Six year's experience with the zygomatic “sandwich” osteotomy for correction of malar deficiency

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DISCUSSION

J Oral Maxillofac Surg 57:14-15, 1999

Discussion Six Year’s Experience With the Zygomatic “Sandwich” Osteotomy Correction of Malar Deficiency

for

Kasey K. Li, DDS, MD Private Practice,

Palo Alto, California

Zygomaticomaxillary osteotomy has been our method of choice in the aesthetic enhancement of malar prominence. The procedure is easily performed intraorally and the result is natural-appearing and predictable. Asymmetric augmentation, which is occasionally encountered with malar implants or onlay bone grafts, has not been a problem because the existing malar arch/prominence is used. In addition, the anatomic enhancement can be easily controlled by the location of the osteotomy and the size of the interpositional graft. It appears that all of the zygomaticomaxillary osteotomies reported by the authors of this article were performed in conjunction with other maxillofacial procedures. In contrast, we often perform zygomaticomaxillary osteotomy as either an isolated procedure or in combination with rhinoplasty and/or genioplasty. The procedure can be easily performed under intravenous sedation via a Caldwell-Luc incision lateral to the pyriform aperture. A subperiosteal flap is raised and tunneling is created to expose the lateral malar arch and its medial surface. By placing a periosteal elevator on the lateral surface of the malar arch for soft tissue protection, an oblique osteotomy is performed from the zygomatic process of the maxilla to the notch between the lateral orbital rim and the temporal process of the zygoma (Figs 1,2). The placement and the direction of the osteotomy is dependent on whether both anterior and lateral augmentation are planned or if only lateral widening is desired. In my opinion, the modified technique described by the authors does not seem to offer any advantages, and it has several inherent problems. The connecting vertical and horizontal osteotomy is more difficult to perform, and mobilization of the zygoma is more difficult to achieve. This osteotomy design weakens the orbit, and fractures of the orbital rim can result while mobilizing the zygoma, which occurred in three patients. The anterior and posterior maxillary sinus walls are also unnecessarily transected. Sinus contamination may increase the risk of infection, especially when alloplastic materials are used. Clearly, infection can also occur without disruption of the sinus walls. In over 100 cases of zygomaticomaxillary osteotomies performed in the past 15 years, we have had two cases of infection; both involved the use of alloplastic implants that ultimately had to be removed. On the other hand, we have not encountered any infection when autogenous bone grafts were used. Therefore, autogenous bone from the calvarium or the mandibular symphysis remains the grafting material of choice. Although the potential for rapid remodeling leading to loss of malar position has been reported in experimental animals,’ it has not been our experience in clinical practice. An important issue in considering malar augmentation is determination of the ideal malar prominence. Various facial

FIGURE 1. Diagram showing the direction of the oblique osteotomy extending from the zygomatic process of the maxilla to the notch between the lateral orbital rim and the temporal process of the zygoma. [A, saw blade] (Reprinted with permission from tippincott Williams 8, Wilkins from Powell N, Riley RW, Laub DR: A new approach to evaluation of the malar complex. Ann Plast Surg 30:206, 1988.1

analyses place the malar prominence at different locations. The malar prominence proposed by Henderer2 and Mladick3 is considerably more inferior and medial than the location advocated by Powell et al4 and Wilkinson.5 Clearly, the ideal malar prominence is sometimes more related to the aesthetic appreciation of both the patient and the surgeon than

FIGURE

2. Basal view diagram of the zygomatic arch showing the oblique nature of the osteotomy. The location of the osteotomy can be shifted medially to include more of the zygomatic process of the maxilla if both anterior and lateral augmentation are planned. [A, zygomatic arch; a, oblique osteotomy) [Reprinted with permission from Lippincott Williams & Wilkins from Powell N, Riley RW, taub DR: A new ap preach to evaluation of the malar complex. Ann Plast Surg 30:206, 1988.)

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KASEY K. LI to any rigid measurement or criteria. However, we have found that the malar prominence is more aesthetically pleasing when it is located more lateral and superior, usually about 1.5 cm lateral and slightly inferior to the lateral canthus. The accentuation of this location can be reliably and predictably achieved by zygomaticomaxillary osteotomy. In summary, the authors have presented excellent results with the use of zygomaticomaxillary osteotomy for the enhancement of malar prominence. However, the procedure can be simplified, while still maintaining a naturalappearing and predictable outcome.

References 1. Vargervik K, FariasM, Ousterhout D: Changesin zygomatic arch position following experimental lateral displacement. J Craniomaxillofac Surg 15:208, 1987 2. Hinderer UT: Malar implants for improvement of the facial appearance. Plast Reconstr Surg 56:157, 1975 3. Mladick RA: Alloplastic cheek augmentation. Clin Plast Surg 1829, 1991 4. Powell N, Riley RW, Laub DR: A new approach to evaluation of the malar complex. Ann Plast Surg 30:206, 1988 5. Wilkinson TX Complications in aesthetic malar augmentation. Plast Reconstr Surg 71:643, 1983