Consideration of the diameter of superficial temporal arteries related to filler injections in the temporal region.

BACKGROUND: The concavity of the temple due to adipose tissue atrophy from aging accentuates the zygomatic arch and lateral orbital rim, leading to an aged appearance. The use of hyaluronic acid filler in the temporal region has gained popularity due to its procedural simplicity and consistent outcomes. OBJECTIVE: To evaluate the safety of administering hyaluronic acid filler in the temporal region concerning the frontal branch of the superficial temporal artery, which is at risk of injury. METHODS: Empirical observations were conducted on the internal diameter of the frontal branch of the superficial temporal artery, a critical anatomical site for potential injury. RESULTS: A significant proportion of the artery segments exhibited an internal diameter below 1 mm. Given that the outer diameter of an 18-gauge cannula is 1.27 mm, this method can be considered a relatively secure approach for enhancing the temporal region. CONCLUSION: The use of an 18-gauge cannula for hyaluronic acid filler administration in the temporal region appears to be a safe and effective method, with the potential risk to the frontal branch of the superficial temporal artery being minimal.

Modeling stability post zygomatic fracture reconstruction.

Zygomaticomaxillary complex (ZMC) fracture repair is one of the most common surgical procedures performed in craniomaxillofacial trauma management. Miniplates and screws are used to stabilize the fractured bone using small local incisions, however, these procedures are not infrequently associated with hardware-related post-operative complications. The amount of fixation hardware utilized varies depending on the fracture pattern and surgical judgment, with three-point fixation being the conventionally accepted treatment. However, limited experimental testing and clinical studies have suggested that ZMC stabilization may be achieved with less than three-point fixation. In this study, we utilized a previously developed finite element modeling approach that allows for detailed bone and muscle representation to study the mechanical behavior of the fractured craniomaxillofacial skeleton (CMFS) under one, two, or three-point fixation of the ZMC. Results suggest that using a miniplate along the infraorbital rim in three-point fixation increases the amount of strain and load transfer to this region, rather than offloading the bone. Two-point (zygomaticomaxillary and zygomaticofrontal) fixation yielded strain patterns most similar to the intact CMFS. One-point (zygomaticofrontal) fixation resulted in higher tensile and compressive strains in the zygomaticofrontal region and the zygomatic arch, along with a higher tensile strain on the zygomatic body. These modeling results provide biomechanical evidence for the concept of over-engineering in the stabilization of facial fractures. Furthermore, they support previous suggestions that less than three-point fixation of ZMC fractures may be adequate to achieve uneventful healing.

El reposicionamiento malar. Presentación de una técnica original: punto MM / Malar repositioning. Presentation of an original technique: point MM

El envejecimiento facial es una sinergia compleja de cambios texturales de la piel, hiper- o hipoactividad muscular, reabsorción del tejido graso y resorción ósea. El déficit de volumen resultante, la deflación y la posterior caída del tercio medio facial produce una cara menos atractiva y juvenil. Los procedimientos inyectables en región malar son cada vez más populares y solicitados por los pacientes. El conocimiento de la anatomía de la cara media es fundamental para el inyector. La comprensión de la irrigación facial puede ayudar a disminuir la exposición a la aparición de hematomas y complicaciones vasculares severas. Existen múltiples técnicas de inyección propuestas para el tercio medio, en este artículo presentamos una técnica original, simple, segura y eficaz con resultados satisfactorios y riesgo reducido

Facial aging is a complex synergy of textural skin changes, muscle hyperactivity, fat dysmorphism, bone resorption. The resulting volume deficit and deflation of the mid face produces a less attractive and youthful face. Injectable midface procedures are becoming increasingly popular and requested by patients. Knowledge of the anatomy of the midface is critical for the injector. Understanding the irrigation of the face can help decrease the risk of hematoma and severe vascular complications. There are multiple injection techniques proposed for the middle third, in this article we present a simple, safe and effective technique with satisfactory results and lower risk

Rotation of a Part of the Composite Flap for Simultaneous Gonion Reduction and Malar Augmentation During Rhytidectomy in Asians.

