Q: Dr. Eppley, I am interested in cheekbone reduction. I have been very insecure about my face structure. I feel like if I get cheek bone reduction it would really change my life because I am tired of thinking about it all over again everyday, it really frustrates me and depresses me. So for my cheek bone reduction would I have any visible scar? And how stable would the cheek be? Would it be stable as before? Would it be able to take a punch? Because I’m really worried. I have attached pictures so you can see how prominent my cheek bones are.
A: Thanks for sending all the pictures. Cheekbone reduction surgery is done mainly from inside the mouth. There is a very small external skin incision on the backside of the sideburn area to get to the posterior tail of the zygomatic arch but it is very small and heals well. The bones are put together with small plates and screws for stabilization afterwards. Once the bones are healed, like any facial fracture, they can resist trauma such as taking a punch in the face. You also have to remember that the cheekbones will already be broken (moved inward) so their ability it get fractured is less anyway.
Dr. Barry Eppley
Q: Dr. Eppley, I had cheekbone reduction surgery done five years ago and I felt it left me with asymmetric cheeks. CT scan pictures after the surgery show that the cheekbones were probably removed too much and they were placed in different positions vertically. There are ‘gaps’ in the cheekbone area. I wonder if this can be fixed.
A: It is not rare to have some asymmetry in the position of the bones after cheek bone reduction surgery. Besides the fact that most people’s cheek bones are not really symmetric initially, there are always going to be differences in the angle of the cuts and the bone fixation points between the sides since they are not independent of each and can not be view intraoperatively in a simultaneous fashion. That being said you do have external cheek bone asymmetry with the right side being more medial or moved inward that the left. I will assume by your comments that your ‘good’ side is the left one and the side you seek improvement is the right side. That could be improved by either repositioning the anterior end of the right cheek bone or adding a small implant over the osteotomy site.
In regards to the cheek bone gaps seen on the CT scan, that is an early after surgery x-ray. At this point years later, those bone gaps have likely filled in and healed with bone. If not, they have a fibrous union and there is no aesthetic benefit to having those bony gaps ‘fixed’.
Dr. Barry Eppley
Q: Dr. Eppley, I did not know i could have cheekbone reduction in the U.S.. I had it done in Asia where my friend had that done too. I am of Asian descent and I have wide prominent cheekbones. I had the cheekbone reduction procedure without plates and screws and now I am afraid of non union of the bones, misalignment and dislocation of the fragments of the zygomatic arch. I hear a clicking sound. My surgeon in Korea says it’s normal and will disappear, but I wanted a second opinion from you.
if you don’t use fixation how you make sure the bones stay in place how you prevent sagging and scleral show after the cheekbone is collapsed. Once you push the zygoma arches in and there are gaps and dents, does new bone is created in years to fill in those gaps or do they remain depressed?
A: Cheek bone reduction surgery can be compared directly to have a facial fracture…albeit a surgically controlled one. The best way to ensure that the bones stay in the desired position and heal is to use some form of bone fixation. (plates and screws) The clicking you hear is the bone segments that are unstable and are moving with their edges rubbing together.
Since the zygomatic arches are not functionally loaded bones, like the lower jaw for example, one can argue that it is not critical that they are stabilized. They will eventually go on to heal even if it is by fibrous rather than bony union. When it comes to cheek bone reduction, however, the position of the bone is just as important as whether it heals. Sagging or dropping of the bone is associated with soft tissue sag and even potentially lower eyelid sag. This is why some form of bone fixation should be done.
Dr. Barry Eppley
Q: Dr. Eppley, I was searching for the information regarding facial sagging after cheek bone reduction surgery. I suffer from facial sagging after cheek reduction surgery that I had four months ago. Even though my bone is tightly fixed, sagging is quite severe and it keeps getting worse. I think it might be because of the loss of skeletal support. He didn’t reposition the unit of my cheek bone but removed part of my front cheekbone by dissecting it as an ‘L-shape’. The worst part is that only the right side of my face is sagging and I don’t know what to do. I’ve been searching for some doctors who are renowned for face lifting. They said that they need to release the zygomatic ligaments and lift the SMAS up as well as the skin. I can see that you are the one who understand the right reason and solution of this problem. So I will be truly thankful if you spare some time to give me some advice. Thank you so much.
