True intraoral reduction malarplasty with a minimally invasive technique

In the Orient, faces are usually wide and short. This physical characteristic is often undesirable in many Asian cultures. Consequently, reduction malarplasty is one of the most common aesthetic procedures performed in the Orient. Previously described techniques for malar reduction such as intraoral chiseling or the burring-down of the zygomatic body and arch often result in minimal invasiveness, with no external scarring. However, they are less effective techniques. Other techniques, such as osteotomy and repositioning of a prominent malar complex by means of a coronal approach also proved fallible, by often resulting in a prominent, visible scar. Furthermore, a combined approach, using both the intraoral and the external (preauricular or sideburn) routes, often results not only in an external scar, but also in possible facial nerve (frontotemporal branch) damage. Thus, we performed a true intraoral osteotomy and reduction malarplasty through upper buccal sulcus incisions, resulting in minimal tissue damage without external scarring. Aesthetic facial contouring surgery has been performed in increasing numbers over the past decade, especially for malar and mandibular angle protrusion. The prominence of the malar area varies according to differences in the inherited bony structure. Essentially, Orientals are mesocephalic, whereas Caucasians are dolichocephalic; the face is wider and shorter in the former than in the latter. An even greater prominence of the zygoma among Orientals, which causes the face to be wider and shorter, is widely regarded as an unattractive feature in the Oriental culture [1,2]. In contrast, a flat cheek bone in Caucasians makes the face appear masculine, in addition to making the nasal and chin prominences more noticeable. Of the previously described techniques for malar reduction, shaving and contouring by the intraoral approach, without the external approach [1,4] is often less effective due to the limitations of shaving. Likewise, osteotomy and repositioning of a prominent malar complex by the coronal approach can result in an extensive visible scar [2,5,6,12]. Additionally, the combined approach by means of the intraoral and external (preauricular or temporal, sideburn) routes [4,7] can result in an external scar and the distinct possibility of facial nerve damage [8]. Therefore, our team created a simple and effective way of conducting a true intraoral osteotomy and reduction malarplasty without external scarring and the instigation of facial nerve damage.     

改良颧骨颧弓截骨缩小术的临床应用

目的探讨矫正颧骨复合体肥大的一种新的手术方法和效果。方法采用口内切口,首先对术前标记的颧骨最高点进行磨骨,然后用微型来复锯进行颧骨体部的L形不完全截骨;采用耳前切口在颧弓结节前1cm垂直截断颧弓,将颧骨复合体向后内移位,不需要进行内固定。结果650例伤口均I期愈合。1例于2周后出现上颌窦炎,经静脉用抗炎药物、局部引流后1周自愈。1例由于同时进行局部脂肪抽吸术后出现直径约1cm的局限性皮肤坏死,经换药后愈合。1例术后1周复查出现单侧额纹消失,2周后完全恢复。随访2～24个月,所有受术者均对面型改善表示满意。结论该术式设计简单,不需要内固定,手术时间短、手术创伤小、恢复时间短、并发症少,是一种比较安全、有效的矫正颧骨复合体肥大的手术方法。     

C形截骨术治疗颧骨颧弓过突

目的 探讨C形截骨术矫正颧骨颧弓过突的手术方法.方法 根据颧骨颧弓肥大的程度和特点,全身麻醉下经口内入路自颧牙槽嵴外侧经眶外下缘到颧弓与眶骨外缘交接处做两条平行C形截骨线,两截骨线间距由颧弓需缩短程度而定,以来复锯截断截除中间骨块,骨凿凿断残余骨连接.耳屏前颞部发际内做长1.5～2.0 cm切口,切开皮肤及皮下,顺面神经走向钝性分离至骨膜,切开骨膜显露颧弓根部,在关节结节前方由后向前斜行截断颧弓.将颧骨颧弓向内上方移动靠拢后以钛板固定.结果 共完成12例,均取得良好效果.结论 C形截骨术矫正颧骨颧弓过突,不损伤上颌窦,面部软组织无下垂,术后效果明显,特别是对颧弓肥大者效果更佳.     

