Seen from the frontal view, the bi-zygomatic width is the widest dimension of the face, followed by the jawbone angles (bi-gonial width), which are again supposed to be somewhat wider than the bi-temporal areas above the cheekbones.
The zygoma or cheekbone area is an essential consideration in the overall aesthetic dimension of a face. Unconsciously, we look at the cheekbones in relation to the boundaries of the face. Well-defined cheekbones bring out distinction and allures in facial appearance. Prominent malar eminences are a hallmark of beauty in many cultures, and fullness of the malar region conveys a youthful appearance. Flat cheekbones make a person’s face dull and inexpressive, and can even provoke a depressive look.
As a rule of thumb, the point of maximum cheekbone prominence is 10mm lateral and 20mm down from the lateral palpebral eye corners.
In profile view, the relation to the eye globe position is paramount. The bone rim, directly underneath the eye, is normally on the same line as the globe, but the soft tissue cheek prominence is two to four millimetres in front of the globe and the infraorbital bone. This gives the cheekbone area its fullness and its notorious convexity.
To evaluate the cheekbones more academically, there are several methods published by different authors in the medical literature, some a bit more sophisticated than others. Probably the most popular is the analysis by Hinderer. Hinderer focused on the ideal light reflection to be kept in the outer quadrant formed by the intersection of two virtual lines. One line runs from the lateral eye corner to the angle of the mouth, and an intersecting line goes from the nasal crease to the ear orifice.
Cheek bones can be built up permanently using two basic approaches. The two techniques can easily be combined.
- We apply onlay material directly to the bone area, this material is intended to become ‘part of the bone’.
- Or tissue filler augmentation (preferably lipofilling) in the cheek’s soft tissues. This fat is intended to become a part of the overlaying tissues. A combination of the two is possible.
Option 1: onlay material applied directly on the bone area
In our office this surgery is usually performed at the same time as a Le Fort I osteotomy and through the same incisional approach. However, it can be done as a single separate procedure through a small incision inside the mouth above the gum line. A tunnel is then created on the bone to expose the cheekbone area. Dr Defrancq uses a technique with hydroxyapatite (or simply H.A.) granules, which are placed on the bone and sutured within a watertight overlying soft tissue closure. The granules are mixed with a human glue (tisseel) and delivered by small syringes. The advantage is that the H.A. can be laid down smoothly and exactly, with the build-up where needed in anterior, lateral or infra-lateral direction, starting from the lateral orbit downwards. Cheekbone implant surgery can be performed in the office with local anaesthesia and IV sedation or under general anaesthesia.
Option 2: Tissue fillers in the soft tissues of the cheek (lipofilling)
A more limited cheek augmentation can be accomplished using fat transfer. It is also possible to correct a significant cheekbone augmentation by using H.A. complemented by fat transfer. See the lipofilling section.
Frequently asked questions
- Why is it that cheekbone augmentations are frequently done at the same time as orthognathic surgery?
The cheek bones are not an isolated island in the face and flat cheekbones are often the blue print of growth abnormalities in the upper jaw. Most young people with flat cheekbones have something wrong with their jaws and teeth positions. Those patients have a long face or an end-to-end bite, or a class III (reversed bite) with mid-face deficiency, for example.
In conclusion, most patients with flat and inexpressive cheekbones have an orthognathic deformity. This is most often a developmental deformity, i.e. occurring during the growth process of the face, and since it is anatomically located in the same facial area they have a profound and direct influence on the cheekbones. During growth with an excessive vertical or retro-directed clockwise vector, the cheekbones are, so to speak, sucked in a mannerism fashion within the same vertical vector line in downward and retro direction.
- Can the cheek bone augmentation also be done with silicone or medpor?
Some surgeons use preformed implants in silicone or medpor material. Exact localisation and fixation on long term is a challenge. Silicone implant is quite easy to remove whenever necessary. Medpor is hard to remove.
- Can the same result be achieved with an osteotomy?
Some surgeons perform an osteotomy with lateralisation of the bone. It is more invasive. The osteotomy certainly gives a lateral dimension, but not more anterior dimension. Symmetry, fixation, and frontal volume is the challenge with an osteotomy.
- What kind of material is hydroxyapatite?
Hydroxyapatite granules are processed from sea corals. Up till now, it is the material implant that most closely resembles natural bone. It has both the sponge-like structure and chemical composition of bone, so the body accepts it completely as part of its own (the dry weight of the human body is hydroxyapatite, exactly the same formula!). Hundreds of patients have been treated for cheek bone augmentation with this material in our clinic. Dr Defrancq has many biopsies available of this area built up with H.A. granules, proving that bone becomes embedded between and inside the porous granules after one year. And so, the structure becomes a bony part of the facial skeleton for real. Could it be more ideal?