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Experience in East Asian Facial Recontouring Reduction Malarplasty and Mandibular Reshaping

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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 com- plex 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- Awith 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 re- moving 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 ob- lique 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 trap- ezoid 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 green- stick-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).
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