Experience in East Asian Facial Recontouring Reduction Malarplasty and Mandibular Reshaping

ORIGINAL ARTICLE Experience in East Asian Facial Recontouring Reduction Malarplasty and Mandibular Reshaping

Xiongzheng Mu, MD

Objective: To review my experience in both malar re- projection of mandibular foramen on the ramus. The sur- duction and mandibular reshaping techniques to estab- gical indications, major complications, and levels of pa- lish optional, effective, and reliable surgical procedures. tient satisfaction for the different techniques were com- A square-shaped face is considered aesthetically unfa- pared, and thus the pros and cons of wedge-section vorable among East Asians; therefore, reduction malar- osteotomy and mandibular reshaping vs conventional plasty and mandibular reshaping are becoming more ac- procedures were analyzed. ceptable for aesthetic facial skeleton recontouring. Results: A total of 585 patients who had undergone either Methods: The techniques of zygoma arch infracture or reduction malarplasty or mandibular reshaping in the cra- mandibular angle reduction were used until 2 alterna- niofacial center at the Shanghai Ninth People’s Hospital tive techniques were introduced in 2002: the wedge- from May 1988 through December 2008 were reviewed section osteotomy in the malar complex and inclined- in this study. Intraoral incision was the dominant method fullness osteotomy in the mandibular angle and margin. of access in both types of osteotomies. Wedge-section ma- Both osteotomies were selected according to personal ex- larplasty osteotomy was more effective and reliable com- perience and communication with patients. The wedge- pared with other conventional methods. More than half section zygoma osteotomy was performed in the lower of the patients in cases of the mandibular reshaping have zygomatic body via an intraoral approach and green- undergone surgery that included both reduction of the stick infracture of the posterior zygomatic arch through mandibular angle and shaving of the mandibular margin. a tiny preauricular incision. The prominent malar complex could be reduced by being pressed inward and was Conclusion: As optimal strategy for aesthetic facial con- stabilized only by surgical suture or self-stabilization with- touring surgery in East Asians, reduction malarplasty and out any fixation, and the latter method was chosen in my mandibular reshaping were proven to be safe, effective, recent cases. For the lower face, I designed an inclined- and easily handled techniques for modifying the square- fullness osteotomy to address the mandibular angle and shaped face. margin along the diagonal of marked projection of the mental foramen on the margin of the mandible and the Arch Facial Plast Surg. 2010;12(4):222-229

PROMINENT MALAR COM- mandibular angle region to develop tech- plex is commonly seen and nical modification of osteotomies for the is considered aestheti- purpose of acquiring an ideal facial shape, cally unfavorable in East especially in Asian women, using diverse Asians. When combined patterns of reduction malarplasty and man- withA a protruding mandibular angle, the dibular reshaping.2-5 facial contour can appear to be square Existing surgical procedures can be clas- shaped, with a masculine, obstinate, and sified by 2 factors: a surgical approach and unlucky image. Patients usually com- a reduction technique. Intraoral, coronal, plain about having a square-shaped face, preauricular, or pretragal incisions or com- not only those with prominent mandibu- binations of these approaches were adopted lar angles but also those with a normal oval based on the purpose and the position of re- Author Affiliations: face. Melon seed–shaped or oval faces are duction.6-9 The main reduction techniques Department of Plastic and Reconstructive Surgery, their favorite facial contours because they include (1) bone shaving of the prominent Shanghai Ninth People’s look like the faces of movie stars. For that zygoma body and mandibular angle by burr- 1,5 Hospital, Shanghai Jiao Tong reason, since the 1980s many authors (eg, ing, chiseling, or chipping, and so forth ; University School of Medicine, Onizuka et al1) have performed bone shav- (2) bone repositioning by I-shaped or L- Shanghai, China. ing or reduction in the zygomatic arch and shaped osteotomy on the zygomatic body

