Q: This is in regards to an unusual form of craniofacial surgery which I have been hoping to obtain for many years. I have a slender jawline and forehead, somewhat prominent browline, and both wide and prominent cheekbones. I was wondering if it were possible to have the cheekbones (by which I mean the zygomatic bone itself, the temporal process, and then the zygomatic process of the temporal bone) replaced entirely by synthetic implants so as to make my face more slender and these features, in particular, well-proportioned to the other features of my face.
A: The slimming effect to which you refer is known as cheek or midface reduction. To do so by conventional craniofacial surgery is well known and the techniques well established. It is a more common request in the Asian poopulation due to their facial shape. Complete cheek reduction is done by osteotomizing the front (zygomatic process) and back part (temporal process) of the cheek, removing bone, and allowing the enture zygomatic bone and arch (which creates the facial width) to move inward. The new bone positions are then secured with small plates and screws. This is done through an incision inside the mouth and a small incision in the temporal hairline. One can usually get a bifacial narrwoing of around 1 to 1.5 cms.
While any type of implants can be fabricated off of 3-D C scans and models, it is not practical to replace the entire zygomatic complex and arch to obtain midfacial narrowing. This would require extensive surgery, a large scalp incision, the removal of masticatory muscles which are attached to the bones, and the significnt risk of facial nerve injury. While this is done for extensive traumatic bone injuries and tumor resections, those risks for a cosmetic concern are not reasonable. This is particularly true when you consider that the same if not better result can be obtained by less invasive and ‘simpler’ surgical techniques.
Dr. Barry Eppley
Q: What method of bony cheek narrowing do you use to? Can you explain the procedure to me. Where do you cut the bone etc? How many cuts are made and what can be done to maximize the narrowing effect?
A: To properly understand the bone cuts, you need to know the anatomy of the zygomatic bone and how it articulates anteriorly with the maxillary and orbital bones and the temporal bone posteriorly. The width of the face in the cheek area is a reflection of the prominence of the cheek bone and its attached arch. Basically, cheek narrowing is done by shortening the attachments of the zygomatic process.
Two vertical bone cuts are made, one anteriorly where the zygomatic arch joins the maxilla and orbit and the other small vertical cut is posterior where the thin sliver of the back end of the zygomatic arch joins the temporal bone just above and forward of the TMJ.
The front cut and bone removal (5 to 7mms) is made with a reciprocating saw from inside the mouth incision. It is narrowed and then held together with a small plate and two screws on each side. The back end cut is done with a small osteotome (chisel) from a small incision inside the temporal hairline. It is simply cut and it falls inward naturally on its own due to the pull of the attached muscles.
The facial narrowing effect through cheek osteotomies is maximized by doing both cuts and allowing the entire arch to move inward.
Dr. Barry Eppley