BACKGROUND: The desired facial shape that Asians aim to achieve through plastic surgery differs from that of westerners. OBJECTIVES: The author facilitates facial volume deflation by using the rotation of a part of the composite flap to the malar area resulting in volumetric augmentation during rhytidectomy; simultaneously, a volumetric reduction was implemented in the gonion. METHODS: Extended deep plane rhytidectomy with the rotation of a part of the composite flap was performed in 49 patients, whereas extended deep plane rhytidectomy without the rotation of a part of the composite flap was performed in 20 patients. For the results, the satisfaction survey of the surgery was conducted in all patients and by 2 surgeons during a follow-up visit 12 months later. To assess the surgical outcome objectively, the author used the Allergan photometric midface volume deficit scale to measure the midface volume. The midface contour and degree of projection were analyzed using lateral view photographs of the patients. The measurement of segment CM (distance between the lateral canthus and mouth corner) and segment MA (distance from segment CM to the most protruding malar area) was performed. RESULTS: The patients who underwent extended deep plane rhytidectomy with the rotation of a part of the composite flap reported higher overall satisfaction and achieved more favorable results, as evaluated by the 2 aesthetic surgeons (P < 0.05). The scores on the Allergan photometric midface volume deficit scale showed a significant increase before and after the surgery in both groups (P < 0.05), also as evaluated by the 2 aesthetic surgeons. However, the change in scores was found to be higher in the extended deep plane rhytidectomy with the rotation of a part of the composite flap group. The midface contour and degree of projection showed an increase of 20.6% on the right face and 22.7% on the left face, respectively (P < 0.001). CONCLUSION: Using the rotation of a part of the composite flap during rhytidectomy resulted in overall satisfactory outcomes for all patients. Based on these findings, it can be concluded that the use of this surgical method is beneficial and effective.

The Spatial Relationship Between Coronoid Process and Zygomatic Complex After Reduction Malarplasty.

BACKGROUND: Reduction malarplasty presents challenges in terms of postoperative complications, particularly limited mouth opening. Excessive inward displacement of the zygomatic complex can impinge on the coronoid process resulting in restricted mouth opening. This study aimed to assess the spatial relationship between the coronoid process and the zygomatic complex after reduction malarplasty. METHODS: A retrospective study was conducted, including consecutive patients underwent reduction malarplasty. Radiological measurements were performed before surgery and during the final follow-up, including the coronoid-condylar index, distance between the coronoid process and zygomatic complex, and thickness and density of the temporal and masseter muscles. Clinical and radiographic data were recorded and analyzed. RESULTS: A total of 159 female patients were included with an average age of 28.1 years and a mean follow-up of 6.7 months. The mean coronoid-condylar index was 1:1.4, ranging from 1:0.6 to 1:2.6. Following surgery, the distances between the coronoid process and the anterior zygoma decreased by approximately 1 mm. Additionally, the postoperative distance between the highest point of the coronoid process and the zygomatic arch decreased by around 4 mm horizontally and changed approximately 1 mm vertically. No significant changes were observed in the thickness and density of the temporal and masseter muscles after surgery. CONCLUSIONS: Reduction malarplasty led to a slight decrease in the distance between the coronoid process and the zygoma. The operation generally resulted in proximity between the highest point of the coronoid process and the zygomatic arch. However, we believe that common reduction malarplasty rarely leads to osseous impingement. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Comparison of stress distribution around all-on-four implants of different angulations and zygoma implants: a 7-model finite element analysis.

