Q: Dr. Eppley, Would a zygomatic osteotomy work on an individual with cheek asymmetry due to hemifacial microsomia? I am considering orthognathic surgery to fix my jaw and masseter muscle. I am also considering a procedure to enhance my cheek symmetry. I have heard implants can be unnatural when placed unilaterally even when custom made. I thought a zygomatic wedge osteotomy may be better. Because the eye and cheek are interrelated it could make eye look smaller?
A: What is best for your cheek symmetry would really require evaluation by pictures of your face and review of a 3D CT scan. But as a general statement, a zygomatic expansion osteotomy (which is what you mean by ‘zygomatic wedge”) only affects one dimension and that is cheek width. It can not change any other cheek dimension. In my experience in the hemifacial microsomia patients, the dimensional changes need to the cheek area are more than just that of width. Plus the bony edges of a zygomatic osteotomy and the plates and screws to hold it would ultimately be able to be felt and many be able to even be seen through the skin. It is not true that a custom implant would look unnatural and, because it is custom made and fits the bone in a smooth transition manner, would probably look more natural than any osteotomy/bone grafting procedure.
Any cheek augmentation procedure, by definition, may make the eye look smaller no matter what technique is used. Although that degree of orbital change may be aesthetically negligible.
These are general statements which are made with no specific knowledge about your case.
Dr. Barry Eppley
Q: Dr. Eppley, Thank you for your amazing job you do as a surgeon and to inform all the patients online. I know (as read on your site) custom implants would be my best choice. However, i really do not want implants, there’s a 0% chance of me getting implants. A friend of mine had a “zygomatic osteotomy” and a “chin wing osteotomy” and I think his results were very good. Do you perform these surgeries? Do you use some bone grafts? Why would you, or why wouldn’t you recommend the following procedures’?
A: When one tries to compare different facial reshaping operations it is important to carefully investigate up front what dimensional changes they can actually make. I have perform many zygomatic osteotomies (for cheekbone narrowing and cheekbone widening) as well as the chin wing osteotomy. The zygomatic osteotomy provides width and width only to the zygomatic arch and the very posterior aspect of the zygomatic body. It can not provide any anterior projection to the cheek as that is not the direction that the bone moves. The interpositional gap created by the zygomatic expansion osteotomy can be grafted by bone or an hydroxyapatite block. The chin wing osteotomy is useful for two types of jawline changes. It is primarily useful in creating a sliding genioplasty effect where the entire jawline is moved as the chin comes forward and downward. It can also be used to vertically lengthen the entire jawline.
The only reason I ever do these types of facial osteotomies is when the patient wants to do a ‘natural’ operation as opposed to the use of custom facial implants for a very specific type of facial dimensional change as outlined above.
Dr. Barry Eppley
Q:Dr. Eppley, I suffered a zygomatic fracture three years ago and its aftermath has caused my entire zygoma to protrude specifically on the arch bone. I think an osteotomy or removal of the bone would be the best way to create more symmetry. I was reading two posts on your website about Zygomatic Osteotomies but they mainly were about osteomizing and removing bone from the anterior cheek area in which it would be performed through an incision in the mouth. My problem is mainly my zygomatic arch and I am wondering if osteotomizing this bone would be difficult while trying to avoid facial nerves or other serious mishaps. How would this be performed and could facial plastic surgeons do this as simple as other facial surgeries or would they be not as keen in doing so? I have attached pictures for your assessment.
A: What I see in the pictures is that the depressed arch fracture is now showing the anterior edge of the temporal process of the zygomatic arch because this is the thicker and unfractured portion behind the more anteriorly depressed arch. It would require that anterior edge to be burred down to get rid of the bulge. Now that I have seen your pictures, I can answer your questions better. To reduce that posterior zygomatic arch bulge, it can not be reached from inside the mouth. It is to posterior to the temple region to do that. The best way to treat it is to osteotomize it from a temporal incision where the bone can be fractured and pushed in. This is done below the deep temporalis fascia so it is below the path of the frontal branch of the facial nerve. This type of surgery, while not complex, is not something I suspect that most facial plastic surgeons would feel comfortable doing. You need to see someone who has experience in doing these procedures and that means a plastic surgeon with craniomaxillofacial surgery experience.
Dr. Barry Eppley