Orbital Rim Injury During Reduction Malarplasty

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To the Editor: Asians usually undergo reduction malarplasty for a smoother, egg-shaped midface, because oval facial shape is considered to be more popular. Since Sumiya et al1 reported on reduction malarplasty using osteotomy and repositioning of the malar complex through an intraoral and preauricular incision, many surgeons use this approach for zygoma complex reduction. Articular tubercle is considered to be appropriate site for arch osteotomy, and could be approached by preauricular approach.2 Regarding the location of zygomatic body osteotomy, inferolateral orbital rim through intraoral incision is usual site for osteotomy; however, the osteotomy line is determined based on the severity of the malar prominence of individual.3 In a patient with a moderately to severely prominent zygoma, the osteotomy line is determined from the zygomaxillary suture to the frontozygomatic suture, whereas in the patient with a mildly prominent zygoma, the osteotomy line in slanted between the zygomaxillary suture and the lateral side of the frontozygomatic suture. There is a possibility of orbital rim injury if the osteotomy line is located too medially in a patient with moderately to severely prominent zygoma.4
We recently experienced a patient who has underwent reduction malarplasty in another hospital, and zygomatic body osteotomy line, which penetrated orbital wall, has been found on computed tomography. Computed tomography scan showed orbital rim injury, which penetrated lateral and inferior orbital rim which might be happened by previous zygomatic body osteotomy (Fig. 1). The decision for zygomatic body osteotomy site is very important for surgeons during reduction malarplasty.
We suggest our own approach for zygomatic body osteotomy. We palpate zygomatic arch and lateral orbital wall externally and make a linear marking at posterior margin of lateral orbital rim (Fig. 2C, a) and upper margin of zygomatic arch above skin before incision (Fig. 2C, b). We also palpate the most prominent part of zygomatic body (Fig. 2C, c), and make a marking 1 cm medial to this point. Between upper margin of zygomatic arch and posterior margin lateral orbital rim, we make a linear line connecting to 1 cm medial to the most prominent part of zygomatic body (Fig. 2C, d). After that, through oral incision, we put periosteal elevator to reach the zygomatic body, and make a line following previously marked line on zygomatic body surface by surgical pencil. And we set this parallel line as a limit for zygomatic body osteotomy to avoid orbital wall injury. Observing the lines on zygoma, we never invade the medial limit to make a zygomatic body osteotomy. This approach alerted us about orbital complication could happened during osteotomy, and was always helpful in preventing orbital rim injury.
Following this procedure, we did not experience any orbital complication among total 261 patients with reduction malarplasty (from July 2013 to June 2016). Although orbital wall injury during reduction malarplasty is not a usual complication, it can bring about serious disability to the patients, and surgeons always pay attention to potential possibility of orbital wall injury during zygomatic body osteotomy.
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