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 222

©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 to remove the excess segment9-12; (3) infracture proce- transverse line) at the medial part of the zygomatic body, re- dure performed on the zygoma body without any bone removing of the mid segment and using miniplates for fixation, moved13; and (4) a curved osteotomy or radiated oste- is a technique introduced in 2000.10 otomy along the junction of the mandibular body and ramus. Intraoral and Preauricular I-Shaped Reflecting on my 20 years of experience in China or L-Shaped Osteotomy making use of the malar reduction and mandibular reshaping methods described herein, I have summed up An I-shaped or L-shaped osteotomy was performed according to their advantages and disadvantages and developed a the method described in the previous subsection, by making a modified wedge-section osteotomy for repositioning the 1.5-cm-long incision in the preauricular area to facilitate the in- zygomatic arch and inclined-fullness osteotomy to con- fracture of the posterior zygomatic arch by using a narrow os- teotome.12 tour the mandibular angle and margin, which overcame the pitfalls of using conventional techniques. Intraoral and Preauricular Wedge-Section Osteotomy

METHODS Since 2002, I have used a modified osteotomy technique: a wedge- section procedure via an intraoral and preauricular approach ac- At the craniofacial center of Shanghai Ninth People’s Hospi- cording to the following steps. (1) Make a 2-cm minor intraoral tal, a total of 585 patients underwent malarplasty and/or man- incision from the canine to the first molar region. (2) Limit the sub- dibular reshaping from May 1988 through December 2008, in- periosteal separation of zygomatico-alveolar area and the inferior cluding 510 women and 75 men. Their ages ranged from 17 to part of the zygomatic process, allowing only enough space for plac- 45 years, with a mean age of 27.5 years. Indications for the op- ing the reciprocating saw. Dissection should be careful and me- eration were cosmetic (in 94.5% of cases), traumatic (4.0%), ticulous to minimize the detachment of the masseteric muscle to and concomitant malarplasty after removal of fibrodysplasia or the zygomatic arch and thus prevent postoperative cheek droop. benign bone tumor (1.5%). The inner cortex of the zygomatic arch can be exposed subperi- A total of 129 patients underwent isolated zygoma reduc- osteally and broadly to the lateral side of the orbito-zygomatic rim. tions for narrowing the middle portion of the face; 261 (3) A mosquito clamp is used for blunt dissection of the subcu- patients underwent isolated mandibular reshaping for the taneous tissue and is extended to the zygoma root through a tiny, lower part of the face, and 195 underwent both zygoma 2-mm-long preauricular “sideburn” incision (in front of the hair reduction and mandibular reshaping to have a more oval or on the temples). At this point, a mastoid chisel can be inserted for melon seed–shaped face. infracture at the root of the zygomatic arch. Before the operation, facial proportion and symmetry were care- The particular point in my method is that I highly recom- fully assessed. All patients underwent preoperative cephalomet- mend performing a 3-dimensional wedge-section osteotomy on ric imaging and a computed tomographic (CT) scan. If necessary, the prominent zygomatic body using a reciprocating saw. Usu- the patients and surgeons can quickly discuss the 3-dimensional ally, the wedge-section column is composed of a trapezoidal base model planning. In addition, facial digital photographs were taken and an oblique vertical linear osteotomy from the zygomatico- with the same nominal distance. This preoperative analysis was maxillary buttress to the orbito-zygomatic rim. Specifically, the helpful in determining the severity prominence of the malar com- vertex of the trapezoid is the inferior portion of the anterior wall plexes and lower facial appearance, which is beneficial in precisely of the zygomatic process, that is, a narrow outer cortex. The base estimating the amount of bone reduction that is needed. of the trapezoid is the posterior wall of the zygomatic body, a broad inner cortex that doubles the wall of the vertex edge. The 2 oblique sides of the trapezoid are equal in length. ZYGOMA REDUTION METHODS The osteotomy type was determined by the severity of the ma- AND WEDGE-SECTION OSTEOTOMY lar prominence. In a mildly prominent malar body, the trapezoid was then simplified to a triangle shape; thus, a wedge- All patients underwent surgery under general anesthesia through section osteotomy could be reduced to a triangular prism a nasotracheal tube. The malar contour and the lateral head of osteotomy. The osteotomy direction was usually started from the the condyle were outlined by marking on the skin. inner cortex to the outer cortex so that excessive dissection of Intraoral Bone Shaving the malar body could be avoided. The excess bone segment was removed, leaving a trapezoid base ranging from 2 to 6 mm in width. In my early experience, burring, chiseling, and chipping were Then, a zygomatic arch infracture was performed. A sharp performed through an intraoral incision, which shaved the outer mastoid chisel was placed at the zygomatic root, which is an- cortex of the cheekbone and flattened out the protruding zy- terior to the temporomandibular joint. Next, the zygomatic root gomatic process. was cut obliquely from outside to inside. Meanwhile, the greenstick-fractured point was the anterior part of the zygomatic tu- Bicoronal I-Shaped Osteotomy bercle. The incomplete fractured arch was displaced inward and forward (Figure 1 and Figure 2). After a bicoronal scalp incision, a lateral orbital I-shaped os- Once the osteotomy was completed, palm pressure was added teotomy was initiated from the frontozygomatic suture down on the posterior arch toward the zygomatic body to rotate the to the inferomedial area in selected cases. The zygomatic arch infracture malar complex curvilinearly inward, with the in- was cut obliquely and then repositioned superoposteriorly by fraction point acting as a pivot. The 2 wedge-section osteoto- sliding it back and fixing it with miniplates or wires.6 mized surfaces resulting from the zygomatic process and the anterior end of the zygomatic arch, respectively, fitted well. The Intraoral I-Shaped or L-Shaped Osteotomy same procedure was repeated on the other side. After check- ing the symmetrical position for the new malar complex to make Via intraoral incision, an I-shaped lateral orbital osteotomy was sure no step-off occurred, silk surgical suture fixation was ap- applied. An L-shaped osteomy (2 parallel vertical lines and 1 plied. It is worth noting that a step-off generally did not occur