BACKGROUND: In recent years, zygomatic implants and the all-on-four treatment concept have been increasingly preferred for rehabilitation of atrophic maxillae. However, debate continues regarding the optimal configuration and angulation of the implants. The aim of this study was to analyze the biomechanical stress in implants and peri-implant bone in an edentulous maxilla with zygomatic implants and the all-on-four concept, using multiple implant configurations. METHODS: A total of 7 models consisting different combinations of 4-tilted dental implants and zygomatic implants were included in the study. In each model, a total of 200 N perpendicular to the posterior teeth and 50 N with 45° to the lateral tooth were applied. A finite element analysis was performed for determination of stress distribution on implants and peri-implant bone for each model. RESULTS: Higher stress values were observed in both cortical and trabecular bone around the 45°-tilted posterior implants in all-on-four models when compared to zygomatic implants. In cortical bone, the highest stress was established in an all-on-four model including 45°-tilted posterior implant with 4,346 megapascal (MPa), while the lowest stress was determined in the model including anterior dental implant combined with zygomatic implants with 0.817 MPa. In trabecular bone, the highest stress was determined in an all-on-four model including 30°-tilted posterior implant with 0.872 MPa while the lowest stress was observed in quad-zygoma model with 0.119 MPa. Regarding von Mises values, the highest stress among anterior implants was observed in an all-on-four model including 17° buccally tilted anterior implant with 38.141 MPa, while the lowest was in the including anterior dental implant combined with zygomatic implants with 20,446 MPa. Among posterior implants, the highest von Mises value was observed in the all-on-four model including 30°-tilted posterior implant with 97.002 MPa and the lowest stress was in quad zygoma model with 35.802 MPa. CONCLUSIONS: Within the limits of the present study, the use of zygoma implants may provide benefit in decreasing biomechanical stress around both dental and zygoma implants. Regarding the all-on-four concept, a 17° buccal angulation of anterior implants may not cause a significant stress increase while tilting the posterior implant from 30° to 45° may cause an increase in the stress around these implants.

The accuracy of virtual surgical planning assisted management for L-shaped reduction malarplasty: A retrospective study.

This study aims to evaluate the accuracy of L-shaped reduction malarplasty with bone setback or resection on the zygoma and the mortice and tenon joint structure on the zygomatic arch under the guidance of virtual surgical planning (VSP). Adult patients with zygomatic protrusion or hypertrophy were enrolled and divided. L-shaped reduction malarplasty with or without bone resection and with the mortice and tenon joint structure on the zygomatic arch was conducted either by digital procedures comprising VSP and three-dimensional (3D) printing titanium templates (Group I) or by conventional methods (Group II). Positions of representative landmarks and superimposition models were analyzed by 3D cephalometry. Satisfaction rate and incidences of clinical complications were compared as well. Satisfactory reduction of zygomatic protrusion or hypertrophy was recognized among all 78 patients. Improved symmetry and great surgical accuracy were observed according to the cephalometry analyses. The bone segment movement of virtual plans and actual results in Group I were measured and showed no obvious difference for the inward movement (5.42 ± 0.98 mm vs. 5.33± 0.93 mm, P = 0.6906) and the sagittal overlap (4.77 ± 1.32 mm vs. 4.87± 1.21 mm, P = 0.7386) at the zygoma roots, along with the step length at the long-arm of the L-shaped osteotomy line (2.43 ± 1.11 mm vs. 2.39± 0.89 mm, P = 0.8665). The high resemblance between virtual plans and actual results was depicted via superimposition models. Meanwhile, a higher satisfaction rate (28 in 36, 78% vs. 20 in 42, 48%) and a lower incidence rate of complications (11 in 36, 31% vs. 21 in 42, 50%) were found in Group I. Within the limitations of the study it seems that the application of VSP in reduction malarplasty could significantly contribute to better surgical accuracy and reduced difficulties in the operation, which would be beneficial to patients with zygoma hypertrophy or prominence.

Novel Clinical Anatomical Consideration of the Superficial and Deep Layers of the Deep Temporal Fascia.