A: I am sorry to hear of your unfortunate unilateral outcome from your cheek bone reduction surgery. The obvious origin of the problem is the loss of ligamentous attachments of the overlying soft tissues to the cheek bone as well as the loss of skeletal support for them. It is interesting, assuming that the same bone reduction techniques were done on both sides, that only one side of your face has this tissue sagging problem. This shows how precarious the soft tissue attachments are to the bone and how slight differences in dissection techniques can make a big difference in their outcomes. As has been pointed out to you, the key to improvement is not just the skin shifting but the need for deeper soft tissue repositioning. The only tissues that possible to relocate are the SMAS layer. But moving the SMAS layer without giving it skeletal support will not provide a significant improvement. The first place to start is to have a good idea of what the underlying bone support looks like between the two sides. I would recommend that you get a 3D CT scan to visualize your cheek bone anatomy as it is now. Then with that information a more complete surgical plan can be devised as to how to manage the bone and the soft tissues.
Dr. Barry Eppley
Q: Dr. Eppley, I am extremely concerned about sagging after cheekbone reduction surgery. The doctor reduced a large amount of my zygoma, about 6 to 8mms. Would this increase my chance of cheek sagging? I had previous buccal fat and facial liposuction. I am worried that I have a higher chance of sagging now. Also, I am 3 weeks after surgery. There is still quite a bit of swelling in my cheeks although a lot of the swelling has gone down. Could you give some rough guidelines as to when the swelling subsides? E.g, 2 to 3 weeks major swelling, 2 months 80% swelling goes down etc.? I greatly appreciate your input. Many thanks!
A: The proper time to asssess the result after any type of facial skeletal surgery, such as cheekbone reduction, is three months. My general guidelines is that 50% of the swelling goes down in 10 days, 70% by 3 weeks, 80% to 90% by 6 weeks and 100% by three months after surgery. Reducing your zygoma width by 6 to 8mms has a high chance of having some cheek sagging afterwards. Done bilaterally that is removing a lot of the cheek tissue support for the middle of the face. But time will tell. No one can say now whether it will or won’t.
Dr. Barry Eppley
Q: Dr. Eppley, I came across your website and am very impressed with your blogs on cheek bone reduction and jawlione shaving surgery. I underwent zygoma and jaw shaving both a month ago and am very worried regarding my decision. I have some questions to ask you, which I hope you can help me.
1) Is facial sagging more common with my surgeries of both zygoma shaving and jaw shaving? Two years previously, I had buccal fat removal and facial liposuction. I am worried that this increased my chances of facial sagging?
2) The right side of my mouth is harder and more painful to open. Is this normal for slightly over one month post-op?
3) My facial swelling changes daily. Some days are more swollen and chubbier than other days. Is this normal?
4) Is zygoma and jaw shaving supposed to give a narrower face? A friend of mine is post op three months and she is chubby at the bottom cheeks. I have heard many stories of young girls having chubby bottom cheeks. Will it go away?
5) I have read that it takes 2 to 3 weeks for majority of the swelling to subside, I still feel I have a large amount of swelling. When would you say the majority of swelling will subside?
6) My doctor says that nothing can be fixed in the following months if facial sagging occurs on the cheeks, is this true?
A: In answer to your questions about cheek bone reduction and jawline shaving:
1) Soft tissue sagging is a more common problem with cheek bone reduction, not so much for jawline shaving. Having had a previous buccal lipectomy and facial liposuction did not increase your risk of soft tissue sagging with these procedures.
2) It would be perfectly normal to have stiffness and soreness of mouth opening and stiffness at the is early point after surgery. Expect full recovery to take 3 months.
3) Facial swelling is very cyclical after surgery due to positional changes of the face and resolving lymphedema.
4) You should not judge the final results from any facial bone surgery until a minimum of 3 and preferably 6 months after surgery. She may be chubby due to swelling and resolving lymphedema or may also perceptual enhanced lower facial fullness due to the now more narrow midface.
5) A few weeks after surgery is way too premature to expect most of the facial swelling to have gone away.
6) You need to wait 6 months to both judge the results and before embarking on any corrective procedures.
Dr. Barry Eppley
Q: Dr. Eppley, I underwent mandible angle and cheekbone reduction surgery over a year ago. I am disappointed with the changes as it has feminized my previously masculine face. I find that the angle reduction from my jaw is unnaturally high and much too straight to be considered normal. What options could I consider to replace the previous bony structure? Another issue that I am faced with is substantial mid to low face sagging. Several areas seem to be affected such as the infra-orbital muscle (clearly visible, elevated on cheekbone), nasolabial folds, and soft tissue isolation (sides of mouth, fat cheek look). Could you explain the causes of these irregularities and possible procedures that I could undertake?