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 223

C D C D

Figure 1. Three-dimensional computerized illustration of wedge-section Figure 2. Three-dimensional computerized illustration of wedge-section osteotomy in a case of mild mandibular prominence: triangular prism osteotomy in a case of severe mandibular prominence: trapezoidal osteotomy. The excess triangular prism bone segment removed is labeled in osteotomy. The excess trapezoidal bone segment removed is labeled in red, red, and the infractured zygomatic arch is labeled in blue. A and C, and the infractured zygomatic arch is labeled in blue. A and C, Preoperative Preoperative views of malar protrusion. B and D, Postoperative views; the views of malar protrusion. B and D, Postoperative views; the infracture malar infracture malar complex rotates curvilinearly inward. complex rotates curvilinearly inward.

Burr and Shaving Method because the wedge-section margin abuts stably. A pinhole was burred on the zygomaticomaxillary buttress, then nonabsorb- For cases of a moderately prominent or outward type of man- able surgical suture was used for the zygomatic arch and mas- dibular angle, the patient usually underwent bone shaving by seter muscle reattachment. In my opinion, the rigid internal burring, chiseling, and/or chipping of the outer cortex of the fixation was not necessary. Self-stabilization, without any su- mandibular angle in the early period. ture, was recommended in my recent cases, considering that a stable contact surface could be provided after a wedge-section Mandibular Angle Reduction Osteotomy osteotomy and thus fixed well (Figure 3). After manipulation of these various techniques in different patients, respectively, the surgical field of each patient was cau- For cases of a severely prominent or inward type of mandibu- terized using electrocautery to prevent further hemorrhage and lar angle, angle osteotomy was used. Usually, the direction line then rinsed with chloramphenicol solution. The mucosal in- was marked with an electric grinder before the osteotomy. The cision, coronal incision, or the preauricular incision was closed full thickness of the mandibular angle was then removed with using a routine method, whereas the tiny sideburn incision did an oscillating saw, including equal amounts of the outer and not need any suturing. Systemic antibiotics were given for 3 inner cortexes. days postoperatively. A clear fluid diet was recommended, and an elastic sleeve on both cheeks was used for at least 2 weeks. Outer Cortex-Splitting Osteotomy

In cases of a moderately prominent or inward type of man- MANDIBULAR RESHAPING METHODS AND dibular angle, I performed sagittal osteotomy of the outer cor- INCLINED-FULLNESS OSTEOTOMY tex in the mandibular angle area. The prominent degree of the region between the molar teeth and the external oblique line General anesthesia with nasal intubation was given to all pa- was the key factor for evaluating the possibility of split corti- tients. An intraoral incision was made 0.5 to 1 cm away from cal osteotomy. The osteotomy line was first labeled by using the attached gingiva along the lower buccal mucosa, begin- an electric drill. The horizontal line on the ramus and the per- ning at the second premolar and ending at the occlusal plane. pendicular line on the mandibular body were then cut super- Subperiosteal undermining was performed meticulously to ex- ficially on the outer cortex. After that, split cortical osteotomy pose the lateral-inferior part of the mandibular angle and body was performed to remove the half-thickness of the outer cor- of the mandible, taking precautions to protect the mental nerve tex, thus reducing the lateral projection of the lower face until sufficient exposure was achieved. (Figure 4).

