English edition

malarplasty

Malarplasty is usually described as a bone operation, and the description is accurate as far as it goes. The zygomatic body is reduced, the arch is moved inward, the segment is fixed in its new position. What it leaves out is everything lying on top of the bone. Skin, subcutaneous fat, the SMAS and the retaining ligaments that tether them were all draped over a surface that has just changed shape. Whether they follow the bone inward or lose their support and settle downward is a separate question, and it is the one this page is about.

01What this page answers, and what it does not

The temporal endoscopic approach used at this clinic was established by its founding director, Dr. Jung Su Lee. Access, osteotomy and fixation belong to that half of the operation: where the incision goes, how the arch is cut and rotated, how the segment is held.

This page begins one step later. It assumes the bone has been moved competently, and asks what happens to the soft tissue afterwards. Why a cheek can descend. Why a midface can read as hollow. Why the face does not narrow by the millimetres on the plan. A patient already operated on and unhappy usually needs this one.

02Why the cheek can descend after malarplasty

The usual assumption is that a cheek droops because the bone was taken too far in, leaving the tissue above it with nothing to sit on. That does happen. More often, as the clinic describes it, the descent has less to do with the final position of the bone than with what had to be released in order to reach it.

The tether, not the platform

Fibrous bands run from the periosteum of the zygoma outward to the dermis. They are why the cheek sits where it does instead of sliding down the face under its own weight. Reaching the body and the arch means passing through or alongside those bands. Once a band is divided, the tissue it held is free to move, and the direction it moves under gravity is downward.

This is why the release matters more than the millimetres. A bone moved 4 mm inward beneath an envelope that is still largely tethered, and the same bone moved 4 mm inward after a wide release, are two different results on an identical radiograph.

The bone can be in exactly the right place and the face can still be wrong. What decides that is everything lying on top of it.

Swelling as a load

Swelling is not neutral. For the weeks it lasts it adds weight to tissue whose attachments have just been divided, and the clinic’s stated view is that heavier and longer swelling raises the likelihood of descent. It is one reason the question has my cheek dropped cannot honestly be answered in the first month.

The deep cheek fat

As the clinic describes it, the deep cheek fat runs from the temporal region, passes deep to the zygoma and reaches the cheek, and its volume differs considerably between people. Where there is a lot of it, it can read as fullness beforehand and contribute to descent afterwards, so a portion is sometimes removed at the same operation. How much, if any, is a judgement about that person’s fat distribution and the balance of the face.

How wide the dissection had to be

The wider the dissection, the more retaining ligament is released, and the more tissue is free to descend. The clinic’s stated approach is to dissect only as far as the planned movement requires, and to combine that where appropriate with liposuction, partial removal of deep cheek fat, and titanium plate fixation to stabilise the moved segment. None of this eliminates descent. It changes the odds.

03Does reducing the zygoma make the midface look hollow?

It can, and the mechanism is not mysterious. The bone was occupying space. Moving it inward vacates that space at once, while the tissue above takes months to settle into the new contour. In a face with limited midface volume, or thin skin over the zygomatic body, the vacated space reads as a shadow.

The distinction that matters is between the anterior zygoma, which carries projection at the front of the cheek, and the lateral zygoma and arch, which set the width seen from the front. Reducing width at the arch without disturbing anterior projection is a different operation from reducing the body, and apparent hollowing follows the second far more often.

The useful question at consultation is therefore not how many millimetres can come off, but where the fullness a patient dislikes actually sits, and how much soft tissue is available to drape over what is left. Where volume is scarce, the plan may move less bone, or split reduction and volume restoration into two stages.

A midface that looks hollow after malarplasty is not always a volume problem. Tissue that has descended leaves the area above it looking empty even when nothing has been lost. Adding volume to a descent, and lifting a genuine deficiency, both fail. The cause is established before anything is added.

04How age and skin quality change the plan

Age changes the answer to the same surgical question. Collagen and elastin decline, skin and SMAS recoil less, and released tissue does not draw back toward its original position as readily. The dissection that leaves a woman of 24 with her cheek where it was can leave a woman of 48 with a cheek visibly lower.

The clinic’s stated position is that the plan is set by examination rather than by a date of birth. A patient of 40 with firm tissue may tolerate a wider release than a patient of 32 with thin, slack skin.

05Operating on a face that has had fillers or fat grafts

A history of injection is common and by itself is rarely a reason not to operate. What matters is not the number of syringes but the state of the tissue now. Several sessions of hyaluronic acid filler years ago may have left nothing. One session of a semi-permanent material, or a fat graft that fibrosed, can change the whole midface.

Material left in the midface, and the scar around it, changes three things. The planes separate less cleanly, so dissection that should stay in a known layer meets tissue that will not divide where it should. The landmarks shift, because fibrosed graft or migrated filler sits where nothing is supposed to be. And released tissue no longer behaves predictably, so the assumption that the envelope will redrape becomes unreliable.

