Intraoral Malarplasty with Setback and Lifting for Preventing Cheek Drooping
Malarplasty is a kind of plastic surgery for the beauty on midface. For the more attractive midface, the curvilinear line from nose, midpupil to malar region should be considered. However, far-east Asians generally have concave line with relatively anterior prominent malar region because of less developed maxilla in their midpupil line. Moreover, the brachycephalic skull development of far-east Asians makes their malar region wider.
The reduction malarplasty makes a curvilinear line in the midface of patient. There are two options in reduction malarplasty which are bicoronal approach and intraoral approach. The advantage of bicoronal approach is that can improve the upper face as well as midface and prevent the cheek drooping which possibly occurred by reduction of malar region. The advantage of intraoral approach is shorter operating time and recovery period of patient who does not want the upper face improvement effect. Recently, the intraoral approach with proper fixation can reduce the complications like as malunion or nonunion and prevent cheek drooping. However, still the large volume bone reduction induced cheek drooping like as balloon deflation effect in the intraoral approach. The authors designed an improved intraoral approach to overcome the cheek drooping.
Methods/Technique:
The authors performed the intraoral malarplasty to 542 patients, including 451 female and 91 male, from April 2006 to June 2013. The average age was 28.7 years, 395 of 542 patients got other facial bone surgeries including genioplasty, mandibular angleplasty and anterior segmental osteotomy, simultaneously. Through intraoral incision, L-shape osteotomy was done and oblique osteotomy was done from inside of zygomatic arch to outside of zygomatic process of temporal bone through sideburn incision. All osteotomy was done by reciprocating saw and L-shape miniplate and 4 screw is used for fixation of anterior L-shape osteotomy site. The authors make three principle to prevent cheek drooping. The first is maximal preservation of origin of zygomaticus muscles. The second is posterior, superior and inward reposition of temporal process of ostectomized zygomatic bone. In zygomatic process of temporal bone, it has a fossa for attachment of temporalis muscle and we used a fossa for a support against to downforce caused by masseter muscle and fixation of temporal process of ostectomized zygomatic bone like as tongue in groove fashion after detach a temporalis muscle. The third is a setback of ostectomized zygomatic bone for stretching of zygomaticus muscles.
Results/Complications:
Most patients were satisfied with their result. In 41 case, a little amount of bony gap was found in upper position of zygomaticofrontal process on 3D-CT, but there was no instability or cheek drooping. The four cases of cheek drooping or irregularity were resolved by additional fat grafting. One case of temporal facial nerve paralysis was recovered within three month of surgery.
Conclusion:
Together with large amount of case experience, the authors suggested that if the three principles are well followed, the intraoral approach malarplasty could be the best choice to the patient who does not want the upper face improvement effect