered unaesthetic and the majority of women with a prominent malar want to reduce the zygoma. Various operative procedures such as shaving or chiseling the zygomatic body or the zygomatic arch have been used for reducing malar eminence, but the zygomatic arch cannot be reduced sufficiently by these methods. By combining intraoral shaving of the zygomatic body and a new effect arch infracture technique through a temporopreauricular incision, we have obtained very satisfactory results in 19 cases and notable minimal complications over the last three years. Key words: Infracture technique--Prominent zygomatic body and arch--Convexity to concavity
While the first type of prominent zygoma has only a prominent body and the second type has both a prominent body and arch, the third type has a prominent body, arch, and frontal process. For the first type we can easily reduce the malar prominence by shaving through the intraoral route. However, this method alone cannot be similarly applied to the second type because of technical difficulty. We made use of both temporopreauricular and intraoral incisions and successfully reduced the prominent zygomatic arch by the infracture technique. From June 1988 to March 1990, 19 patients underwent reduction of the zygomatic body and arch by this method and the results obtained have proved satisfactory so far.
Materials and Methods The contour of the middle of the face tends to be greatly affected by the shape of the nose and malar eminences. Because of a small nose, the prominent malar eminence of Oriental people makes the nose more shallow and the midface more flat. Since Onizuka [6] first described the reduction malar plasty through intraoral incision and chiseling in 1983, many other methods have been developed and tried for reducing the prominent zygoma. We classified the prominence of the zygoma into three types and defined the operative method according to the type. Moreover, we developed a new operative procedure, called the infracture technique, and applied it to reducing the zygomatic arch.
From clinical examination, photographs, and a basal skull x-ray view, we classified our patients as type 1, 2, or 3: type 1 needs reduction of the zygomatic body (Fig. 1), type 2 needs reduction of the body and arch (Fig. 2), type 3 needs reduction of the body, arch and frontal process. A different operative method was applied to the clinical type: type 1--only malar shaving through the intraoral route, types 2 and 3--intraoral route body shaving and infracture technique through temporopreauricular incision. In the last three years, we performed 67 reduction malar plasties and used the infracture technique for 19 cases of types 2 and 3.
Postoperative Results and Complications Address reprint requests to Doo Byung Yang, M.D., or Chul Gyoo Park, M.D., Jelim Plastic Surgical Clinic, Seoul National University Hospital, Seoul, Korea.
A postoperative basal skull x-ray view and photograph were taken and compared with the preopera-
356
Zygomatic Body and Arch Reduction
Fig. 1. Type l: prominent zygomatic body only, basal skull x-ray view
tire status (Figs. 3-6). Postoperative complications included one case of irregularity of the zygomatic arch (Fig. 3) and one case of transient palsy of the frontal branch of the facial nerve. The latter, which was caused by nerve traction, was fully resolved after 3 months.
Operative Procedure At the beginning of surgery, 1% lidocaine mixed with epinephrine (1 : 100,000) is infiltrated into the upper buccal sulcus. An incision is made in the upper buccal sulcus extending from the canine tooth to the second molar tooth. The mucosa, muscle, and periosteum is detached from the underlying maxilla and zygoma. The infraorbital nerve must be carefully protected. The dissection area is extended over the frontal and temporal process of the zygoma. One important point to keep in mind during this procedure is that the origin of the masseter muscle should not be detached from the maxilla and zygoma. After a complete subperiosteal dissection, the malleable retractor and the Petri intraoral retractor with fiberoptic cable are used to see the inferior orbital rim, zygomatic body, and frontal and temporal processes of the zygoma, all of which make up the malar prominence. Shaving should start from the inferior border of the zygoma and zygomatic process of the maxilla in which the masseter muscle originates (Fig. 7). All of the outer cortex can be carefully shaved while guarding with the retractors. Thus, soft tissue curling and surface irregularities can be avoided. After completing the shaving procedure, we can now see the lateral prominence of the zygomatic arch more clearly and we can continue on to the next step (Fig. 8). The
curvilinear temporopreauricular incision
starts from 5-6 cm above the root of the helix and continues downward along the preauricular skin crease to the upper border of tragus. A strip of temporal and preauricular skin about 5 mm wide should be excised to facilitate the procedure and reduce postoperative skin redundancy (Fig. 9). A dissection plane is created beneath a layer of deep temporal fascia with the dissection proceeding inferiorly to the level of the zygomatic arch. The periosteum of the zygomatic arch is lifted from the posterior part of the arch; thus, we can safely connect the subperiosteal pocket to the anterior side without facial nerve injury (Fig. 10). The outer cortex of the zygomatic arch may also be shaved. Then we determine three cutting points (Fig. 11):
Point A: the junction where the zygomatic body plane meets the zygomatic arch plane. The black A line is applied to a type 2 patient which has a prominent zygomatic body and arch. The red A line is applied to a type 3 patient which has a prominent zygomatic body, arch, and frontal process. Point B: the midpoint between A and C. Point C: a few millilmeters anterior to glenoid fossa. Under the direct vision, we make three greenstick fractures with a pneumatic saw and osteotome on the points A, B, and C and perform infracturing by applying digital pressure. Interosseous fixation procedures were not necessary. The deep fascia should be closed sequentially. After closing the skin, the oral wound is also closed by two layers.