BACKGROUND: The deep temporal fascia provides anchoring during thread lifting, which is a minimally invasive face-lifting procedure. However, anatomical studies involving the deep temporal fascia in addition to effective and safe thread-lifting procedures are scarce. The authors clarified the anatomy of the superficial layer of the deep temporal fascia and its surrounding structure using ultrasonography, histologic sections, and cadaveric dissection to propose an effective thread-lifting procedure guideline. METHODS: The authors included 20 healthy young participants from the Republic of Korea. Real-time, two-dimensional, B-mode ultrasonography was performed. Longitudinal scanning was performed along three vertical lines: the line passing through the jugale, the anterior margin of the condylar process of the mandible, and the midpoint between the jugale and anterior margin of the condylar process. Histologic samples from three fresh adult cadavers were harvested from 2.5 cm above and below the zygomatic arch. Eighteen fresh adult hemifaces of cadavers from the Republic of Korea (six men and three women, aged 67.3 ± 7.2 years) were used to confirm the morphology of the deep temporal fascia. RESULTS: The superficial layer of the deep temporal fascia crossed the zygomatic arch and was connected to the origin of the zygomaticus major muscle at the line passing through the jugale. The superficial layer continued inferiorly to the parotidomasseteric fascia at the line passing through the midpoint and condylar process of the mandible. CONCLUSION: This study yielded the novel anatomy of the superficial layer of the deep temporal fascia, and this anatomical structure may be used for an ideal thread-lifting procedure.

Anatomical Relationship between the Inferior Temporal Septum and the Temporal Branch of the Facial Nerve for Clinical Applications.

BACKGROUND: The inferior temporal septum (ITS) is a fibrous adhesion between the superficial temporal fascia and the superficial layer of the deep temporal fascia. This study identified detailed the anatomical relationship between the ITS and the temporal branch of the facial nerve (TBFN) for facial nerve preservation during temple interventions. METHODS: Among 33 Korean cadavers, 43 sides of TBFNs in temporal regions were dissected after identifying the ITS between the superficial temporal fascia and superficial layer of the deep temporal fascia through blunt dissection. The topography of the ITS and TBFN were investigated with reference to several facial landmarks. Regional relationships with the ITS and TBFN within the temporal fascial layers were histologically defined from five specimens. RESULTS: At the level of the inferior orbital margin by the tragion, the mean distances from the lateral canthus to the anterior and posterior branches of the TBFN were 5 and 6.2 cm, respectively. At the lateral canthus level, the mean distance from the lateral canthus to the posterior branch of the TBFN was similar to that to the ITS, at 5.5 cm. At the superior orbital margin level, the posterior branch of the TBFN ran cranial to the ITS adjacent to the frontotemporal region. The TBFN ran through the subsuperficial temporal fascia layer and the nerve fibers located cranially, and within the ITS meshwork in the upper temporal compartment. CONCLUSION: The area of caution during superficial temporal fascia interventions related to the TBFN was clearly identified in the upper temporal compartment, which is known to lack important structures.

Anatomical variations of the zygomaticofacial foramen and its related canal through the zygomatico-orbital and zygomaticotemporal foramina in dry human skulls.

PURPOSE: The aim of this study is to reveal the location of the zygomaticofacial foramina, the variations of their numbers, and their connections between the zygomatico-orbital and zygomaticotemporal foramina. METHODS: Ethics committee approval of our study was received by the Istanbul Medical Faculty Clinical Research Ethics Committee (date:30.07.2021, number:358356). 171 zygomatic bones of unknown gender from the Department of Anatomy, Istanbul University, were included in this study. The number of zygomaticofacial foramina and their connections with the zygomatico-orbital foramen and the zygomaticotemporal foramina were examined. Also, the morphometric distances between the zygomaticofacial foramen were calculated. Evaluation of the data was done with SPPS v.21. RESULTS: The number of zygomaticofacial foramina was found as 299. It was found single, double, three, four, five and six foramina, in 52 (30.4%), 52 (30.4%), 24 (14.03%), 10 (5.85%), 5 (2.93%), 1 (0.58%) zygomatic bone, respectively. Zygomaticofacial foramen was absent in 27 (15.8%) bones. Of these 299 foramina, 129 were found to be connected with zygomatico-orbital foramen and 23 with zygomaticotemporal foramen. It was noted that 147 zygomaticofacial foramina had no connection with any foramina. The distances between the zygomaticofacial foramen and the frontozygomatic suture, temporal process, maxillary process, the lowest point of the zygomatic bone, and orbital rim were found as 25.30 ± 2.81mm, 18.74 ± 3.56mm, 21.56 ± 4.16mm, 18.72 ± 2.57mm, 6.67 ± 3.27mm, respectively. CONCLUSION: Consequently, the location and variations of ZFF are of great importance for maxillofacial surgery and regional block anesthesia. Knowing its location and variations will help prevent complications during any surgical intervention in this region.

