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Restoration of Facial Sagginess and Indentation After Zyogmatic Bone and Zygomatic Arch Surgery

[ Author:Fushun Ma | Time:2012-01-17 20:15:27 |  Font Size: [Large Medium Small]
Tags: facial sagginess, facial indentation, zygomatic reduction, zygoma revision

Facial sagginess is a problem that is mostly concerned by the zygomatic surgery candidates and also a hot topic on the net. That is because some of the surgical procedures such as The Frontal End Osteotomy Zygoma and Zygomatic Arch Reduction that can easily get a saggy result after surgery. This kind of facial sagginess mostly comes with a zygomatic complex downward displacement. As a matter of fact the zygomatic complex displacement actually causes the facial sagginess. So once the sagginess happened the displaced segment of the zygomatic complex needs to be restored. Only by doing this the facial sagginess could be fixed fundamentally.

If the bone displacement is big enough the supporting function of the zygoma and the zygomatic arch for the face is compromised then facial sagginess is bound to happen or even the zygomatic arch and the coronoid processor of the mandible bone can bounce to each other when chewing, thus the function of the mandible is interfered. However the displacement of the zygomatic bone dose not cause anyvisible  facial problems at the early post surgery period as the post surgical facial swelling hides the underneath newly formed structural defect. When the facial swelling subsides eventually the facial sagginess or local indentation on the frontal lateral face will show up. As aging facial soft tissue atrophy happens the soft tissue coverage for the bone defect gets weaker this makes the local indentation looks ever worse.

zygomtic arch and zygomatic bone restoration for post surgery displacement and sagginess
Left side facial indentation and sagginess(indicated by the white arrow) after zygomatic arch and zygomatic bone reduction surgery, on the right side picture the facial defect is reconstructed by zygomatic complex restoration.

revision surgery for post surgical zygomatic arch and zygomatic bone displacement
The white arrow directs to the post surgery facial indentation on the left side of this girl's face, after revision surgery the facial indentation disappeared (refer to the right side picture).

zygomatic arch and zygomatic bone revision surgery in profile view
On the lateral view the indentation caused by the zygomatic complex displacement is slightly front to the center of the lateral face an area difficult to hide. After restoration the lateral face is fuller again.

restoration of post surgical displaced zygomatic arch and zygomatic bone
The CT image shows the zygomatic complex inward and downward displacement after surgery. The right side picture shows a multiple plate and screw fixation is needed to hold the bone in a restored position.

This is a facial bone surgery case with a complication of severe zygomatic bone and zygomatic arch downward and inward displacement. The bony displacement again caused facial sagginess and local face indentation. A restoration surgery is definitely needed and her finial result after the second surgery is acceptable and satisfied by herself. Her primary surgery was the Frontal End Zygomtic Bone and Zygomatic Arch Osteotomy Reduction Surgery. The above images are this girl's CT scan images. The left side image shows the situation of the zygomatic bone after the primary surgery. Both sides of the zygomatic complex are displaced on this image and the left side displacement is more sever as the red arrows showing. As the right side displacement was not severe and didn't cause any visible facial surface defect, no restoration surgery is applied on this side. A zygomatic arch and zygomatic bone restoration surgery was done only on the left side. The right side CT image shows the post revision zygomtic bone and zygomaitc arch structure. As we can see from the image that the left side zygomatic complex has been reconstructed to a whole structure with three places of plate and screw fixation as the yellow arrows depicting.

downward displaced zygomatic bone and zygomatic arch
After zygomatic arch and zygomatic bone reduction surgery the structure of zygoamtic complex is been destroyed.

Normally a severe displacement of the zygomatic bone happens during the surgery see the image on the right side, not due to the muscle traction after surgery as the degree of displacement already exceeded the range of muscle contraction. That is to say even the muscle contracts in its most capacity the range of bone movement is less than the actual bone movement in this image. The displaced zygomatic complex bone has dropped down to cover part of the mandible bone( see the red arrow). Referring to the above white image the displaced bone also moves inward to a position where the zygomatic bone and the mandible bone could contact each other. In this case the mandible movement function could be interfered because the bone free space between these two bones disappeared. Whenever the mandible bone moves a friction between these two bones occurs.

The displacement of the zygomatic bone destroys the structure of the zygomatic complex and forms a big gap on the originally sound bone at the place where the yellow arrows indicate. On top of this downward displacement the bone also moves inward. Thus a obviously visible indentation appears on the front lateral face as the first three photos show on this page. The location of this indentation is on the center front part of the lateral face, a most exposing area of the face and the lack of bone coverage in this region rendered a possibility of showing the underneath temporal muscle movement when chewing or speaking, making the facial defect ever more noticeable. For this reason once there is a severe zygomatic bone displacement, an in time restoration surgery is strongly recommended to improve the facial appearance and to avoid possible freed zygomatic bone absorption after long period of detachment. Bone absorption can make the restoration surgery more difficult and may compromise the eventural facial appearance.

The facial indentation defect is obvious in this group of photos. However the facial sagginess is not so easily noticeable. From experience Dr. Ma knows that the facial sagginess in a photo is often more obscure than on the face of real person. That is to see the facial sagginess tend to be noticeable on real person than in photo. In the photos of this page, if we carefully exam the before surgery photo we will see sing of soft tissue sagginess in the area above the nasal labia fold and this sign disappears in photo after restoration surgery. Another signs of sagginess include the lowered left mouth corner and a narrowed mouth opening caused by the left side facial sagginess. Again all these signs of facial sagginess have gone following the revision surgery.

The restoration surgery was done 6 months after the primary surgery for this girl and bone absorption is not bad for the freed zygomatic bone. It is discovered during the surgery that a slice of bone has been removed from the zygomatic complex at the point with the gap is located. So even no bone absorption there is still a shortage of bone to reconstruct the whole zygomatic complex. Dr. Ma can raise and rotate the displaced bone piece to its original location but the replaced bone can't close the entire gap. Titanium plates and screws are used as supplemental materials to meet the need. It is proved that this is a good approach for the reconstructed zygomatic complex is stable and surgery receiver is happy. The post revision surgery photos were token half year after the primary surgery, the post revision photos show that the indentation is no more noticeable and the whole face looks full and natrual.

The plates and screws used in restoration surgery can be removed after one year of surgery. However if there is a need for the plates to mandate the bone shortage these fixation tools are not recommended to be removed unless a confirmed bone regeneration has already covered the bone defect.

Revision surgery, especially revision surgeries with a big bone displacement like this girl, can hardly get a perfect outcome than the primary surgery. It is important to be cautious to choose the right indication and right surgical procedures for a satisfactory result at the first try. If a surgical complication has already happened it is advise to have a detailed discussion with your surgeon and pay enough attention to the pre surgery image analysis before the restoration surgery to avoid second time complication or unwanted result.

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