Can My Cheek HA Bone Cement Be Removed?

Q: Dr. Eppley, Fourteen years ago, I underwent a procedure in which calcium phosphate bone granules (β-tricalcium phosphate) were placed in a subperiosteal pocket over the zygomatic region of my right cheek. A fixation screw was also used. Since then, I have experienced persistent facial asymmetry, a visible and palpable bulge, chronic tension in the surrounding muscles (masseter and temporal region), and ongoing discomfort that has significantly affected my quality of life. Given the duration of the implant and its subperiosteal location, I am particularly interested in your experience with the removal of these types of structures. I recently obtained a high-resolution facial CT scan (0.5–1 mm cuts) focused on the zygomatic region. The doctor who reviewed the scans noted the following: • The imaging shows persistent calcium-based particulate material located superficially to the zygomatic bone. • Importantly, the underlying bone itself appears intact, without destructive changes or aggressive remodeling. • The material does not appear to have fully integrated into the bone, but rather presents as clustered granules embedded within the surrounding soft tissue. (I have attached screenshots with arrows indicating the particulate matter.) • This appears consistent with long-standing β-tricalcium phosphate that has only partially resorbed and is now embedded within fibrotic tissue. • The findings correlate with my clinical symptoms, particularly the fact that firm manual pressure temporarily improves the facial symmetry. The reviewing surgeon suggested that a reasonable next step may be a surgical approach aimed at relieving the mechanical effect of the material. This would involve re-entering through the original intraoral access, with the possible addition of a subciliary approach (under the eye) if necessary. The proposed plan would include removal of the mobile particles using a burr or other instruments, removal of the fixation screw, and release of the surrounding fibrotic tissue. He also mentioned that a midface suspension procedure might be required if extensive fibrosis is encountered, in order to prevent descent of the tissues during healing. In that case, bilateral treatment might be necessary for symmetry. Whether the procedure would involve partial or more complete removal would ultimately depend on the intraoperative findings and the degree of adherence of the material. Any remaining contour irregularities could potentially be addressed later with conservative fat grafting after the tissues have stabilized. Could you please let me know whether, based on your experience, it may be possible to remove these granules and improve the associated fibrosis and asymmetry? Do you have experience with these kind of surgeries? Please find attached screenshots from the CT scans, with arrows indicating the particulate material. Thank you very much for your time and consideration

A:I have removed HA bone cement many times. Given the method by which it was placed, intraoral,and in the scan showing it sits in the subzygomatic position it should be able to be removed completely through an intraoral approach. I would like the outcome of its removal to determine whether any soft tissue suspension is needed, which I doubt, and when you’re dealing with a problem be certain that you don’t create any new problems by doing a concurrent procedure which has its own set of risk and complications and whose need is completely unknown.

Dr. Barry Eppley

Plastic Surgeon