Postoperative Care A liquid diet must be provided for seven days followed by a soft diet for two weeks. Intermaxillary
D.B. Yang and C.G. Park
357
Fig. 2. Type 2: prominent zygomatic body and arch, basal skull x-ray view
fixation is not necessary. The patient should be cautioned to avoid impact injury to the infractured sites for two months.
Discussion
It is well known that there is no general aesthetic standard that is universally accepted. This is true of facial aesthetic plastic surgery. What patients ask of the plastic surgeon may be different in different situations. Many people, especially in Western countries, think that a flat malar curve with loss of relative submalar shallowness, or reversed curve, is not visually pleasing. They think that malar flatness may contribute to premature aging which is exaggerated by downward pooling of degenerated soft tissue and skin; this results in a "drawn down" appearance. As mentioned by Gonzalez-Ulloa [2] and Hinderer [3], patients who have high cheek bones retain their youthful looks in their later years and make them better candidates for rhytidectomy procedures because of the skeletal support provided. Thus, various kinds of malar augmentation methods have been applied [2-5, 7, 8, 10]. Of course, augmented malar features may satisfy Caucasians who have a dolichocephalic face. However, the concept of malar area beauty is different in Orientals who have a mesocephalic face. In the Orient, especially in Korea, most people regard a small, slender face as the ideal shape, but we see many Korean people with a large, square face with increased transverse width or prominent malar areas. Some Korean patients ask the plastic surgeon for a narrower face with an inconspicuous malar area.
Remarkable developments have occurred in correcting facial deformities, but reduction of the malar prominence remains a challenge. Onizuka [6] was the first to describe the method of chiseling and shaving of the zygomatic body and arch through the intraoral approach. In his photographs, the anterior malar eminence was reduced to a certain degree, but lateral bulging still remained. Another approach was attempted by Whitaker [9] who described zygomatic shaving through a bicoronal incision which provides excellent exposure. However, shaving can reduce the malar prominence to a certain degree, but it has little effect on lateral bulging of the zygomatic arch. To narrow the width of the face, including lateral bulging of the zygomatic arch, Edgerton [1] proposed a more radical procedure that included resection of the zygomatic arch. This procedure is quite radical. It is difficult to control lateral irregularities. We also have experience with using the malar shaving procedure in many cases and we are convinced that lateral prominence of the zygomatic arch is still present even after aggressive shaving. In order to solve this problem, we have devised the infracture technique which makes three greenstick fractures on the zygomatic arch and converts the prominent convex arch into a smooth concave one. We prefer the dual approach through an intraoral incision and a temporopreauricular incision because the intraoral approach alone cannot provide direct vision of the zygomatic arch; only through the dual approach can we expose the entire malar eminence including the zygomatic arch and frontal process of the zygoma. None of the 19 cases in which we used the combined intraoral and temporopreauricular approaches needed a blood transfusion. We can safely perform
358
Zygomatic Body and Arch Reduction
Fig. 3. (A-C) Preoperative and postoperative views and (D) basal skull x-ray view, (Right) Slight irregularity remains. For the broad and short face, a deep concave arch infracture is made
D.B. Yang and C.G. Park
359
4. ( A - C ) Preoperative and postrative views and (D) basal skull y view. For the broad and short ,, a deep concave arch infracture lade