Long-term survival and complications of Quad Zygoma Protocol with Anatomy-Guided Approach in severely atrophic maxilla: A retrospective follow-up analysis of up to 17 years.

INTRODUCTION: The objective of the study was to provide long-term clinical outcomes and complications in the severely atrophic edentulous maxillae treated by means of the quad zygoma protocol (QZP) using the Anatomy-Guided Approach (AGA). METHODS: This was a retrospective cohort study of all consecutive patients with severely atrophic edentulous maxilla and insufficient bone height and width in the anterior and posterior regions bilaterally, who underwent rehabilitation with the QZP between May 2006 and December 2021. All patients were followed for at least 1 year. All zygomatic implants (ZIs) were placed by the same surgeon. The primary endpoint of the study was the implant survival rate. Secondary endpoints were implant success rate, prosthesis success rate, complications, and Oral Health-Related Quality of Life using the OHIP-14 questionnaire. RESULTS: A total of 56 patients (men 16, women 40) with 224 ZIs (Nobel Biocare, n = 204; Straumann, n = 16; Southern Implant, n = 4) placement were included with a mean follow-up period 8.8 ± 3.9 years (range, 1.2-17.0). The survival (success) rate was 97.7%. Five ZIs in four patients failed. The mean time between implant placement and failure was 8.6 years (range, 0.5-13.3). All patients received immediate loading with acrylic prosthesis. The successful rates for the definitive prosthesis were 98.2%. Forty-two patients received posterior cantilever for rehabilitation of fixed definitive prosthesis. Local orofacial inflammation (35.7%) and Sinusitis (12.5%) were the most common complications, occurring at a mean follow-up of 10.0 (range, 4.2-14.9) and 10.3 (range, 4.3-16.2) years, respectively. In 48 patients, the mean score of the OHIP-14 questionnaire was 1.7 ± 2.6 with the follow-up period of 9.0 ± 4.1 years. CONCLUSIONS: The rehabilitation of severely atrophic edentulous maxilla using the QZP has shown a predictable and high survival rate in the long term. The implementation of an immediate loading protocol offers potential benefits in stabilizing ZIs with cross-arch stabilization. Moreover, the use of a posterior cantilever in reconstruction can effectively establish functional occlusion through well-distributed ZIs, eliminating the need for additional implant placement.

Successful Reduction of Unilateral Zygoma Fracture Following Bilateral Malar Reduction Surgery.

Malar reduction surgery can increase its susceptibility to fractures in case of trauma. Patients who had malar reduction surgery and sustained a zygoma fracture pose unique challenges for treatment and management. This is a case of a 28-year-old female patient who presented with a unilateral zygoma fracture following bilateral malar reduction and augmentation rhinoplasty 6 years ago. Physical examination revealed a clicking sound when opening the mouth at the right zygomatic buttress and a depressed preauricular area, suggesting arch fracture. Computed tomography imaging demonstrated a loosened screw at the right zygomatic buttress and a depressed arch fracture. She wanted to remove all plates and treat her right fractured zygoma with absorbable materials. Through the bilateral intraoral incisions, the authors removed the plates and screws and reduced the depression with the Langenbeck elevator through the same right intraoral incision without fixation. The reduction was well-maintained without complications based on postoperative plain x-rays 1 month after surgery. She reported that the pain was mostly gone and that she did not hear any abnormal sounds when opening her mouth after the surgery. In this case, if the zygomaticomaxillary buttress is minimally displaced, but the zygomatic arch fracture is significantly depressed, the authors believe that fracture reduction with only an intraoral incision would be enough to achieve an optimal outcome. If the plates and screws used in the previous malar reduction are not well maintained, it may be necessary to remove them.