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 224

C D Figure 4. Design of cortical split mandibular osteotomy.

Figure 3. A patient who underwent wedge-section reduction malarplasty and mandibular angle reduction concomitantly. Preoperative frontal (A) and upward (C) views. Postoperative frontal (B) and upward (D) views. B

Inclined-Fullness Osteotomy B in the Mandibular Angle and Margin

In 2000, I modified the conventional procedure to include inclined-fullness osteotomy in the mandibular angle and margin area; this technique has been preferred in many recent cases. The design of the osteotomy is as follows (Figure 5A): (1) The starting point of the osteotomy is the intersection point where the occlusal plane meets the posterior edge of the ramus (point A). (2) The end point of the osteotomy is the in- Figure 5. Specimen showing the design of the osteotomy. A, Diagram tersection point where the vertical line from the second pre- showing the marking of the inclined-fullness mandibular angle and margin osteotomy. The starting point (point A) of the osteotomy is the intersection molar meets the edge of the mandible (point B). Usually, the point where the occlusal plane cut meets the posterior edge, or the ramus. position of the mental foramen is just beneath the second pre- The end point of the osteotomy (point B) is the intersection point where the molar.14 We can also set point B according to the mental fora- vertical line from the second premolar cut meets the edge of the mandible. men shown on a cephalogram. (3) For a curved osteotomy, the B, Specimen after inclined-fullness mandibular angle and margin osteotomy. curvilinear osteotomy line is drawn from point A to point B. See the “Inclined-Fullness Osteotomy in Mandibular Angle and Margin” The actual osteotomy procedure is composed of 2 steps. First, subsection in the “Methods” section. the upper half of the curvilinear line is cut with a reciprocating saw, with more outer plate removed than inner plate in the sometimes appear in the cheek bone, caused by a postop- mandibular angle portion. Then, a second osteotomy is per- erative step-off deformity, in which the zygomatic body was formed on the lower half of the curvilinear line, also with more moved during both zygoma bone shaving and an I- outer plate removed than inner plate in the mandibular mar- shaped or L-shaped osteotomy. In bicoronal I-shaped zy- gin. These 2 surgical steps can be helpful to avoid damage to goma osteotomy, problems included the patient’s focus on the alveolar nerve (Figure 5B). scarring after the coronal incision, the possibility of facial nerve injury, lack of smoothness in the lateral orbital rim RESULTS by rigid fixation, and damage to the maxillary sinus. Com- paring intraoral and preauricular wedge-section osteoto- The major problems with zygoma bone shaving included mies with zygoma reductions, in my experience the modi- hyperosteogeny and periosteal proliferation caused by lo- fied practice is proven to be a simple, effective, and ideal cal grinding and in filing procedures. It is hard to accept method for reduction malarplasty. that there could be malar prominence relapse and postop- In view of this, a total of 342 patients with a promi- erative cheek droop caused by large periosteum dissec- nent malar complex underwent reduction malarplasty tion. Local skin shading and nonsmooth bone contour using the different procedures described herein, of whom

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 225

No. (%) Patients, No. Duration of Blood Loss, Recovery Surgical Procedure (n=342) Surgery, h mL Period, wk Complications Secondary Surgery Bone shaving 24 0.8 80 3 9 (37.5) 6 (25.0) Bicoronal I-shaped osteotomy 64 3.2 350 6 8 (12.5) 2 (3.1) Intraoral I- or L-shaped osteotomy 88 2.0 200 4 6 (6.8) 3 (3.4) Intraoral ϩ preauricular I- or 62 1.6 120 3 5 (8.1) 3 (4.8) L-shaped osteotomy Wedge-section osteotomy 104 0.4 30 2 3 (2.9) 1 (1.0)

