**4. Angle modification**

II, III, and IV).<sup>70</sup>

deficiency. Int. J. Oral Maxillofac. Surg. 2006]

ideal correction require two surgical techniques.

**4. ANGLE MODIFICATION** Caucasians consider a prominent mandibular angle to be unappealing in their populations, and mandibular angle ostectomy has been popular since Baek et al. introduced it in 1989.66 Standard Caucasians consider a prominent mandibular angle to be unappealing in their populations, and mandibular angle ostectomy has been popular since Baek et al. introduced it in 1989.[66] Standard procedure to correct prominent mandibular angles is mandibular angle ostectomy with anoscillating saw through the intraoral approach, although a number of modifications and improvements in operative techniques have been reported in the last two decades.[68, 69]Kim et al.[70] classified all the patients with prominent mandibular angle according to mandibular angle shape into four classes (I, II, III, and IV).[70]

procedure to correct prominent mandibular angles is mandibular angle ostectomy with anoscillating saw through the intraoral approach, although a number of modifications and improvements in operative techniques have been reported in the last two decades.68,69Kim et al.70 classified all the patients with prominent mandibular angle according to mandibular angle shape into four classes (I,

**Clinical evaluation:** For patients analysis it is important to consider the plans for correcting the lateral and frontal appearances of the lower face separately, because the 

**Figure 8:**Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi et al. Lower face reduction with full-thickness marginalostectomy of mandibular corpusangle followed by corticectomy. J Plast Reconstr Aesth Surg. 2010.] **Figure 8.** Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi et al. Lower face reduc‐ tion with full-thickness marginalostectomy of mandibular corpus-angle followed by corticectomy. J Plast Reconstr Aesth Surg. 2010.]

**Clinical evaluation:** For patients analysis it is important to consider the plans for correcting the lateral and frontal appearances of the lower face separately, because the ideal correction require two surgical techniques. **Surgical technique:** Firstly, the ostectomy of the marginal part of the mandibular corpusangle was performed, then corticectomy after evaluating the thickness of the resected bone fragment Mandibular corticectomy was performed to improve the frontal appearance.66 After designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex using a

**Surgical technique:** Firstly, the ostectomy of the marginal part of the mandibular corpus-angle was performed, then corticectomy after evaluating the thickness of the resected bone fragment Mandibular corticectomy was performed to improve the frontal appearance.[66] After designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex using a round burr. [66] round burr. <sup>66</sup>

**Figure 9.** Operative procedures for en-bloc mandibular corpus-angle ostectomy (MCAO) with a contra-angle hand‐ piece. [from Hirohi et al. Lower face reduction with full-thickness marginalostectomy of mandibular corpus-angle fol‐ lowed by corticectomy. J Plast Reconstr Aesth Surg. 2010.]

**Figure 10:**schematic view of sites of corticectomy and ostectomy. **Figure 10.** schematic view of sites of corticectomy and ostectomy.

**Clinical evaluation:** For patients analysis it is important to consider the plans for correcting the lateral and frontal appearances of the lower face separately, because the ideal correction

**Surgical technique:** Firstly, the ostectomy of the marginal part of the mandibular corpusangle was performed, then corticectomy after evaluating the thickness of the resected bone fragment Mandibular corticectomy was performed to improve the frontal appearance.66 After designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex using a

**Figure 8:**Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi et al. Lower face reduction with full-thickness marginalostectomy of mandibular corpus-

**Figure 8.** Preoperative evaluation and planning for mandibular angle reshaping. [from Hirohi et al. Lower face reduc‐ tion with full-thickness marginalostectomy of mandibular corpus-angle followed by corticectomy. J Plast Reconstr

angle followed by corticectomy. J Plast Reconstr Aesth Surg. 2010.]

**Surgical technique:** Firstly, the ostectomy of the marginal part of the mandibular corpus-angle was performed, then corticectomy after evaluating the thickness of the resected bone fragment Mandibular corticectomy was performed to improve the frontal appearance.[66] After designing the ostectomy line with a pencil, a groove was hollowed out on the lateral cortex

require two surgical techniques.

166 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

using a round burr. [66]

round burr. <sup>66</sup>

Aesth Surg. 2010.]

reshaping and underwent mandibular corpus-angle ostectomy and corticectomy. The postoperative frontal view shows that the width of his lower face was greatly reduced by ostectomy and corticectomy. **4-1-Reduction malarplasty Figure 11.** A 28 year-old woman with a muscular and square face desired mandibular reshaping and underwent man‐ dibular corpus-angle ostectomy and corticectomy. The postoperative frontal view shows that the width of his lower face was greatly reduced by ostectomy and corticectomy.