Volume Redistribution of the Buccal Fat Pad After Reduction Malarplasty.

BACKGROUND: During reduction malarplasty, cheek bulging could be found immediately after zygomatic complex is moved inwards, backwards and upwards. As patient is in the supine position during surgery, the effect of gravity is eliminated, so the only reason for the bulge is the redistribution of the soft tissue in the deep facial spaces. The buccal fat pad, with its main body behind the zygomatic arch and buccal extension in the cheek area, is most likely to be responsible for the bulge. METHODS: 3D buccal extension models were reconstructed from preoperative and long-term follow-up CT images and the volume measured. By comparing the pre- and postoperative 3D models, the shape deviation of the buccal extension and facial soft tissue can be identified. RESULTS: Eleven patients (22 buccal extensions) met the inclusion criteria. Compared with the preoperative buccal extension volume, the postoperative volume increased significantly. By comparing the reconstructed models, the buccal extension volume increase with anteroinferior protrusion can be visually detected, and cheek bulging was clearly identified on the lower face. The bulging area coincided with the projection of the buccal extension on the skin surface. CONCLUSIONS: Reduction malarplasty may cause volume redistribution of the buccal fat pad. Therefore, preoperative assessment of the size of the buccal fat pad based on CT images is recommended. The buccal extension volume increase with anteroinferior protrusion is an important cause of postoperative cheek bulging and should be considered during treatment. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Peri-zygomatic complications on zygomatic implants with or without penetrating the external surface of zygoma: A 2-year retrospective study.

OBJECTIVES: The main purpose of this retrospective study was to assess the difference in the incidence of peri-zygomatic complications (PZCs) when zygomatic implants (ZIs) penetrate or do not penetrate the external surface of zygoma. MATERIALS AND METHODS: This study included 32 patients with edentulous maxillae or potentially edentulous maxillae undergo zygomatic implantation. The patients were divided into the penetration group (P-group) and the non-penetration group (N-group) according to whether the apex of implants penetrated the external surface of zygoma in postoperative CBCT. The extension length, the penetration section of the implants, and the skin thickness at the corresponding position were simultaneously measured. Clinical follow-up was conducted regularly until 2 years after surgery. The occurrence of PZCs (including peri-zygomatic infection, skin numbness, non-infectious pain, and foreign body sensation) was recorded. A mixed effect logistic model was used to compare the difference of complication rate between the P-group and the N-group, and odds ratio (OR) was calculated. Then identify the impact of the extension length, penetration section and skin thickness in P-group with the same model. RESULTS: A total of 71 ZIs were implanted in 32 patients, including 37 implants in the P-group and 34 implants in the N-group. During the 2-year follow-up, a total of 13 implants occurred PZCs, with an overall complication rate of 18.3%. Thereinto, the incidence rate was 29.7% in the P-group, and 5.9% in the N-group (OR = 6.77). In P-group, there was a significant difference in complication rate of different extension lengths, while the penetration section and skin thickness had no statistical significance on the complication rate. CONCLUSION: Under the limitation of this study, to minimize the risk of PZCs, ZI should be placed in a manner that avoids the apex penetrating the external surface of the zygoma.

Combining Patient-specific Implant With Malar Reduction to Repair Mid-facial Asymmetry Caused by Craniofacial Fractures in Asians.