C形截骨术治疗颧骨颧弓过突

目的 探讨C形截骨术矫正颧骨颧弓过突的手术方法.方法 根据颧骨颧弓肥大的程度和特点,全身麻醉下经口内入路自颧牙槽嵴外侧经眶外下缘到颧弓与眶骨外缘交接处做两条平行C形截骨线,两截骨线间距由颧弓需缩短程度而定,以来复锯截断截除中间骨块,骨凿凿断残余骨连接.耳屏前颞部发际内做长1.5～2.0 cm切口,切开皮肤及皮下,顺面神经走向钝性分离至骨膜,切开骨膜显露颧弓根部,在关节结节前方由后向前斜行截断颧弓.将颧骨颧弓向内上方移动靠拢后以钛板固定.结果 共完成12例,均取得良好效果.结论 C形截骨术矫正颧骨颧弓过突,不损伤上颌窦,面部软组织无下垂,术后效果明显,特别是对颧弓肥大者效果更佳.     

C形截骨术治疗颧骨颧弓过突

目的 探讨C形截骨术矫正颧骨颧弓过突的手术方法.方法 根据颧骨颧弓肥大的程度和特点,全身麻醉下经口内入路自颧牙槽嵴外侧经眶外下缘到颧弓与眶骨外缘交接处做两条平行C形截骨线,两截骨线间距由颧弓需缩短程度而定,以来复锯截断截除中间骨块,骨凿凿断残余骨连接.耳屏前颞部发际内做长1.5～2.0 cm切口,切开皮肤及皮下,顺面神经走向钝性分离至骨膜,切开骨膜显露颧弓根部,在关节结节前方由后向前斜行截断颧弓.将颧骨颧弓向内上方移动靠拢后以钛板固定.结果 共完成12例,均取得良好效果.结论 C形截骨术矫正颧骨颧弓过突,不损伤上颌窦,面部软组织无下垂,术后效果明显,特别是对颧弓肥大者效果更佳.     

Lateral facial contouring via a single preauricular incision

Many Asians have faces with prominent zygomas, and therefore reduction malarplasty is one of the most frequently undergone surgeries in Asia, including South Korea. It is performed using various surgical approaches (external, intraoral, bicoronal or their combination). The reduction technique that is the most effective, safest and with the lowest morbidity needs to be determined. From December 2005 to January 2010, 1652 patients who wanted to undergo zygoma reduction for purely aesthetic reasons were operated on using a novel technique that we have developed (the 3S technique), which is a simple and safe surgical technique that results in only a short scar. First, under local anaesthesia, a 13- to 15-mm-long skin incision is made at each sideburn. The subperiosteal dissection is continued anteriorly all the way to the body of the zygoma. Zygoma reduction is then performed in three steps: (1) malar shaving (lateral area of the zygoma body), (2) lateral corticotomy (zygomatic arch) and (3) full-thickness osteotomy (pretubercular area of the temporomandibular joint). Next, the zygomatic arch is displaced medially with digital pressure (infracture). Finally, a Silastic drain is inserted through the incision site, skin repair is completed and a gentle compressive dressing is applied. Most of the patients were satisfied with the results of the operation. This technique provides the following advantages: (1) it is simple and safe because it is performed under only local anaesthesia; (2) only one scar is created at the sideburn; (3) no foreign bodies, such as wires or miniplates, are used; and (4) it is minimally invasive, and as such there are fewer potential complications (e.g., no cheek drooping due to a wide muscle incision or dissection, less oedema and bleeding and a short hospitalisation time). The presented technique is simpler?and more effective than previously described surgical techniques for reduction malarplasty.     

耳屏前小切口内镜辅助颧弓骨折的复位内固定

目的探讨经耳屏前小切口内镜辅助下颧弓骨折复位内固定的相关技术及临床价值。方法单侧颧弓骨折7例,单侧颧骨、颧弓骨折10例,均采用经耳屏前小切口内镜辅助下颧弓复位内固定治疗。结果所有病例术后双侧颧部对称,无张口、咀嚼功能障碍及明显并发症发生。结论经耳前隐匿小切口内镜辅助下颧弓骨折复位内固定可作为部分颧弓骨折病例治疗的选择术式。     