**Figure 11:**A 28 year-old woman with a muscular and square face desired mandibular

#### Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior midface. Reduction body and arch malarplasty (RBAM) is suited for patient with a hyperplastic anterior and posterior midface which will soften their square and wide facial **4.1. Reduction malarplasty**

appearance.90,94,**<sup>95</sup>** Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior mid-face. Reduction body and arch malarplasty (RBAM) is suited for patient with a hyperplastic anterior and posterior midface which will soften their square and wide facial appearance.[90, 94, 95]

**Surgical techniques:** since many years ago numerous surgical technique have been introduce to reduce the prominent malar.which some of these techniques are discussed here.

**Zygoma shaving procedure:** After intra oral flap elevation the entire zygomatic body and arch is exposed and subperiosteal dissection is carried out. [89] The most prominent portion of the zygoma, including part of the zygomatic arch, is shaved using a broad chisel or a bone bur. [89]

**I-shaped osteotomy:** Using a reciprocating saw, 2 parallel cuts are made on the zygomatic body from inner cortex toward the outer cortex resembling an I shape. [89] Then, the zygoma and the zygomatic arch complex are displaced antero-medially.

**Figure 12.** A 38 year-old oriental woman with severe malar prominence. wide faces due to a prominent zygoma are considered unsightly. frontal (left) and oblique (right) views.[from Zou C, et al. midface contour change after reduction malarplasty with modified L-shaped osteotomy: a surgical outcomes study. Aesthetic plast surg.2014]

**Figure 13.** Illustration of zygomatic shaving procedure. Note the shaving area involved the zygoma and the anterior part of zygomatic arch. **I-shaped osteotomy:** Using a reciprocating saw, 2 parallel cuts are made on the zygomatic body from inner cortex toward the outer cortex resembling an I shape.**<sup>89</sup>**Then, the zygoma

**L-shaped osteotomy:** This technique is similar to I-shaped osteotomy which can be

**FIGURE 14.** Illustration of I-shaped osteotomy. **Figure 14.** Illustration of I-shaped osteotomy.

considered in special cases.

zygoma and the anterior part of zygomatic arch.

and the zygomatic arch complex are displaced antero-medially .

**Figure 11:**A 28 year-old woman with a muscular and square face desired mandibular reshaping and underwent mandibular corpus-angle ostectomy and corticectomy. The postoperative frontal view shows that the width of his lower face was greatly reduced by

**Figure 11.** A 28 year-old woman with a muscular and square face desired mandibular reshaping and underwent man‐ dibular corpus-angle ostectomy and corticectomy. The postoperative frontal view shows that the width of his lower

> Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior midface. Reduction body and arch malarplasty (RBAM) is suited for patient with a hyperplastic anterior and posterior midface which will soften their square and wide facial

Reduction body malarplasty (RBM) can be done for patients with a hyperplastic anterior mid-face. Reduction body and arch malarplasty (RBAM) is suited for patient with a hyperplastic anterior and posterior midface which will soften their square and wide facial

**Surgical techniques:** since many years ago numerous surgical technique have been introduce

**Zygoma shaving procedure:** After intra oral flap elevation the entire zygomatic body and arch is exposed and subperiosteal dissection is carried out. [89] The most prominent portion of the zygoma, including part of the zygomatic arch, is shaved using a broad chisel or a bone bur. [89]

**I-shaped osteotomy:** Using a reciprocating saw, 2 parallel cuts are made on the zygomatic body from inner cortex toward the outer cortex resembling an I shape. [89] Then, the zygoma

to reduce the prominent malar.which some of these techniques are discussed here.

and the zygomatic arch complex are displaced antero-medially.

ostectomy and corticectomy. **4-1-Reduction malarplasty** 

appearance.90,94,**<sup>95</sup>**

**4.1. Reduction malarplasty**

appearance.[90, 94, 95]

face was greatly reduced by ostectomy and corticectomy.

168 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**FIGURE 15.**Illustrationof L-shaped osteotomy. **Figure 15.** Illustrationof L-shaped osteotomy.

