Your Questions

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

Indianapolis Indiana

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

Indianapolis Indiana