Mid-facial asymmetry caused by bone defect or deformation resulted from craniofacial fracture was a common secondary complication needed to repair. Patient-specific implant (PSI) designed with the unaffected side as a template is a good choice to repair this kind of facial asymmetry. However, in Asians, the broad and prominent zygomatic bone in unaffected side is not an optimal template, because the oval facial shape was considered as a more attractive appearance in Asian esthetic concept. To repair the mid-facial asymmetry and to improve the facial contour, the authors combined PSI implantation with malar reduction in one-stage surgery. The authors referred the facial proportion index (the optimal ratio of mid and lower face was 1.27) as a basis for preoperative precise design to determine the ideal facial shape of unaffected side, and used mirror image overlay technique with the ideal shape of unaffected side as a template to design the PSI. With this surgical strategy, patients not only can repair facial asymmetry but also can get a more attractive appearance.

Long-term evaluation of soft-tissue changes after miniscrew-assisted and conventional rapid palatal expansion using voxel-based superimposition of cone-beam computed tomography scans.

INTRODUCTION: This study aimed to evaluate the soft-tissue changes in the long-term after miniscrew-assisted rapid palatal expansion (MARPE) and conventional rapid palatal expansion (RPE) appliances compared with a matched control group using voxel-based superimposition of cone-beam computed tomography (CBCT) scans. METHODS: A total of 180 CBCTs for 60 patients at 3-time points were evaluated: pretreatment (T1), postexpansion (T2), and posttreatment (T3) for 3 groups: (1) MARPE, (2) RPE, and (3) controls (time-period T1 to T3: MARPE, 2 years 8 months; RPE, 2 years 9 months; control, 2 years 7 months). The voxel-based superimposition technique was used to superimpose the CBCT scans, after which the soft-tissue surfaces were extracted from the superimposed T1-CBCT, T2-CBCT, and T3-CBCT scans. Nine landmarks were identified on the CBCT scans: nasion, A-point, pogonion, right and left alar base, right and left zygoma, and right and left gonion. The coordinates of the 9 parameters were obtained in the x-axis, y-axis, and z-axis for the CBCT scans and subjected to statistical analyses. The changes in the soft-tissue surfaces were also evaluated by color-coded maps for short-term (T2) and long-term (T3) changes. The mean changes from T1 to T2 and T1 to T3 were tested against no change within the groups by paired t test, and the mean changes among the 3 groups were compared with analysis of variance F test with Tukey's Honest significant difference used for adjusting P values for multiple testing. RESULTS: In the short term, both MARPE and RPE led to a significant downward movement of pogonion, left gonion, and lateral movement of the right and left alar base compared with controls at T2 (P <0.05). In addition, MARPE led to a significant downward movement of right gonion than controls at T2 (P <0.05). Moreover, RPE led to a significant downward and forward movement of A-point and downward movement of the right and left alar base than controls at T2 (P <0.05). However, in the long-term, there were no significant differences in the soft-tissue changes among the MARPE, RPE, and control groups. CONCLUSIONS: MARPE and RPE do not lead to significant soft-tissue changes in the long term when compared with controls.

Anti-sagging Method in Reduction Malarplasty: Application of the Bracing System with the Preservation of the Zygomaticus Major Muscle Bony Attachment.

BACKGROUND: Cheek drooping after reduction malarplasty remains a concern for patients. OBJECTIVES: To evaluate the anti-drooping effectiveness of the bracing system technique with the preservation of the zygomaticus major muscle (ZMj) bony attachment and to determine the role of ZMj in anti-drooping. METHODS: A retrospective analysis was conducted of patients who accepted this method in our department from February 2016 to May 2021. Patients' subjective evaluation and two plastic surgeons' objective assessment of photographs were performed. The pre- and postoperative three-dimensional (3D) ZMj models were reconstructed and compared. ZMj length and tortuosity were also measured from 3D models. RESULTS: Twenty-two patients (44 ZMjs) met the inclusion criteria. Most patients (21/22, 95.45%) were satisfied with the postoperative appearance without ageing after reduction malarplasty, except for one feeling slightly older after the operation. The objective scoring results showed no deepening of the nasolabial fold in the majority (20/22, 90.91%) of patients. Two patients were one-grade worse, from score 1 to 2. Upward movement of the postoperative ZMj bony attachment was clearly observed compared with the preoperative 3D model. The significantly reduced ZMj tortuosity (p < 0.001) and the slightly increased ZMj length (not significant) after surgery supported the straightening of the ZMj which was also seen in the 3D comparison. CONCLUSIONS: The bracing system technique with preservation of the bony attachment of the ZMj is an effective and cost-effective anti-sagging method for reduction malarplasty. The ZMj was lifted and straightened after reduction malarplasty, which helped to prevent sagging. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Orbital Decompression: Conceptual Approach for Orbital Volume Expansion.