**C-shaped osteotomy** The main difference of this technique with L-shaped osteotomy is in

**FIGURE 16.** Illustration of C-shaped osteotomy. **Figure 16.** Illustration of C-shaped osteotomy.

**FIGURE 16.** Illustration of C-shaped osteotomy.

**L-shaped osteotomy:** This technique is similar to I-shaped osteotomy which can be considered in special cases.

**C-shaped osteotomy** The main difference of this technique with L-shaped osteotomy is in the oblique part of the osteotomy line; the oblique line is moved more toward the external orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike Lshaped osteotomy in which we have only 1 line of osteotomy. [89]

**Modified L-shaped Osteotomy:** The modified L-shaped osteotomy differed from the original method mainly in that the two parallel osteotomy lines are made vertically so that the zygomatic body and arch can be shifted (Fig. 17).

**Modified L-shaped Osteotomy:** The modified L-shaped osteotomy differed from the original method mainly in that the two parallel osteotomy lines are made vertically so that

the zygomatic body and arch can be shifted (Fig. 17).

**Figure 17. A.** Kim's L-shaped osteotomy. **B.** The original L-shaped osteotomy. **C.** The modified L-shaped osteotomy. [fromNakanishi Y, et al. The boomerang osteotomy - A new method of reduction malarplasty. 2012]

**Figure 18.** (Left Above) Location of the most prominent part of the zygoma body (red point) (Right Above) Incision of the Boomerang Osteotomy (Left Below) Mobilization of the bone (Right Below) The complex of the zygoma body and zygomatic arch is shifted medially.

**L-shaped osteotomy:** This technique is similar to I-shaped osteotomy which can be considered

**C-shaped osteotomy** The main difference of this technique with L-shaped osteotomy is in the oblique part of the osteotomy line; the oblique line is moved more toward the external orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike

**C-shaped osteotomy** The main difference of this technique with L-shaped osteotomy is in the oblique part of the osteotomy line; the oblique line is moved more toward the external orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike

**C-shaped osteotomy** The main difference of this technique with L-shaped osteotomy is in the oblique part of the osteotomy line; the oblique line is moved more toward the external orbital rims in comparison with the L-shaped osteotomy and consists of 2 parallel lines unlike L-

**Modified L-shaped Osteotomy:** The modified L-shaped osteotomy differed from the original method mainly in that the two parallel osteotomy lines are made vertically so that the

shaped osteotomy in which we have only 1 line of osteotomy. [89]

**FIGURE 16.** Illustration of C-shaped osteotomy.

**FIGURE 16.** Illustration of C-shaped osteotomy. **Figure 16.** Illustration of C-shaped osteotomy.

**FIGURE 15.**Illustrationof L-shaped osteotomy.

**FIGURE 15.**Illustrationof L-shaped osteotomy.

170 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 15.** Illustrationof L-shaped osteotomy.

L-shaped osteotomy in which we have only 1 line of osteotomy.**<sup>89</sup>**

L-shaped osteotomy in which we have only 1 line of osteotomy.**<sup>89</sup>**

zygomatic body and arch can be shifted (Fig. 17).

in special cases.

adjustment. The vertical height of the zygomatic arch presents no change with boomerang method. **Figure 19.** With Kim's method, the zygomatic arch shifts upward as the rotation for subtle adjustment. The vertical height of the zygomatic arch presents no change with boomerang method.

Horizontal v-shaped osteotomy : this technique is similar to L-shaped osteotomy .

Figure 20. Horizontal V-shaped osteotomy used to correct protrusion of the zygoma and zygomatic arch. Not that the free part of the root of the zygomatic arch was locked into the gap between the rigid part and the temporal bone as a mortice and tenon structure.[fromTang K, et al. New horizontal v-shaped osteotomy for correction of protrusion of the zygoma and the zygomatic arch in East Asiansindication and results. Br J Oral Maxillofac Surg .

2014]

**Horizontal v-shaped osteotomy :** this technique is similar to L-shaped osteotomy.

**Figure 20.** Horizontal V-shaped osteotomy used to correct protrusion of the zygoma and zygomatic arch. Not that the free part of the root of the zygomatic arch was locked into the gap between the rigid part and the temporal bone as a mortice and tenon structure.[fromTang K, et al. New horizontal v-shaped osteotomy for correction of protrusion of the zygoma and the zygomatic arch in East Asiansindication and results. Br J Oral Maxillofac Surg. 2014]

**Figure 21.** Preoperative views of the same patient **(a, c).** Postoperative views after an L-shaped malar osteotomy and repositioning and mandibular reduction **(b, d).**[fromChen T, et al. correction of zygoma and zygomatic arch protrusion in east Asian individuals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2011].

