The purpose of malarplasty is to shape a beautiful cheek that suits the contours of the face. Aesthetically pleasing cheek means that it does not project too much over the cranial bones, and it should become narrower from the zygomatic arch to the zygomatic body, and the body of the cheek should maintain a dynamic volume by the movement of the zygomaticus muscles, when smiling. Surgical plans must be made focusing on the final shape of the cheekbones. Excessive excision of the bones or excessive amount of infracture can cause sagging and depression.
By examining the patient’s face and 3-dimensional computed tomography, surgeons must first characterize the shape of the cheekbones, determine how much protruded they are, and identify the location of the projection before performing surgery. Regarding the body, the surgeon should resect the cheekbones as much as is desirable to medialize them, since repositioning the cheekbones to the posterior and medial direction can make a slimming effect. The amount of setback is determined by using a prebent plate. After determining the position of the body, the prebent plate is used again to determine the amount of medicalization of the arch.
To prevent temporomandibular joint problems such as trismus or pain with mouth opening, patients must practice opening their mouths once their swelling subsides within 2 weeks. If the trismus or pain persists, conservative treatment (like massage of the muscles, mouth opening exercise, and medications for the serious cases) can be helpful.
This video is edited to introduce a malarplasty technique in Asians and to show that reposition is more important than resection amount in building a slim appearance (see video, Supplementary Digital Content 1, which shows the overall operation procedure with an animation. This video is available in the “Related Videos” section of PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A416).
For steps 1–6, see video, Supplementary Digital Content 2, which shows the operation procedure from irrigation to osteotomy, http://links.lww.com/PRSGO/A417.
- Massive irrigation: to wash away dirty and infectious material in the oral cavity. The author prefers saline irrigation to betadine solution.
- Local solution (1:100,000 epinephrine) injection of incision site.
- Upper gingivobuccal incision and subperiosteal dissection.
- Body osteotomy—rectangular design with wider base → bone chip removal.
- Preauricular incision—inside or just behind sideburns. Dissection should be done by spreading soft tissues not cutting, so facial nerve would not be sacrificed.
- Arch osteotomy—movable zygoma complex → inward and downward reposition.
For steps 1–4, see video, Supplementary Digital Content 3, which shows the operation procedure from osteotomy to wound closure. This video is available in the “Related Videos” section of PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A418.
- Body fixation: prebent rectangular plate.
- Arch fixation: prebent mono plate.
- Irrigation—washing bone dust—saline is preferred.
- Suture with absorbable material.
See video, Supplementary Digital Content 4, which shows the preoperative 3-D computed tomography scan and postoperative (3 months) 3-D computated tomography scan. This video is available in the “Related Videos” section of PRSGlobalOpen.com or at http://links.lww.com/PRSGO/A419.
In comparison with preoperative and postoperative 3-D computed tomography scans, the zygoma complex is repositioned and the malar width is reduced.
- Temporomandibular joint problem: discomfort, pain → early exercise and physiotherapy.
- Depression on skin.
- Cheek drooping → to avoid points 2 and 3 noted above, the resection amount should be minimal.
To make malar width narrower, bone resection and reposition is important and to avoid any complications, resection amount should be minimal.