The Mini-Zygoma Reduction Surgery: A Simple and Reliable Approach for Mid-Face Narrowing

An Ultrasonographic Analysis of the Deep Inferior Tendon in the Masseter Muscle: Implications for Botulinum Toxin Injections

(1) Background: With the increasing aesthetic pursuit of facial features, the clinical use of Botulinum Toxin Type A (BoNT-A) injections for masseter hypertrophy has been on the rise. However, due to variations in masseter muscle structure and differences in clinicians' injection techniques, blind injections may lack precision, potentially compromising treatment accuracy and increasing the risk of complications. (2) Objectives: The study aims to use ultrasonography to detail the deep inferior tendon (DIT) within the masseter muscle in a young Chinese cohort, refine its classification, analyze muscle belly thickness and variations across groups, and propose a customized ultrasound-guided BoNT-A injection protocol. (3) Methods: Ultrasound imaging was used to observe the bilateral masseter muscles at rest and during clenching. The features of the DIT were classified from these images, and the thickness of the masseter's distinct bellies associated with the DIT types was measured in both states. (4) Results: The study cohort included 103 participants (27 male, 76 female), with 30 muscles in the normal masseter group and 176 muscles in the hypertrophy group. The DIT was categorized as Type A, B (subtypes B1, B2), and C. The distribution of these types was consistent across normal, hypertrophic, and gender groups, all following the same trend (B > A > C). In hypertrophy, Type B1 showed uniform thickness across masseter bellies, B2 presented with a thinner intermediate belly, and Type C had mainly superficial muscle enlargement. Changes in muscle thickness during clenching were noted but not statistically significant among different bellies. (5) Conclusions: The study evidences individual variation in the DIT, highlighting the importance of precise DIT classification for effective BoNT-A injections. A tailored ultrasound-guided BoNT-A injection strategy based on this classification may enhance safety and efficacy of the therapy.

Effects of surgical factors on the outcomes of zygoma reduction malarplasty: a quantitative computed tomography study

BACKGROUND

Malarplasty is widely performed for zygoma reduction. The effects of body segmentation, plate bending, and postoperative arch location on zygomatic movement have not been analyzed using computed tomography (CT).

RESULTS

We quantitatively analyzed the effects of surgical factors on zygomatic movements via superimposition of preoperative and postoperative CT images using three-dimensional software. Our results showed that segmentation had the most significant effect on the horizontal reduction of malar eminence (β = 0.593, r = 0.696, adjusted r² = 0.479, F = 79.595; p < 0.001). In addition, upward and posterior arch movements had significant effects on the anterior and posterior movements of the eminence (β = - 0.379 for vertical arch movement, β = 0.324 for arch setback, r = 0.603, adjusted r² = 0.352, F = 31.943; p < 0.001). The major factors that influenced inward arch movement at the coronoid process included segmentation and inward movement at the arch osteotomy site. To prevent interference of the coronoid process and arch, surgeons should pay attention to the degree of segmentation (β = 0.349) and inward movement at the arch osteotomy site (β = 0.494; r = 0.688, adjusted r² = 0.464, F = 50.412; p < 0.001).

CONCLUSIONS

Surgical factors related to malarplasty affect the movement of specific parts of the zygoma. In addition, accurate application is possible by considering the anatomical structure of the application area when using the bending plate.

A Systematic Review and Meta-Analysis of Complications among Various Reduction Malarplasty

BACKGROUND

Reduction malarplasty is one of the most common aesthetic procedures to improve a wide bizygomatic width and a prominent zygomatic body. Although there are various kinds of modifications, any method is imperfect, while some complications may occur. The purpose of this review was to compare kinds of complications of reduction malarplasty to provide certain suggestions for clinical application.

METHODS

A comprehensive computerized search of scientific literature was performed via the PubMed, Web of Science, and Library of Congress databases, involved in articles from January 1st, 1983 to February 28th, 2022. The outcomes were extracted and analyzed by 3 independent authors, including patient demographics, diagnoses, surgical techniques, postoperative outcomes, and complications.

RESULTS

A total of 29 studies covering 6611 patients were included according to the inclusion and exclusion criteria. The L-shaped osteotomy may obtain a better effect when someone has both zygomatic body and arch protrusion. In the view of complications, our conclusion suggested that L-shaped osteotomy without bony resection reduced the zygomatic complex effectively with the lowest incidence of postoperative complications (0.02%). But the amount of bone resection is limited. If increasing bone resection is necessary, L-shaped osteotomy with long arm bony resection and L-shaped osteotomy with short arm bony resection are both preferable choices with lowest incidence of structural and functional complications, respectively.

CONCLUSION

L-shaped osteotomy may obtain a better effect when a patient has both zygomatic body and arch protrusion. L-shaped osteotomy without bony resection reduced the zygomatic complex effectively with the lowest incidence of postoperative complications.