### **4.2. Aumentation malarplasty**

**Horizontal v-shaped osteotomy :** this technique is similar to L-shaped osteotomy.

172 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 20.** Horizontal V-shaped osteotomy used to correct protrusion of the zygoma and zygomatic arch. Not that the free part of the root of the zygomatic arch was locked into the gap between the rigid part and the temporal bone as a mortice and tenon structure.[fromTang K, et al. New horizontal v-shaped osteotomy for correction of protrusion of the

**Figure 21.** Preoperative views of the same patient **(a, c).** Postoperative views after an L-shaped malar osteotomy and repositioning and mandibular reduction **(b, d).**[fromChen T, et al. correction of zygoma and zygomatic arch protrusion

in east Asian individuals. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.2011].

zygoma and the zygomatic arch in East Asiansindication and results. Br J Oral Maxillofac Surg. 2014]

**Clinical evaluation:** Oval shaped face with the key component of malar prominence is considered to be a sign of beauty and youth in Caucasians. [73] Many tricks using artificial highlighting and darkening are developed by makeup artists to accentuate the malar promi‐ nence. [73] Flattened cheeks and narrow face makes people look sad and prematurely aged. [73] This transverse midface deficiency can be addressed by widening the bimalar width.[73]


**Table 1.** Analyses of malar projection

Malar recontouring involves not only the zygomatic region, but also the infraorbital,paranas‐ al, and buccal regions. Furthermore, imperfections of other facial areas may reflect negatively on the malar region. The buccal region should be slightly concave or flat in adults,within the

**Figure 22.**analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and Guilden. d, Wilkinson analysis. **Figure 22.** Analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and Guilden. d, Wilkinson analysis.

confines of a tangent from the cheekbone to the mandibular angle. Fullness in the buccalregion can give the illusion of a poorly developed malar eminence. In these patients, partial excision of the buccal fat pad may be indicated.[104] Shadowing in the concavity of the buccal area highlights the malar eminence, giving it a sculptured, well-defined look. Caucasian women tend to accentuate this effect by using makeup, whereas Asians prefer much softer contours. But excessive buccal hollowness results in an emaciated, gaunt appearance with exaggerated malar definition. Excessive width and prominence of the mandibular angle and masseter muscles make the malar eminence look small and give the face a square or triangular shape. Reduction of the mandibular angle and masseter muscles might be more adequate than malar augmentation. The malar eminence is also examined relative to the periorbital region. A high and prominent mala eminence enhances the appearance of the beautiful eye. Fullness of the area 10 mm lateral and15–20 mm inferiorto the lateral canthus shouldbe obvious.(Fig. 21)[105] Malar recontouring involves not only the zygomatic region, but also the infraorbital,paranasal, and buccal regions. Furthermore, imperfections of other facial areas may reflect negatively on the malar region. The buccal region should be slightly concave or flat in adults,within the confines of a tangent from the cheekbone to the mandibular angle. Fullness in the buccal region can give the illusion of a poorly developed malar eminence. In these patients, partial excision of the buccal fat pad may be indicated.**<sup>104</sup>** Shadowing in the concavity of the buccal area highlights the malar eminence, giving it a sculptured, well-defined look. Caucasian women tend to accentuate this effect by using makeup, whereas Asians prefer much softer contours. But excessive buccal hollowness results in an emaciated, gaunt appearance with exaggerated malar definition. Excessive width and prominence of the mandibular angle and masseter muscles make the malar eminence look small and give the face a square or triangular shape. Reduction of the mandibular angle and masseter muscles might be more adequate than malar augmentation. The malar eminence is also examined relative to the periorbital region. A high and prominent mala

eminence enhances the appearance of the beautiful eye. Fullness of the area 10 mm lateral and

**Figure 23.** Schoenrock analysis of malar projection in oblique view. (ME): malar eminence.

15–20 mm inferior to the lateral canthus should be obvious. (Fig. 21)**<sup>105</sup>**

#### **Surgical thechniques:**

**Zygomatic arch osteotomy:** A subperiosteal flap is raised to expose the ascending malar buttress and the zygomaticomaxillary suture. The position of an oblique sagittal cut is selected by deciding whether augmentation should include any of the anterior buttress or whether it should be totally lateral to zygomaticomaxillary suture line. The cut is then made with a sagittal reciprocating saw starting from the inferior portion of the zygomaticomaxilary suture to the notch of both lateral orbital rim and malar zygomatic process. A previously selected graft may now be placed between the two segments. The result is an increase in interarch width (zygionzygion).(Fig 22)