颧骨颧弓缩小截骨术的手术径路比较

目的：颧骨颧弓肥大多见于东亚人，通过颧骨颧弓缩小截骨术手术径路的比较，选择更简捷有效的截骨术。方法：比较经冠状切口或经口内或经口内加耳前切口暴露颧骨的颧突、颧弓部缩小术。截骨位于颧骨根部、颧弓远端，使高耸的颧骨内陷、下移，并固定。结果：通过经冠状切口截骨的45例，口内切口切、磨骨的12例，口内切口“L”形截骨的21例，口内加耳前切口的“L”形截骨的58例分类比较，结果显示：口内切口创伤小、切口隐蔽，明显优于冠状切口入路，而口内加耳前切口则使截骨术更为简捷有效。对大于45岁的患者，冠状切口可同时进行颧骨颧弓缩小和去皱术。结论：经口内加耳前切口的颧骨颧弓缩小截骨术，可作为首选方法之一。     

Reduction Malarplasty Using an L-Shaped Osteotomy Through Intraoral and Sideburns Incisions

The slender, oval-shaped face is considered to be attractive in East Asia. To obtain the ideal contour of the midface, reduction malarplasty has been popularized in oriental countries in recent years. This report describes a surgical technique for reduction of the zygomatic body and arch. After labiobuccal vestibular incisions are made, the anterior zygomatic body and lateral orbital rim are exposed by subperiosteal dissection. Thereafter, an L-shaped osteotomy is performed. Two parallel horizontal osteotomies are made in the anterior part of the zygomatic body, and the middle bone segment is removed. The zygomatic arch root is fractured through a small sideburn incision just anterior to the articular tubercle. Finally, the freed zygomatic complex is medially repositioned and fixed with one or two bicortex screws. Operations on 32 patients demonstrated that this technique may be a sound method for malar complex reduction, with the advantages of simple manipulation, stable fixation, and less risk of a drooping face.     

Reduction Malarplasty without External Incision: A Simple Technique

Background: The concept of Eastern facial beauty is different from that of the Western. Prominent malar bones are perceived as unattractive by Easterners, including the Thai. Many techniques for malar reduction, such as chiseling or burring of the zygomatic body, are ineffective in reducing facial width. At present, the concept of medial movement of the zygomatic body is accepted as the treatment of choice. However, all current approaches leave some external facial scars, usually at the preauricular area. Objective: A new, effective, and simple technique for reduction malarplasty that leaves no external scars is described here by the authors. Method: The technique consists of a purely intraoral approach to remove a segment of anterior zygomatic body, to create a greenstick fracture at each zygomatic arch, and to medially mobile the zygomatic body, which is then fixed by wiring at the end. Results: All eight patients who underwent this surgical procedure have satisfactory results without complications after one to six years of follow-up. Conclusion: This technique represents another step of improvement in cosmetic craniofacial surgery to reduce both anterior and lateral projections of the malar eminences for better facial harmony. Presented in part at the Second International Conference of the Asian-Pacific Craniofacial Association, Adelaide, Australia, November of 1998. Also, presented at the Eleventh ASEAN Congress of Plastic and Reconstructive Surgery, Singapore, February 1, 2002.     

颧骨“L”形截骨降低术的三维有限元模型的建立与分析

目的:建立关于颧骨"L"形截骨降低术的三维有限元模型,探讨该术式在生物力学方面的特点。方法:采集高颧骨畸形患者术前头颅螺旋CT,将数据导入相应医学图像处理软件,对颧骨复合体及手术相关区域进行分体三维重建、手术模拟,应用有限元软件对模型进行网格划分,通过CT扫描灰度值的转换,对各部分材质的弹性模量、泊松比参数进行赋值,再模拟术中对颧骨、颧弓的施力,分析颧骨复合体生物力学情况。结果:建立了颧骨"L"形截骨降低术的三维有限元模型,其几何相似性、力学相似性高。运用三维有限元法生物力学分析,术中按压颧骨复合体,颧弓根部出现一个明显的应力集中,颧骨颧弓产生向内侧的形变。结论:在颧骨"L"形截骨降低术术中按压颧骨复合体,是能够在颧弓根部造成预期的青枝骨折,使颧骨产生内收、降低的形变。     