LEVEL OF EVIDENCE III

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Face Lift after Facial Feminization Surgery: Indications and Special Considerations

SUMMARY

Iatrogenic jowling can be an unintended consequence of facial feminization surgery. Reduction of the mandible and chin without overlying changes to the soft tissue can lead to a redundant and deflated soft-tissue envelope, requiring a face lift to address jowling, cervicofacial laxity, and/or lower facial rhytids. Prospective quality-of-life outcomes data support this hypothesis, as patients who underwent mandible contouring with or without angle osteotomies were significantly more likely to express interest in face lift following facial feminization surgery on univariable analysis (90.0 percent versus 10.0 percent, p = 0.038). Patients with inherent skin laxity are at particularly high risk, such as those with advancing age, extrinsic skin damage (e.g., sun exposure, cigarette smoke), and history of massive weight loss. Before facial feminization surgery, the authors recommend comprehensive patient counseling that includes a discussion of the possible future need for a face lift, preferably around 1 year after facial feminization surgery. When performing a face lift after facial feminization surgery, technical considerations include those related to sequelae of prior facial surgery, anatomical differences between cismale and cisfemale facial soft tissue, and the mechanism of jowling after facial feminization surgery versus normal facial aging. The authors believe that these considerations can set more realistic expectations for facial feminization surgery patients, improve surgeons' ability to skillfully execute this procedure, and ultimately contribute to ongoing quality-of-life improvements in facial feminization surgery patients.

Radiologic Analysis of Malar Arch Movement in Reduction Malarplasty Without Bony Resection

BACKGROUND

Reduction malarplasty has been popular among Asians with a wide facial width. In general, malar setback after bony resection is regarded as the standard objective of reduction malarplasty. However, unnecessary bony resection may lead to various postoperative complications. Therefore, we suggest the use of reduction malarplasty without bony resection to achieve a similar narrowing effect of the facial width, based on radiographic analysis of malar arch movement.

PATIENTS AND METHODS

This retrospective study analyzed 48 patients with a wide midface who underwent reduction malarplasty between September 2018 and December 2019. We included 40 cases of advancement repositioning malarplasty (AR) without bony resection and 8 cases of setback reduction malarplasty (SR) with bony resection. The three-dimensional position of the malar arch expressed by coordinates (x, y, and z) on three-dimensional computed tomography scans was used to compare the positional change between the surgical methods. The paired t-test, Wilcoxon text, and independent t-test were used in data analysis, and statistical analysis was performed using SPSS 23.0 software.

RESULTS

Medial and superior movement of the freed malar arch segment was significantly different between AR and SR (P < 0.05). Although medialization and superiorization were not significantly different between AR and SR, there was a significant difference in anterior-posterior movement between AR and SR (P < 0.05).

CONCLUSION

The radiologic analysis based on malar arch movement between AR and SR showed similar narrowing effects on medialization and superiorization of the malar arch regardless of bony resection. Therefore, the AR can be effectively applied in case of arch dominant type or malar asymmetry. In addition, further comprehensive study including analysis on movement of facial soft tissue following malar bony movement is expected based on this study in near future.

An improved technique for zygoma reduction malarplasty

Zygoma reduction malarplasty is a standard procedure primarily performed in Asia on patients who prefer an oval facial shape. The technique is well established and standardized. However, the esthetic results are frequently unsatisfactory or accompanied by complications such as nonunion, malunion, and cheek drooping. These complications are generally attributed to postoperative bone fragment movement. In this study, we present an improvement to this standard procedure that involves modifying the surgical technique. With our suggested modification, the chance of displacement is decreased because of increased locking resulting from greater surface-to-surface contact between the posterior bone segments. Moreover, the prominence of the anterior zygoma is maintained, whereas posterior zygoma width is slightly decreased. In our technique, fixation is performed only in the zygoma body area, and posterior fixation can be avoided. In addition, in cases where fixation is not performed, the protrusion of the posterior aspect of the articular tubercle can be decreased by grinding. We believe that the modified technique has the potential to markedly improve the treatment outcomes of zygoma reduction malarplasty.

A Novel Technique for Reduction Malarplasty by Inward Displacement of Infractured Zygomatic Arch Without Fixation

PURPOSE

Reduction malarplasty is one of the most common esthetic surgical procedures performed in the Asian population. Traditional procedures have several complications, such as bone nonunion, malunion, cheek drooping, and damage to the infraorbital nerve and maxillary sinus. Therefore, a more straightforward and effective method of reducing the width of the midface is needed. In this study, we introduce an infracture technique using inward displacement of the zygomatic arch without fixation.

PATIENTS AND METHODS

A total of 680 patients received zygoma reduction using our method from 2012 to 2016 in the Department of Plastic Surgery, Minhang Shanghai Hospital. Radiologic and photographic documentation was completed preoperatively. The mean follow-up period was 24 months. The preoperative and postoperative photographs were compared.

RESULTS

All patients were satisfied with their results. The mean operation time was approximately 35 minutes. The patients were discharged 5 days after the surgical procedure, and the mean recovery time was 2 weeks. The continuity of the outer cortex of the zygomatic complex and excellent bone union were observed in all patients 6 months postoperatively. The malar prominence underwent relapse in 23 patients and was reset.

CONCLUSIONS

The new method that we developed has been proved safe and effective. It has 3 advantages. First, cheek drooping is avoided, and the damage caused by periosteum dissection on the whole zygomaticomaxillary area is limited. Second, bony fixation is unnecessary; thus the risk of bone nonunion, malunion, and a step-off deformity caused by improper fixation or looseness is prevented. Third, the operation time and the recovery time are short.