**Figure 24.** Surgical steps of zygomaticarch osteotomy.

confines of a tangent from the cheekbone to the mandibular angle. Fullness in the buccalregion can give the illusion of a poorly developed malar eminence. In these patients, partial excision of the buccal fat pad may be indicated.[104] Shadowing in the concavity of the buccal area highlights the malar eminence, giving it a sculptured, well-defined look. Caucasian women tend to accentuate this effect by using makeup, whereas Asians prefer much softer contours. But excessive buccal hollowness results in an emaciated, gaunt appearance with exaggerated malar definition. Excessive width and prominence of the mandibular angle and masseter muscles make the malar eminence look small and give the face a square or triangular shape. Reduction of the mandibular angle and masseter muscles might be more adequate than malar augmentation. The malar eminence is also examined relative to the periorbital region. A high and prominent mala eminence enhances the appearance of the beautiful eye. Fullness of the area 10 mm lateral and15–20 mm inferiorto the lateral canthus shouldbe obvious.(Fig. 21)[105]

Malar recontouring involves not only the zygomatic region, but also the infraorbital,paranasal, and buccal regions. Furthermore, imperfections of other facial areas may reflect negatively on the malar region. The buccal region should be slightly concave or flat in adults,within the confines of a tangent from the cheekbone to the mandibular angle. Fullness in the buccal region can give the illusion of a poorly developed malar eminence. In these patients, partial excision of the buccal fat pad may be indicated.**<sup>104</sup>** Shadowing in the concavity of the buccal area highlights the malar eminence, giving it a sculptured, well-defined look. Caucasian women tend to accentuate this effect by using makeup, whereas Asians prefer much softer contours. But excessive buccal hollowness results in an emaciated, gaunt appearance with exaggerated malar definition. Excessive width and prominence of the mandibular angle and masseter muscles make the malar eminence look small and give the face a square or triangular shape. Reduction of the mandibular angle and masseter muscles might be more adequate than malar augmentation. The malar eminence is also examined relative to the periorbital region. A high and prominent mala eminence enhances the appearance of the beautiful eye. Fullness of the area 10 mm lateral and

**Figure 22.**analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and

**Figure 22.** Analyses of malar projection. a, hinderer analysis. b, pwell et al analysis. c, Silver and Guilden. d, Wilkinson

**Figure 23.** Schoenrock analysis of malar projection in oblique view. (ME): malar eminence.

15–20 mm inferior to the lateral canthus should be obvious. (Fig. 21)**<sup>105</sup>**

**Zygomatic arch osteotomy:** A subperiosteal flap is raised to expose the ascending malar buttress and the zygomaticomaxillary suture. The position of an oblique sagittal cut is selected

**Surgical thechniques:**

Guilden. d, Wilkinson analysis.

174 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

analysis.

**Zygomatic sandwich osteotomy (ZSO):** To solve some problems, modifications of zygomatic arch osteotomy technique have been presented. Mommaerts et al [81]modified Powell's technique by connecting a vertical with a semihorizontal osteotomy which both transect the maxillary sinus, thereby maximizing anterior as well as lateral augmentation.

**Figure 25.** Comparison of zygomatic arch osteotomy (Powell et al) and zygomatic sandwich osteotomy (Mommaerts et al).(A) difference in design (zygomatic arch osteotomy [ZAO] = horizontal lines; zygomatic sandwich osteotomy [ZSO] = verticallines). (B) amount of augmentation, caudal view (x = lateral displacement with ZAO; x' = lateral displacement with ZSO; y =anterior displacement with ZAO; y' = anterior displacement with ZSO).

**FIGURE 23.** Comparison of zygomatic arch osteotomy (Powell et al) and zygomatic sandwich osteotomy (Mommaerts et al).(A) difference in design (zygomatic arch osteotomy [ZAO] = horizontal lines; zygomatic sandwich osteotomy [ZSO] = verticallines). (B) amount of augmentation, caudal view (x = lateral displacement with ZAO; x' = lateral displacement with

ZSO; y =anterior displacement with ZAO; y' = anterior displacement with ZSO).

**FIGURE 24.a.** vertical osteotomy, **b.** semihorizontal osteotomy,**c.** Opening of the vertical osteotomy and insertion of spacer material. **Figure 26. a.** vertical osteotomy, **b.** semihorizontal osteotomy,**c.** Opening of the vertical osteotomy and insertion of spacer material.