全口内微切口颧骨复合体缩小整形术

目的：寻找一种体表没有手术痕迹,可以自如地调整颧骨复合体任何部位的宽窄程度,使面部有效达到三维立体缩小的颧骨整形手术方法。方法：采用全口内切口,自颧弓后间隙入路,不剥离功能性肌肉。用往复锯行颧骨体和颧弓根部截骨,根据患者的具体情况和要求,自如调整颧骨复合体移位的位置和幅度,将肥大的颧骨和颧弓按照自然弧度自如地推入到理想的位置。用锦纶编织线将断端捆绑式固定,切口采用可吸收缝线分层缝合。结果：本组全口内切口入路颧骨复合体缩小术296例效果满意。结论：①全口内切口入路,体表不会遗留任何手术痕迹;②颧弓后间隙行颧弓根部和颧骨体截骨,非常安全;根据患者的具体情况和要求,自如地调整颧骨复合体宽度和突度,从而达到颧骨复合体最大幅度、最有效地立体缩小;③颧骨截骨断端采用锦纶编织线捆绑式固定,不仅固定牢固,而且术后在x线下不会显影：④术野功能性肌肉不做剥离,切口分层缝合,术后不会出现软组织下垂。     

Technical Refinements of Infracture for the Zygomatic Body and Arch Reduction

Nowadays the infracture technique for the zygomatic body and arch has been popularized in Oriental countries for the reduction of zygoma. We can obtain sufficient operative field to handle the zygoma through the intraoral and temporopreauricular incision and control the amount of shaving and infracturing zygomatic prominence. We developed three types of infracture technique for the reduction of the zygomatic body and arch according to the degree of severity of the zygomatic prominence and the shape of the face: Type A, infracturing with bone-to-bone contact for mild prominence with/without a long face; Type B, infracturing beyond bone-to-bone contact for moderate prominence; and Type C, infracturing far beyond bone-to-bone contact and microplate fixation for severe prominence with/without a broad and short face. By applying the criteria described above, we can obtain aesthetically acceptable results in zygoma reduction.     

Deep dissection plane for endoscopic-assisted comminuted malar fracture repair

Endoscopic technique has been used in the management of comminuted malar fractures. However, the reported dissection plane is close to the frontal branch of the facial nerve, and paralysis of the frontal muscle is sometimes noted postoperatively. From January 1998 to November 2001, 42 patients underwent endoscopic-assisted zygomatic bone repair at Kaohsiung Medical University Hospital and Kaohsiung Municipal Hsiao Kang Hospital. The zygomatic arch was approached via a dissection plane beneath the deep temporal fascia, and the plate was fixed on the upper border of the arch. The advantages of this method are 1) one temporal incision is sufficient for dealing with the zygomatic arch fracture; 2) the learning curve for endoscopic technique is shortened; 3) there is less risk of injury to the frontal branch of the facial nerve; and 4) the periosteum at the anterior and inferior border of the zygomatic arch is preserved. The deep method is a safe alternative for endoscopic-assisted comminuted malar fracture repair.     

颧骨、颧弓缩小整复术的临床研究

目的：总结颧骨、颧弓肥大的治疗体会,三维CT的临床应用及诊断标准。方法：通过测量制定颧骨,颧弓肥大的诊断标准,对64例患者经头皮冠状切口和口内切口,进行灌骨,颧弓截骨,颧弓缩小整复术,使颧骨向上,内,后移位。结果：所有病例臃肿粗犷的方形面型轮廓均得到改善。结论：颧骨,颧弓缩小整复术能改善面型轮廓,三维模拟设计和坚固内固定技术可提高手术的精确性。     

口内入路颧骨缩小术的数点改进

目的 对口内入路颧骨缩小术做数点改进。方法 我们在颧骨截骨线的形态、是否增加耳前切口、颧突复合体的移动方向、内固定的方式、面颊部软组织松弛的防治等方面作了一些改进。结果 2000年6月至2004年4月，我们在临床应用17例，均获得了满意效果。结论 改进后的方法解决了口内入路颧骨缩小术出现的一些问题。     

Preauricular approach to infratemporal fossa

We present an approach to the skull base that allows access to both the infratemporal fossa and the middle cranial fossa with minimal morbidity. This approach is different from most of the previously described approaches in that it uses a preauricular incision, preserves the facial nerve, and avoids the mastoid bone. It involves dividing the zygomatic arch and displacing it inferiorly, dividing the malar eminence (zygoma) and displacing it anteriorly, and cutting the coronoid process and retracting it superiorly with the attached temporalis muscle. Reconstruction is accomplished by using the temporalis muscle or a pericranial flap to cover the dura, a free fat graft to fill the space left by tumor excision, and by wiring the zygomatic arch and malar eminence into their original positions. Case reports of both benign and malignant lesions are presented.     