Table 2. Complications in Reduction Malarplasty in 342 Patients

Patients, No. (%)

Intraoral؉Preauricular Bicoronal I-Shaped Intraoral I- or I-Shaped or L-Shaped Wedge-Section Bone Shaving Osteotomy L-Shaped Osteotomy Osteotomy Osteotomy Complication (n=24) (n=64) (n=88) (n=62) (n=104) Asymmetry 4 (16.7) 2 (3.1) 2 (2.3) 1 (1.6) 1 (1.0) Overcorrection 1 (1.6) 1 (1.6) Recurrence 6 (25.0) 1 (1.6) 1 (1.1) Nerve injury 2 (3.1) 2 (2.3) Swelling/hematoma 3 (4.7) 1 (1.1) Unfavorable scars 4 (6.3) Skin shading 2 (3.1) 1 (1.1) 2 (3.2) Cheek drooping 3 (3.4) 2 (3.2) Malar numbness 1 (4.2) 1 (1.1) Malunion 1 (1.6) 1 (1.1) TMJ disorder 1 (1.6) Temporal depression 3 (4.7)

Abbreviation: TMJ, temporomandibular joint.

195 were treated with either mandibular angle reduc- dure to be used; of these adverse effects, a rough border tion or genioplasty concomitantly to obtain a better aes- after angle reduction was the most debated issue, as a so- thetic facial contour. Among all zygoma reductions, 104 called secondary mandibular angle. Outer cortical split patients underwent the new wedge-section procedure, osteotomy (performed in42 patients) seems to be a sort and the different surgical procedures and their clinical of alternative method to avoid an uneven border on the data are listed in Table 1. Patients were required to have mandible. But it was still difficult to control the recip- the first follow-up 3 months postoperatively, and thus rocating saw and chisel to split the thickness of the man- the longest follow-up period is 10 years. Postoperative dible, and it was easy to break the ramus and damage the assessments, such as panoramic radiographs, Waters view mandibular nerve. Inclined-fullness osteotomy in the man- radiographs, or CT imaging, were included in the data dibular angle and margin (performed in 227 patients) was collection. Most patients were satisfied with the postop- the procedure preferred in most of the recent cases, but erative facial outcome and indicated that there had been complications still happened, as shown in Table 3. a sufficient reduction in their facial width and malar A total of 195 patients underwent combined surgical prominence. Complications associated with different sur- procedures of both malar reduction and mandibular re- gical procedures are displayed in Table 2. shaping (Figure 6). Mandibular reshaping, which included one-third of the lateral and inferior portion of the mandible, was performed in a total of 456 cases. Burring and shaving in COMMENT the mandibular angle region (performed in 23 patients) is easy to control even for new surgeons and in cases of Malar complex prominence usually appears as a pro- a prominent outward mandibular angle. It is a safe protruding cheekbone in anterior, lateral, and oblique di- cedure, but the results usually did not satisfy most of these rections, and therefore the zygomatic bone arch junc- East Asian patients. Mandibular angle osteotomy (per- tion is the key element in reducing the sharp cheekbone. formed in 114 patients in this study) used to be a popu- Inward alteration of the zygomatic arch is also an im- lar procedure in China and resulted in obvious lateral re- portant element in narrowing the facial width in the fron- duction in the mandibular region. Adverse effects have tal view (Figure 7). appeared from time to time, depending on the skill of the My initial reduction malarplasty method was the bone surgeons and the appropriate indication of the proce- shaving procedure introduced by Onizuka et al1; how-

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 226

Patients, No. (%)

Outer Cortex-Splitting Inclined Full-Thickness Burr and Shaving Angle Osteotomy Osteotomy Osteotomy Complication (n=23) (n=114) (n=42) (n=277) Asymmetry 1 (4.3) 3 (2.6) 1 (2.4) 4 (1.4) Overcorrection 5 (4.4) 2 (4.8) 3 (1.1) Rough border 2 (8.7) 8 (7.0) 2 (0.7) Hematoma 2 (8.7) 16 (14.0) 1 (2.4) 9 (3.2) Delayed infection 4 (3.5) 2 (0.7) Ramus fracture 2 (1.8) 1 (2.4) Nerve injury (M) 1 (0.9) 2 (4.8) 4 (1.4) TMJ disorder 2 (1.8) 1 (2.4) 1 (0.4)

Abbreviation: TMJ, temporomandibular joint.