**Figure 27.** Malar augmentation, differences in osteotomy design: Mommaerts et al (left) compared with Kim and Seul (right).

**Zygomatic Sagittal Split Osteotomy (ZSSO):**in this technique the zygomatic arch is isolated from its temporal origin to its zygomatic insertion both on its lateral and medial surfaces Using a waver sewer, a sagittal full thickness osteotomy of the zygomatic arch is performed (Fig. 26).Later, 2 separate partial thickness osteotomies: one on the arch's osteotomies are connected with the previously released sagittal osteotomy. After correction of the zygomatic arch according to presurgical programs. Stabilization is achieved using bicortical titanium screws (Fig. 26).

to presurgical programs. Stabilization is achieved using bicortical titanium screws (Fig. 26).

to presurgical programs. Stabilization is achieved using bicortical titanium screws (Fig. 26).

**FIGURE 25.** Malar augmentation , differences in osteotomy design: Mommaerts et al (left)

**FIGURE 25.** Malar augmentation , differences in osteotomy design: Mommaerts et al (left)

**Zygomatic Sagittal Split Osteotomy (ZSSO):**in this technique the zygomatic arch is isolated from its temporal origin to its zygomatic insertion both on its lateral and medial surfaces Using a

**Zygomatic Sagittal Split Osteotomy (ZSSO):**in this technique the zygomatic arch is isolated from its temporal origin to its zygomatic insertion both on its lateral and medial surfaces Using a waver sewer, a sagittal full thickness osteotomy of the zygomatic arch is performed (Fig.

compared with Kim and Seul (right).

compared with Kim and Seul (right).

**FIGURE 26.** Two vertical partial-thickness osteotomy are performed: one on the posterolateral surface of the zygomatic arch and the other on its anteromedial surface. **left)** Sagittal fullthickness osteotomy of the zygomaticarch, performed with a waver sewer.**right)** Stabilization of the osteotomy with bicortical titanium screws.[fromGasparini G et al. Zygomatic Sagittal Split Osteotomy: A Novel and Simple Surgical Technique for Use in Midface Corrections. J Craniofac Surg.2010] **Figure 28.** Two vertical partial-thickness osteotomy are performed: one on the posterolateral surface of the zygomatic arch and the other on its anteromedial surface. **left)** Sagittal full-thickness osteotomy of the zygomaticarch, performed with a waver sewer.**right)** Stabilization of the osteotomy with bicortical titanium screws.[fromGasparini G et al. Zygo‐ matic Sagittal Split Osteotomy: A Novel and Simple Surgical Technique for Use in Midface Corrections. J Craniofac Surg.2010] **FIGURE 26.** Two vertical partial-thickness osteotomy are performed: one on the posterolateral surface of the zygomatic arch and the other on its anteromedial surface. **left)** Sagittal fullthickness osteotomy of the zygomaticarch, performed with a waver sewer.**right)** Stabilization of the osteotomy with bicortical titanium screws.[fromGasparini G et al. Zygomatic Sagittal Split Osteotomy: A Novel and Simple Surgical Technique for Use in Midface Corrections. J Craniofac

**Figure 29.** A 32 years woman with malar deficiency, No orthognathic surgery was performed in this case. The patient desired definition of the cheekbones with zygomatic sandwich osteotomy (ZSO) (left) preoperative view, note the tri‐ angular shape of she's face; (right) 18 month postoperative view.

## **5. Frontal modification**

Surg.2010]

**Figure 27.** Malar augmentation, differences in osteotomy design: Mommaerts et al (left) compared with Kim and Seul

**FIGURE 24.a.** vertical osteotomy, **b.** semihorizontal osteotomy,**c.** Opening of the vertical osteotomy and insertion of spacer material. **Figure 26. a.** vertical osteotomy, **b.** semihorizontal osteotomy,**c.** Opening of the vertical osteotomy and insertion of

**FIGURE 23.** Comparison of zygomatic arch osteotomy (Powell et al) and zygomatic sandwich osteotomy (Mommaerts et al).(A) difference in design (zygomatic arch osteotomy [ZAO] = horizontal lines; zygomatic sandwich osteotomy [ZSO] = verticallines). (B) amount of augmentation, caudal view (x = lateral displacement with ZAO; x' = lateral displacement with

ZSO; y =anterior displacement with ZAO; y' = anterior displacement with ZSO).

