Can Zygomatic Osteotomies Be Done At The Same Time As Orthognathic Surgery?
Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.
A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.
Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.
While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.
The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.
Dr. Barry Eppley