A B A B

Figure 7. A patient with a square-shaped face who underwent wedge-section Figure 6. A patient with a prominent mandible who underwent reduction malarplasty and inclined-fullness mandibular reshaping. inclined-fullness mandibular reshaping. A, Preoperative frontal view. A, Preoperative frontal view. B, Postoperative frontal view. B, Postoperative frontal view.

ever, this method was applicable only for cases of mild zy- ables the surgeon to remove the excess protruding por- gomatic body prominence and was soon out of use owing tion of the bone by adjusting the distance between the to a high recurrence rate with periosteal proliferation. Lo- lines of the parallel osteotomy.9,11 However, these meth- cal grinding and filing procedures flattened the zygomatic ods usually need extensive periosteum dissection of the process, which caused the face to appear broader after sur- whole zygomaticomaxillary area, including the malar gery, leading to a more angular contour appearance. Post- body, the lateral orbital rim, and the lateral or medial sur- operative relapse due to hyperosteogeny or periosteal pro- face of the zygomatic arch, which leads to postoperative liferation was much more apt to occur. Other limitations, cheek droop owing to the broad separation of the mas- such as unnatural curvature, undercorrection, or asym- seteric and musculus zygomaticus attachments. In ad- metry, restricted its prevalence. dition, infraorbital nerve and facial nerve injury may oc- Therefore, zygomatic arch osteotomy and segment re- cur. Besides, these methods generally cause damage to positioning tended to be popular procedures because of the maxillary sinus, and the oblique osteotomy plane was the effective and stable result. I-shaped osteotomy in the difficult to fit well, which resulted in step-off and post- zygomatic arch and rigid fixation in the lateral orbit rim operative skin shading. Although the technique of com- via a bicoronal approach have been adopted to provide plete fracture of the posterior arch was widely applied definite manipulation under a wider surgical field. and could reduce the facial width to a large extent, post- But facial nerve injury, minor protuberance of the fixed operative facial depression in the preauricular area was palate in the orbital rim, and a longer scar are the main a common problem because the medially replaced arch adverse effects that conflict with the aesthetic appear- may generate a step-off. The impaction of the arch might ance desired, except in older women, who prefer to ac- also cause restriction of mouth opening. cept the face contouring surgery, intend to undergo a To avoid these drawbacks, I used a wedge-section os- face-lift in the future, and do not care about the coronal teotomy procedure that minimized the dissection area incision. to the inferior border of the zygomatic body, and the me- The I-shaped or L-shaped osteotomy of the zygo- dial wall of the malar process was just large enough to matic body through an intraoral approach, combined with admit a reciprocating saw blade. The posterior portion a complete or greenstick fracture of the zygomatic arch of the arch was accessed by the tip of a mosquito clamp for reposition, is presented as a modification that en- before the temporomandibular joint via a tiny incision