176 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Zygomatic Sagittal Split Osteotomy (ZSSO):**in this technique the zygomatic arch is isolated from its temporal origin to its zygomatic insertion both on its lateral and medial surfaces Using a waver sewer, a sagittal full thickness osteotomy of the zygomatic arch is performed (Fig. 26).Later, 2 separate partial thickness osteotomies: one on the arch's osteotomies are connected with the previously released sagittal osteotomy. After correction of the zygomatic arch according to presurgical programs. Stabilization is achieved using bicortical titanium screws

(right).

spacer material.

(Fig. 26).

**Frontal bossing reduction:**Frontal Bossing known as a prominent supraorbital region and considers as a masculine characteristic. Generally men have more prominent frontal bossing than women which tends to have a smooth transition from brow area into a forehead. Frontal Bossing patients range from those with craniofacial anomaly such as thalassemias, Crouzon/ apert syndrome, Hurler syndrome to those without any underlying medical problem(figure 28,29). [112]

**Figure 30.** The main difference between male and female foreheads is that males often have a ridge of bone around the upper edge of the eye sockets called the "brow ridge" or "brow bossing". Female foreheads tend to have little or no bossing.Between the ridges of the two eye sockets a flat area can be visible. As women don't have the ridges, also the flat area between them is not present. [from facialfeminization.eu]

**Figure 31.** Schematic view of the slob of the forehead. Because of the brow ridge the general angle of the forehead in males (below-right) is steeper and the angle between the forehead and nose is sharper in lateral view. Women,(belowleft) because they don't have the brow ridge, have a more vertical appearance of the forehead in lateral view. The angle between nose and forehead is more open. [from facialfeminization.eu]

The most common method of brow bone reduction is an open approach using a bi-coronal flap with either a burring reduction, an infracture technique or osteotomies and reshaping. Simple burring can be effective if the outer table of the brow bone is thick enough.

In the course of normal skull growth, satisfactory reduction of anterior bossing without direct surgical correction of the shape of the forehead can be achieved through sagittal suturectomy along with biparietal barrel stave cuts[113]. More correction of biparietal width and the occipital deformity, on the other hand, may also result in a gradual correction of the frontal

**Figure 32.** bi-coronal flap.

apert syndrome, Hurler syndrome to those without any underlying medical problem(figure

**Figure 30.** The main difference between male and female foreheads is that males often have a ridge of bone around the upper edge of the eye sockets called the "brow ridge" or "brow bossing". Female foreheads tend to have little or no bossing.Between the ridges of the two eye sockets a flat area can be visible. As women don't have the ridges, also the

**Figure 31.** Schematic view of the slob of the forehead. Because of the brow ridge the general angle of the forehead in males (below-right) is steeper and the angle between the forehead and nose is sharper in lateral view. Women,(belowleft) because they don't have the brow ridge, have a more vertical appearance of the forehead in lateral view. The angle

The most common method of brow bone reduction is an open approach using a bi-coronal flap with either a burring reduction, an infracture technique or osteotomies and reshaping. Simple

In the course of normal skull growth, satisfactory reduction of anterior bossing without direct surgical correction of the shape of the forehead can be achieved through sagittal suturectomy along with biparietal barrel stave cuts[113]. More correction of biparietal width and the occipital deformity, on the other hand, may also result in a gradual correction of the frontal

burring can be effective if the outer table of the brow bone is thick enough.

flat area between them is not present. [from facialfeminization.eu]

178 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

between nose and forehead is more open. [from facialfeminization.eu]

28,29). [112]

**Figure 33.** Frontal bossing re-shaping.With the thick bone, the surgeon only has to grind down the bone to the desired level and there will still be plenty of bone left to cover the frontal sinus as you can see.With the thin bone sutgeons can't grind it down to the ideal line or very much at all without breaking through into the sinus. In this case, most FFS surgeons will perform a forehead reconstruction so after grinding down what they can, they actually take the wall of bone apart, re-shape it and move it backwards to the desired position. [from www.virtualffs.co.uk]