360
Zygomatic Body and Arch Reduction
Fig. 5. ( A - C ) Preoperative and postoperative views and (D) basal skull x-ray view. For the long face, a slight concave arch infracture is made
D.B. Yang and C.G. Park
361
Fig. 6. (A-C) Preoperative and postoperative views and (D) basal skull x-ray view. For the asymmetric face, the infracture is made in the zygomatic arch on the left side only
Fig. 7. Intraoral operative view
Fig. 10. The zygomatic arch is exposed beneath the deep temporal fascia and periosteum
Fig. 8. After completing the intraoral shaving procedure, the left prominent zygomatic body is reduced
Fig. 11. Markings of points A, B, and C and concave right side zygomatic arch after infracture Fig. 9. The temporopreauricular incision, for a 5-mmwide excision of skin, is marked the infracture technique without use of interosseous wiring because (1) the remaining medial periosteum can maintain the continuity of the zygomatic arch,
(2) the underlying temporalis muscle provides additional support that prevents displacement of the fractured zygomatic arch and prevents its impinging on the coronoid process of the mandible, (3) the fracture line A to C remains in the state of greenstick fraction.
D.B. Yang and C.G. Park
It is hard to expect good healing of the bone graft which m a y occur after wiring procedure. The m a s s e t e r muscle should not be detached from the z y g o m a and zygomatic process of the maxilla because this m a y lead to an hourglass deformity of face. Also, the shape of the face is an important factor in determining the degree of fracture. For a broad and short face, a deep concave arch infracture is needed to m a k e the face look long (Figs. 3, 4). F o r a long face, a slight c o n c a v e arch infracture is necessary to produce smooth face look. (Fig. 5). Conclusions
We have p e r f o r m e d the reduction malar plasty in 19 cases using a technique that combines shaving and infracture. This led us to the following conclusions: (1) Our operative method is safe and effective. (2) The dual a p p r o a c h through intraoral and temporopreauricular incisions can sufficiently expose the zygomatic b o d y and arch. (3) This operative method is the only one that effectively changes the c o n v e x arch to a c o n c a v e one. (4) We can safely p e r f o r m the infracture technique without using interosseous wiring. (5) The shape of the face is an important factor in determining the degree of infracture.
363 References
1. Edgerton MT et al: Patients seeking symmetrical recontouring for "perceived" deformities in the width of the face and skull. Aesth Plast Surg 14(I):59, 1990 2. Gonzalez-Ulloa M: Building out the malar prominences as an addition to rhytidectomy. Plast Reconstr Surg 53:293, 1974 3. Hinderer U: E1 injerto oseo herterologo de Kiel en perfiloplasties y depresiones faciales (indicasiones y experiencia). Rev Latinoam Cir Plat 11:156, 1967 4. Hinderer U: Malar implants for improvement of the facial appearance. Plat Reconst Surg 56:157, 1975 5. Hinderer U: Malar implants to improve facial proportions and aging. In: Stark RB (ed): Plastic Surgery of the Head and Neck. New York: Churchill, 1987, pp. 1097-1107 6. Onizuka T et al: Reduction malar plasty. Aesth Plast Surg 7:121, 1983 7. Spadafora A, de los Rios E, Toledo Rios R: Pomulos planos (platizigion), endoprotesis de polietileno insertadas por vis subperiostica del arco cigomatico. Prensa Med Argent 58:1946, 1971 8. Whitaker LA: Aesthetic augmentation of the malar-midface structures. Plast Reconstr Surg 80:337, 1987 9. Whitaker LA et al: Aesthetic surgery of the facial skeleton. Persp Plast Surg 1:23, 1988 10. Wilkinson TS: Complications in aesthetic malar augmentation. Plast Reconstr Surg "/1:643, 1983
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