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 227

©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 in front of the hair on the temples. The dissection was cludes not only mandibular angle reduction but a decrease performed according to the direction that the facial nerve of the thickness of the mandibular body and body margin. branches run, and the tunnel was made just large enough Outer cortex-splitting osteotomy was reported for the to admit a mastoid chisel. By doing this, the broad detach- treatment of reduction mandibuloplasty.18 Although it is ment of the arch could be avoided, and the facial nerve was a simple method, it provides limited effectiveness. I fur- less likely to be injured. The tiny incision can also avoid ther modified this procedure to include a sagittal outer the superficial temporal artery in the preauricular region, cortex–splitting osteotomy. However, although it could and the sideburn scar was almost invisible after the sur- remove the half-thickness of the outer cortex and re- gery. The wedge-section osteotomy surface could fit bet- lieve the lateral projection of the lower face, it did not ter, and the infracture malar complex after the greenstick change the angle between the ramus plane and the man- fracture of the arch was pushed forward and curvilinearly dibular plane. Female patients still complained about a inward. In this way, patients could gain sufficient reduc- postoperative masculine appearance from the lateral view. tion and achieve a smooth malar contour. It can also keep Furthermore, a splitting osteotomy could decrease the the malar soft tissue inward so as to prevent postoperative rigidity of the mandible and increase fracture risk. cheek droop. The direction of the mastoid chisel was de- The inclined-fullness osteotomy that I introduced had termined by the amount of the malar body segment being key modifications in that it not only could achieve a natu- removed. When removing a large amount, the angle of the ral mandibular margin outline that is well connected to chisel should be oblique to avoid the dislocation of the in- the chin, but it also could reduce the full thickness of fraction point and thus guarantee stability. I recom- the mandibular angle area without damaging the solid- mended suture fixation instead of rigid internal fixation to ity of the mandible and could alter the angle between the allow autoregulation of the infracture segment. Kim and ramus plane and the mandibular plane through a 1-stage Seul11 emphasized the importance of fixation with miniplates operation. The problem was how to determine the loca- because they thought that the repositioned zygomatic com- tion of the new mandibular angle. In my experience, the plex could undergo external rotation from the force of the new mandibular angle was usually set at the point infe- masseter muscle. rior to the earlobe (no more than 1 cm). In my experience, it is enough to apply suture fixa- Soft-tissue decrement simultaneously was considered as tion under minimal dissection, zygomatic arch infrac- a supplementary way to narrow the lower face. In my ex- ture, and fixed attachment of the masseter and tempo- perience, the amount of masseter would gain volumetric ralis muscle. Suture fixation also has merit in that the atrophy by 30% after surgery for mandibular reshaping.19 muscle attachment adheres to the zygomaticomaxillary But in treating the aging patient, if the woman is older than buttress, and it plays a role in prevention of soft-tissue 45 years, even though mandibular angle reduction actu- drooping. Recently, I developed a “self-stabilization” tech- ally can smooth the prominent lower face, loss of soft tis- nique that does not use any fixation and suture between sue, such as buccal fat and parts of the masseter, will prob- the osteotomy and infracture segment. It is feasible to per- ably result in drooping skin of the lower face and other signs form in consideration of the contact surface, which, ac- of an aging appearance in the future. cording to geometry, self-stabilizes after wedge-section In my patients, although a large number of inclined- osteotomy. fullness mandibulectomies and procedures for com- A combination of molding and osteotomy methods pro- plete cortical bone removal of the lateral mandible were posed by Lee and Park13 includes 3 steps: filing the zy- performed for sufficient reduction in facial width and man- gomatic body, a partial-thickness osteotomy of the pos- dibular prominence, the oral functions (eg, biting strength, terior orbital rim, and a full-thickness osteotomy of the occlusion, and temporomandibular joint function) ex- posterior zygomatic arch. According to the major ele- amined postoperatively showed a satisfactory outcome. ments determining the reduction consequence, which I Transient alveolar nerve injury still occurred in 4 cases, analyzed in the “Results” section, the inward reposition- which caused numbness of the mental foramen area. It ing of the zygomatic arch by greenstick fracture of the is necessary to mark up the anatomic structure of alveo- orbital rim and a complete fracture of the posterior os- lar nerve before surgery to avoid mistaking the location teotomy site resulted in undercorrection of the promi- of the nerve. Careless work or mistakes caused by a less nent malar complex for this method and insufficient re- experienced surgeon that cause mandibular fracture will moval of the excess malar segment. probably lead to nerve injury. I emphasize that inclined- Mandibular angle osteotomy was first introduced by fullness osteotomy should be performed under the di- Beckers15 through an external approach. This technique rection of an experienced and skilled surgeon. was considered to be acceptable until Converse16 re- In conclusion, this retrospective study of aesthetic sur- ported a surgical method via an intraoral incision. Both gery in facial proportion reviews the different methods methods used linear osteotomies, which did not adapt used in the past 20 years. Intraoral wedge-section ma- to the East Asian aesthetic concept, and usually resulted larplasty and/or mandibular reshaping are the proce- in the “second mandibular angle.” Baek et al17 proposed dures most often used in my clinic to deal with facial con- a multiosteotomy method to overcome this disadvan- touring surgery in East Asian patients. tage; however, it was complicated, and the patient did not present a natural mandibular outline. Accepted for Publication: August 21, 2009. I use the term “mandibular reshaping” instead of de- Correspondence: Xiongzheng Mu, MD, Department of scribing reduction osteotomies in the lower mandibular re- Plastic and Reconstructive Surgery, Shanghai Ninth Peo- gion. Actually, recontouring surgery of the lower face in- ple’s Hospital, Floor 18, Building 1, No. 639, Zhizaoju