deformity to satisfactory. In severe cases, however, the natural development of the calvarial shape with physiological skull growth following the described technique will not suffice as a cosmetically compromising frontal bossing will be most likely to persist. In such cases, a direct surgical correction, including radial osteotomies, rotation of bone flaps, "frontal to occipital switch", π-procedure, morcellation, use of distraction or contraction devices, total cranial vault reconstruction, and other techniques have been suggested in the craniofacial literature.[114] The general approach in these techniques includes excision, remodeling, transposition, and re-insertion of free bone flaps. The direct approach will then require complex bone fixations using wires or plates and screws. More advanced modifications of these techniques to avoid free bone flaps have been discussed where the shortened and re-approximated bone tongues stay attached at their normal calvarial position at the base or the apex of the calvaria. For example, in the technique described by Wagner and Wiewrodt[113] in 2008, following sagittal suturectomy and parietalbarrel stave incisions, four or five lanceolate pieces of thefrontal bone are excised resulting in three or four vertical bone bridges. These osteotomies are designed to extend radially from thecranial base towards the fontanel. Small strips rectangular to the apicobasal axis are then cut out from these bridges, leaving basal and apical bone tongues. [113] The tabula externa at the base of the basal tongues is drilled off and the tongues are bent inward to correct the inferior aspect of the frontal bossing. [113]

Corresponding basal and apical bone tongues arethen re-approached and fixated with sutures.

The gold standard procedure for correction of severe frontal bossing is still open approach with osteotomy of the anterior table of the frontal sinus which provides excellent outcome. Complications such as long coronal scars, alopecia, blood loss, forehead paresthesia, neuromas and traction palsy of the facial nerve makes this operation invasive, with increased chance of morbidity and less desirable for mild to moderate frontal bossing correction. [112]

Despite the widespread use of endoscopic frontal bone operations such as remodeling of bony defects and removal of osteomas of the frontal bone, only recently has "endoscopic frontal bossing correction" been introduced.[112] This emerging method seems to have rendered frontal bossing correction much simpler, significantly safer, and minimally invasive.

Moreover, the introduction of the endoscope revolutionized the surgical approach to the forehead, as it allowed for smaller incisions, magnified visualization, decreased risk of bleeding, faster recovery, and decreased chance of neuropathy by preserving cutaneous nerves. Endoscopic contouring of the forehead was first described by Song et al. on a Korean woman with frontal bone deformities.[115] Since then, most published endoscopic manipu‐ lation of the frontal bone and supraorbital ridge has involved osteoma mass excision or frontal sinus fracture repair. Retrospective reviews of patients receiving endoscopic correction of frontal bossing have shown promising aesthetic results with minimal postoperative morbidity. This method of improving forehead contour, however, should be carried out on properly selected groups of patients. Mild deformities of frontal bossing and adequate bone thickness over the frontal sinus makes patients a great choice for endoscopic frontal bossing correction. [112] Some complications such as neurosensory damage, vascular injury, and extended operative time. [112]. Similarities like incision line and dissection planes for this technique with standard endoscopic forehead lift allows easy access to the frontal bone for contouring in patients with frontal bossing and undergoing concurrent forehead rejuvenation.[112]

#### **6. Summary**

The major architectural promontories of the facial skeleton, including the malar-midface region, nose, chin,angle of the mandible and frontal buttress provide the base upon which the soft tissues of the face drape. By altering these promontories, dramatic changes can be made in the estheticappearance of the face—much more so than by changing soft tissue and skin alone.Since many years ago numerous surgical and office based techniques have been introduce to augment, reduce or refine the most projected points of the face such as cheek,chin,nose, Para-nasal area, angle of the jaw.When reduction of these esthetic points is planed not only we don't have multiple choices but also without using these methods the precise and predictable correction is almost impossible. In case of augmentation although we have the more options such as soft tissue office based procedures or facial prostheses[110, 111] a precise pre-surgical evaluation in according to patient complaints, social and economic conditions, soft or hard tissue deficiency, amount of augmentation,the past similar procedure, ect. should be considered and the best method for each patient should be selected.Aesthetic adjunct facial osteotomy techniques have proved to be expedient techniques, with low morbidity, producing a controllable and predictable increase or decrease of the facial promi‐ nences and stable short and long-term morphological results.The most common complication of esthetic adjunct osteotomy techniques are under- correction and over-correction; presurgical evaluation and precise estimation of amount of excess or deficiency is a best method to reduce these complications the relation between hard and soft tissue change is also impor‐ tant,for example the hard tissue to soft tissue ratio in case of advancement genioplasty is almost 1:1 but in case of reduction genioplasty or chin narrowing is almost 1:0.5.Another complication is bad split ; although it is a rare complication and often is simple to manage but in cases in whom correction is impossible the best way is internat fixation,close the incision and set an another appointment with patient. Other complications such as nerve injury, relapse or sever bleeding is very rare. The more surgeon experience the less incidence of complications.