A: I have seen a few cases just like yours where the jaw angles have been completely amputated. The angular shape and the vertical height of the ramus of the mandible can be restored by jaw implant augmentation. But the implant shape can not be a standard jaw angle implant. it needs to be shaped to just have a vertical augmentation only that has an oblique superior shape to match the oblique cut. That can be done by either using one of the custom jaw angle implant shapes that I have previously used or have one made off of a 3D CT scan.
As for the other facial changes those are obviously a result of the cheekbone reduction. I am going to assume that this procedure was done intramurally with n obliquely oriented osteotomy of the zygomatic body and a posterior osteotomy of the zygomatic arch. That has caused loss of support of the surrounding cheek tissues which not sag creating an orbicular is muscle edge show, deepening of the nasolabial folds and sagging in the submalar area. Like the jaw angle issue, adding back some skeletal support would seem like a logical approach. That effectiveness, however, is not as clear as it would be in the jaw angle area.
Dr. Barry Eppley
Q: I am trying to make my face symmetrical. My jaw is not aligned, making my mouth and smile crooked and my nose is wide with a pronounced bump. I have attached some pictures for you to evaluate, image, and give me recommendations as to what to do. Thanks!
A: An analysis of your pictures shows that you do have a deviated nose with a hump and a wide tip. But in addition, you have left facial hypertrophy. This is the origin of why you feel that your jaw and smile is crooked. The left side of your face, from the orbit down to the jaw angle is bigger and wider. This creates your facial imbalance/crookedness. I have done some imaging of your rhinoplasty, with and with adjustment of the left facial enlargement. In facial asymmetry it is always a question as to whether to build up the smaller side or reduce the bigger side. In your case, I think it is better to try and make the larger side smaller through cheekbone and jaw angle reduction. This is shown in your rhinoplasty front view imaging, both with and without it being done. From a side view, I have also added a small chin augmentation as your profile shows some mild horizontal chin deficiency.
I think the combination of rhinoplasty, cheekbone and jaw angle reduction and chin augmentation can make for a more symmetrical and balanced face. This will not change the asymmetry in your smile as that is soft tissue-based and can not be adjusted like the underlying harder facial structures.
Dr. Barry Eppley
Q: Hi, it was so interesting reading your thoughts on cheekbone reduction surgery after a facial injury. I have some questions about almost the same problem. My right cheekbone is bigger than the left one and it is growing bigger. When I look at two year old photos you can see a big difference. I was in a car accident about 15 years ago and hit the right side of face on the dashboard of the car. Is it possible to have some sort of surgery?
A: While cheek bone injuries are common from many types of trauma, they are largely that of fractures and displacement. Secondary reconstruction is often needed to bring out a cheek bone that is too flat or has inadequate projection. The reverse problem, overgrowth or too much projection of a cheek bone is very rare. The presumed cause is that a hematoma has developed above or around the bone, stimulating some bone deposition or ‘growth’. Depending upon the dimension of the cheek bone overgrowth, surgery can be done to reduce. Shaving of the cheekbone is always possible but is not usually my preferred technique unless the overgrowth area can be precisely identified. It is far more common to do a cheek osteotomy and remove a vertical wedge of bone to allow it to move inward. A very helpful diagnostic tool is a 3-D CT scan. This allows one to study the shape of the cheekbones on both sides and determine the exact location of what is making the bigger cheek bone look the way it does. This allows for a precise surgical procedure for bone reduction to be planned.
Dr. Barry Eppley
Q: I am interested in getting my cheekbones slimmer or smaller. Is there any way to apply pressure to them everyday or put something on them to make them gradually get smaller without the need to undergo plastic surgery?
A: The concept of making facial bones smaller is a surgical one. No amount of pressure or any form of outward manuevers will change the shape of a facial bone. Outward pressure, even if it were possible to do, would only make the overlying soft tissues thinner (pressure resorption) but would not change the shape of the underlying bone.
Cheek bone reduction requires cutting the ‘legs’ of the bone and allowing it to sit down or inward. In some cases, only the front legs of the bone need to be cut (body of the zygoma).In other cases, the back legs (zygomatic arch attachment to the temporal bone) need to be cut as well. By inward positioning of the cheek bone and its backward bony arch, the width of the face is narrowed. When done on both sides of the face, the narrowing effect can be quite noticeable.
Dr. Barry Eppley