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 228

©2010 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/26/2021 Road, Shanghai 200011, China (craniomu@gmail complex: clinical review and comparison of two techniques. J Craniofac Surg. .com). 2003;14(3):383-392. 10. Kim J, Choi HY. New aesthetic zygoma recessive osteotomy for the correction Financial Disclosure: None reported. of zygoma protrusion. J. Korean Soc Plast Reconstr Surg. 1991;18(6):1081- 1090. REFERENCES 11. Kim YH, Seul JH. Reduction malarplasty through an intraoral incision: a new method. Plast Reconstr Surg. 2000;106(7):1514-1519. 12. Yang DB, Chung JY. Infracture technique for reduction malarplasty with a short 1. Onizuka T, Watanabe K, Takasu K, Keyama A. Reduction malar plasty. Aesthetic Plast Surg. 1983;7(2):121-125. preauricular incision. Plast Reconstr Surg. 2004;113(4):1253-1261. 2. Sumiya N, Kondo S, Ito Y, Ozumi K, Otani K, Wako M. Reduction malarplasty. 13. Lee JG, Park YW. Intraoral approach for reduction malarplasty: a simple method. Plast Reconstr Surg. 1997;100(2):461-467. Plast Reconstr Surg. 2003;111(1):453-460. 3. Lee TH, Jung YS, Choi SH, et al. Correction of the prominent malar. J Korean 14. Jing H. Study of the location of mental foramen between Chinese and Japanese Soc Plast Reconstr Surg. 1987;14(1):107-114. adults. Chinese J Dental Materials Devices. 2003;12(03):124-131. 4. Hahm JW, Baek RM, Oh KS, et al. A 10-year experience on reduction malarplasty. 15. Beckers HL. Masseteric muscle hypertrophy and its intraoral surgical correction. J Korean Soc Plast Reconst Surg. 1997;24(6):1487. J Maxillofac Surg. 1977;5(1):28-35. 5. Satoh K, Ohkubo F, Tsukagoshi T. Consideration of operative procedures for zy- 16. Converse JM. Deformities of the jaw. In: Converse JM, ed. Reconstructive Plas- gomatic reduction in Orientals: based on a consecutive series of 28 clinical cases. tic Surgery. Philadelphia, PA: WB Saunders; 1977:1406-1408. Plast Reconstr Surg. 1995;96(6):1298-1306. 17. Baek SM, Baek RM, Shin MS. Refinement in aesthetic contouring of the promi- 6. Baek SM, Chung YD, Kim SS. Reduction malarplasty. Plast Reconstr Surg. 1991; nent mandibular angle. Aesthetic Plast Surg. 1994;18(3):283-289. 88(1):53-61. 18. Han K, Kim J. Reduction mandibuloplasty: ostectomy of the lateral cortex around 7. Uhm KI, Lew JM. Prominent zygoma in Orientals: classification and treatment. the mandibular angle. J Craniofac Surg. 2001;12(4):314-325. Ann Plast Surg. 1991;26(2):164-170. 19. Gui L, Yu D, Zhang Z, Changsheng LV, Tang X, Zheng Z. Intraoral one-stage curved 8. Yang DB, Park CG. Infracture technique for the zygomatic body and arch reduction. osteotomy for the prominent mandibular angle: a clinical study of 407 cases. Aesthetic Plast Surg. 1992;16(4):355-363. Aesthetic Plast Surg. 2005;29(6):552-557. 9. Cho BC. Reduction malarplasty using osteotomy and repositioning of the malar

Announcement

Visit www.archfacial.com. As an individual subscriber you can search the full text of Archives of Facial Plastic Surgery or all 10 JAMA and the Archives Journals. Ad- vanced Search enables you to search by citation, title, author, keywords, and date ranges. You can search by jour- nal or by topic collection. Finally, you can choose to search only tables and figures.

(REPRINTED) ARCH FACIAL PLAST SURG/ VOL 12 (NO. 4), JULY/AUG 2010 WWW.ARCHFACIAL.COM 229