The Aesthetic Midface Analysis: Diagnosis and Surgical Planning
Prominent high cheekbones are regarded as attractive and youthful by Western standards of beauty. However, they considered as less attractive by Asians as it gives a strong and aggressive impression. To attain a more slender and smooth midfacial contour, reduction malarplasty is commonly performed among Asians.
The successful correction of prominent zygoma first requires the identification and classification of the wide variety of the shape of cheekbone and then followed by appropriate application of surgical technique according to the subtype of zygomatic prominence as all patients have different degrees of protrusion and morphology of the zygomatic bone.
Based on the distinct features of several morphologic subcomponents, the prominent zygoma can be classified into six types and five types of corresponding surgical techniques including I-, L-, and high L-osteotomy combined with reduction of external orbital rim and tripod osteotomy.
In addition to the standard technique using L-shaped osteotomy via intraoral and preauricular approach, further refinements such as high L-shaped osteotomy and inferolateral orbital rim reduction through periocular access allow us to prevent the potential for complaints with aesthetic consequences of remaining prominence of orbital rim.
Critical factors including bizygomatic width, volume, and position of zygomatic body should be thoroughly evaluated. Also the new position of the point of maximal malar projection carefully planned because the zygomatic body and arch usually moves medially, posteriorly, and sometimes superiorly.
The thickness of overlying soft tissues including skin, subcutaneous fat, muscles, and buccal fat should be evaluated. In the patient with thin skin and minimal cheek fat, the operative results are obvious and postoperative soft tissue drooping is minimal. On the other hand, if the patient has thick skin with abundant fat, the effect is less obvious, and cheek drooping is more probable. This patient should be informed about the possibility of cheek drooping and appropriate adjunctive measures.
The following factors are considered high risk for skin and soft tissue sagging: (1) over 40 years of age, (2) abundant cheek fat, (3) thin skin and skin laxity, (4) class II mandible or ill-defined mandible neckline, and (5) deep nasolabial fold or jowl.
Reduction malarplasty can be performed solely or in combination with mandible reduction, genioplasty, or forehead augmentation.
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