Reduction Malarplasty by 3-mm Percutaneous Osteotomy

Oriental people usually have a wide midface and a prominent malar curve. The zygomatic bone forms the prominence of the cheek, and it is the most important part in determining the ideal oval shape of the face on the frontal view and the character of the oblique profile. Therefore, zygoma contouring is commonly performed. Women with a prominent zygoma have an inferiority complex associated with unattractive facial features resembling aged, melancholic, and strong characters in oriental culture. Zygoma is the highlighted area of the midface and a major determinant of midfacial shape, but harmony with the adjacent area is very important. Therefore, to obtain the optimal outcome of reduction malarplasty, various ancillary procedures must be performed simultaneously. The authors performed 30 reduction malarplasties during the past 2 years. The amount of bone to be removed was determined by the preoperative interview, physical examination, and x-rays. Intraoral incisions provided access to the zygomatic body and lateral orbital rim. After the L-shaped osteotomy, two parallel vertical and transverse osteotomies in the medial part of the zygomatic body, the midsegment was removed. The posterior portion of the zygomatic arch was approached through a stab incision in the preauricular area. A 3-mm osteotome was used. After completion of the osteotomy, the movable zygomatic complex was reduced medially and superiorly, then fixed with miniplates and screws on the zygmaticomaxillary buttress. The combined operations with reduction malarplasty were as follows: reduction of the mandibular angle in 15 cases, rhinoplasty in 14 cases, and double-fold operation in 11 cases. The follow-up period was 2 months to 2 years, and all the patients were satisfied with the results. In conclusion, this method is a very simple, easy, and safe method that reduces the operating time to 1 h and minimizes postoperative edema and swelling. Consequently, recovery time is relatively short, and no conspicuous scars in the preauricular area are left. The authors also performed many ancillary procedures, thereby obtaining optimal satisfaction with their results, including decreased facial width and superior mobilization of the prominent area. They were able to prevent postoperative cheek drooping, and to give the patients a more youthful, charming look.     

The subzygomatic fossa: a practical landmark in identifying the zygomaticus major muscle

OBJECTIVE: To test the validity of the subzygomatic fossa as a possible landmark in identifying the origin of the zygomaticus major muscle (ZMM). METHODS: Twenty-three fresh cadaver facial halves were dissected. Four references points were identified in each cadaver head: the zygomatic arch, the malar eminence, the modiolus, and the ZMM insertion notch. The ZMM insertion notch is a palpable landmark that is typically identified midway between the zygomatic arch and the malar eminience. A straight line was drawn from the ZMM insertion notch to the modiolus. An additional line was drawn from the malar eminence to the modiolus. An incision was made along the each line to the depth of the facial muscles. The presence or absence of the ZMM was recorded, and the location of the ZMM insertion notch was characterized in each cadaver. RESULTS: The ZMM insertion notch was palpated and identified in 23 of 23 facial halves. It was accurate in identifying the course of the ZMM in all 23 facial halves. The line created by the malar eminence to the modiolus was inaccurate in all 23 facial halves. CONCLUSION: The ZMM insertion notch is a reliable landmark for identification of the ZMM.     

口内入路L型截骨术矫正高颧骨

目的：探讨口内入路截骨术矫正高颧骨的新方法。方法：根据颧骨的解剖特点,设计了一种新型的可完全截断颧骨体的L型截骨术：包括颧骨体上份斜形截开,颧骨体前份垂直截断及颧骨弓根部的“青枝状”折断。再参考颧骨高出的程度把颧骨体前下后份切除后将颧骨体和颧弓整体降低。结果：1995-2000年临床已应用39例。其中对称性高颧骨畸形32例,非对称性高颧骨畸形7例,均获满意效果。结论：L型截骨术矫正高颧骨畸形在保证颧骨体和颧弓解剖结构完整性的前提下降低高颧内,操作简单、并发症少,效果良好,是一种比较理想的手术方法。