27.1 Indications
Key words: esthetic improvement by zygomatic arch augmentation, reconstruction of malformations, zygomatic bone reduction in Asian-type skulls
Reconstructive surgery of the zygomatic bone and zygomatic arch is medically indicated in cases of hypoplasia or malformation within a facial syndrome. Hyperplasia or hypoplasia of the zygomatic arches may be the reason for corrective surgery, mainly for esthetic reasons.
In women, more prominent cheekbones in combination with a narrow nose and chin are rated as attractive (Fig 27-1a).1 Despite unlimited variations of human skull shapes, this assessment of an esthetic face runs in a similar way through all ethnicities, all possible mixed variants, and across all cultures (Fig 27-1b).
Fig 27-1a Caucasian-type face of a 38-year-old woman with concave contour of narrow cheeks, emphasizing zygomatic arches and legs. This gives the esthetic facial expression a striking component.
Fig 27-1b Asian-Caucasian face of a 26-year-old woman with accentuated zygomatic arches and round filled cheeks harmoniously forming the entire face and emphasizing Asian esthetics with almond eyes and epicanthus.
In Central Europe, Caucasian skulls predominate. If they have a rather elongated shape, they often show a reduced zygomatic prominence. They may additionally show a dentofacial malformation (see Figs 27-2a to 27-2d). Individual harmonization of facial shape can be achieved by augmentation of the zygomatic bone and zygomatic arch, even with simultaneous maxillomandibular osteotomy. The esthetic extent of the augmentation is extremely subjective and must be discussed in detail with the patient. Zygomatic arch correction can also be performed as a standalone surgical procedure. Hypertrophic zygomatic bones or arches are rare in Central Europe; they have more commonly been requested mainly by Asian men.
Figs 27-2a to 27-2d Caucasian-type face of an almost 18-year-old female patient with midface deficit, hypoplastic zygomatic arches, long nose, and plump nasal tip. Postpubertal orthodontic multibracket treatment (ages 13 to 15) was successful with dental adjustment of an Angle Class I occlusion.
Figs 27-2e to 27-2g Further mandibular growth resulted in mandibular prognathism with headbite dentition between ages 15 and 18. Temporomandibular joint discomfort necessitated the wearing of a bite splint, which led to functional adjustment of the mandibular heads, and also to the formation of a circular open bite. A maxillomandibular osteotomy (17 years, 7 months) was planned.
Figs 27-2g and 27-2h After opening the access to the Le Fort I osteotomy, the infraorbital nerve was first exposed, then the lateral orbital rim including the zygomatic prominence was undermined (g and h, right side). This was followed by an angular osteotomy of the zygomatic massif, careful mobilization of the zygomatic arches bilaterally with the chisel, and lateral expansion of the zygomatic arch.
Figs 27-2i and 27-2j Immediately after Le Fort I osteotomy with trisection of the maxilla and maxillary fixation in a new position with micro- and miniplates, the interposition of a 6-mm-wide bone block for transverse zygomatic bone augmentation and then stable fixation with two microosteosynthesis plates was performed on the right side.
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