PURPOSE: To review the advances in the surgical techniques of orbital decompression. METHODS: A literature review of orbital decompression surgery and experience-based consideration of bony areas for decompression. RESULTS: In the 100-year-plus span of orbital decompression literature, multiple incisions and multiple bone and fat removal strategies have been described. In general, bone removal has been conceptualized as consisting of 4 walls of the orbit. However, the orbital bony anatomy is more subtle than a simple box, and considering 6 areas of potential bony removal allows a more nuanced paradigm for clinical decision-making and for understanding various technique descriptions. Historical and current techniques, and surgical planning and decision-making, are described from the perspective of a 6 area paradigm. Potential complications are reviewed. CONCLUSION: A conceptual framework for orbital decompression focusing on 6 potential areas of bone removal provides a nuanced and flexible paradigm for understanding and describing surgical techniques, and for designing individualized surgery. Orbital decompression surgery should be customized to the patient's anatomy and symptoms.

Técnica quirúrgica con Zigoma quad con carga inmediata en maxilar atrófico: a propósito de un caso / Surgical technique with quad Zygoma with immediate loading in an atrophic maxilla: a case report

Introducción: En la actualidad existen técnicas quirúrgicas predecibles y reproducibles para los tratamientos en pacientes con atrofias de rebordes maxilares, los implantes cigomáticos son unas de las alternativas. El trabajo interdisciplinario entre el rehabilitador oral y el cirujano maxilofacial es fundamental para el éxito de la rehabilitación del paciente. El presente caso clínico reporta un paciente de sexo femenino de 60 años, sin antecedentes médicos, donde se observa en el conebean atrofia del reborde alveolar por lo que se planifica cuatro implantes cigomáticos. Objetivo: El objetivo del informe clínico es mostrar una alternativa de tratamiento quirúrgico implantologico en paciente con maxilar atrofiado. Resultados: Los resultados demostraron la eficacia de los implantes cigomáticos en pacientes edéntulos con atrofia del reborde alveolar más la colocación de una prótesis inmediata. Conclusión: Unas de las alternativas de tratamiento en maxilares con rebordes atróficos son la colocación de implantes cigomáticos junto a una buena planificación digital. varios estudios han descrito que la tasa de éxito de estos implantes es muy alta, debido a que la técnica es segura, reproducible y genera alta satisfacción en los pacientes. (AU)

Introduction: At present there are predictable and reproducible surgical techniques for treatments in patients with maxillary rim atrophy, zygomatic implants are one of the alternatives. The interdisciplinary work between the oral rehabilitator and the maxillofacial surgeon is fundamental for the success of the patient's rehabilitation. The present clinical case reports a 60 year old female patient, with no medical history, where atrophy of the alveolar ridge was observed in the conebean and four zygomatic implants were planned. Objective: The objective of the clinical report is to show an alternative implantological surgical treatment in a patient with atrophied maxilla. Results: The results demonstrated the efficacy of zygomatic implants in edentulous patients with alveolar ridge atrophy plus immediate prosthesis placement. Conclusion: One of the treatment alternatives in maxillae with atrophic rims is the placement of zygomatic implants together with a good digital planning. Several studies have described that the success rate of these implants is very high, due to the fact that the technique is safe, reproducible and generates high patient satisfaction, (AU)