Ultrasound maps what is there by layer and depth; CT is used where the question involves bone. Where adhesion is extensive, the sensible order may be to deal with the injected material first, let the tissue settle, and reassess the bone afterwards.

06What a zygomatic CT is actually read for

A facial bone CT is not ordered to confirm that a patient’s cheekbones are prominent. That is visible without it. It is read for what examination cannot supply.

Position and shape

Where the zygomatic body sits relative to the maxilla and the arch, and which is producing the width the patient dislikes.

Thickness of bone

How much bone is available at the planned osteotomy and fixation sites.

Left and right difference

Whether a visible facial asymmetry corresponds to a real difference in bone position, and how large it is.

Arch and body

Whether width comes from the arch, the body, or both, since the corrections differ.

Previous surgery

Osteotomy lines, state of union, plate position, and any step-off from an earlier operation.

What a CT does not show is soft tissue behaviour. It will not say how far a cheek will descend, how elastic the skin is, or how much a fat pad will move. Those are examination findings, and reading the two together is the point of ordering the scan.

07Why the face does not shrink by the amount the bone moved

A plan may call for the arch to come in by several millimetres on each side, and a patient may reasonably expect the width of the face to fall by the same amount. It does not, or not immediately, and often not entirely.

Skin, subcutaneous fat and SMAS are draped over the bone. They are not bonded to it. When the underlying surface narrows, the envelope has to contract or redistribute to follow, and it does that slowly and incompletely. Part of the early difference is swelling, which resolves. Part is envelope that never takes up the slack, and shows as fullness lower on the cheek.

How closely the outside follows the inside depends on the same variables as descent: age, elasticity, how much was released, how much fat lies over the area. It is why a result is not judged at six weeks. Swelling having left the face is not the same as tissue having finished settling.

08When malarplasty and a facelift are considered together

The two are considered together in a narrow set of circumstances, not as a package offered to everyone.

• Descent is already present, and reducing the bone will make it more visible rather than less.
• The release required is wide and the tissue has low elasticity, so significant descent is expected.
• Part of the complaint is heaviness at the jawline or depth of the nasolabial fold, which malarplasty alone does not address.
• A previous malarplasty has left descent that is soft-tissue in origin, with bone in an acceptable position on CT.

Where the two are combined, the operation and the anaesthetic are longer, and the recovery is not the sum of two recoveries but closer to the longer of them with more swelling. Where none of those conditions applies, doing the bone work alone and reassessing once the tissue has settled is usually the better order.

09When asymmetry remains

Perfect symmetry is not an accurate description of any face, before or after surgery, and small differences are normal. The question worth asking is what kind of asymmetry is present.

1. Bone. The two sides were already different, the two osteotomies did not produce equal movement, or one segment has shifted. CT answers this.
2. Soft tissue. Bone positions match, but one side has descended further, carries more fat, or is losing its swelling more slowly. Examination answers this, and time answers part of it.
3. Both at once. Common, and the reason the two are separated before anything is planned.

Timing matters here more than anywhere else on this page. Swelling does not leave the two sides at the same rate, and an asymmetry obvious at eight weeks may be much less obvious at six months. Revision is not planned on an unsettled face, unless imaging shows a problem with bone position or union that will not improve on its own.

Where the difference is genuinely in the bone, a revision addresses the bone. Where it is in the soft tissue, re-cutting bone will not correct it, and the correction is a lifting or volume procedure. Treating those two as one problem is the most common reason a second operation disappoints.

10Where the measuring habit comes from

None of Dr. Kang’s published papers are about the zygoma. Six are in print, on nasal bone fracture, postoperative pain after breast augmentation, volume change in breast reconstruction flaps, and a classification of gluteal ptosis. None is offered as evidence for facial contouring.

Their method is another matter. In 2017 he graded closed reduction of nasal bone fractures on CT in 313 patients by fracture type, and set those objective results against what the same patients reported; the two correlated. In 2021 he measured the muscle and the fat portions of one flap separately, in 16 patients after breast reconstruction, and the two changed at different rates. That second finding is why this page separates skin, fat, SMAS and bone rather than discussing the cheek as one thing.

Neither study shows anything about malarplasty. They are the origin of a way of looking, and that is the only claim made for them.

Malarplasty: the soft tissue side

What this page covers

What happens to the tissue over the zygoma after the bone has been moved

Access and osteotomy

The temporal endoscopic approach established here by Dr. Jung Su Lee, founding director

Assessed before surgery

Facial bone CT for position, thickness, union and left-right difference; examination for skin quality, existing descent and fat distribution

Stated measures against descent

Dissection limited to the planned movement, liposuction where indicated, partial removal of deep cheek fat, titanium plate fixation

Not answerable by CT

Soft tissue elasticity, likely descent, how far the envelope will redrape

When a result is judged

After swelling has substantially resolved; the timing varies between people

Responsible surgeon

The clinic advises which surgeon is responsible at the time of consultation

This page describes how decisions are approached. It does not establish that any individual is a candidate for malarplasty, and makes no claim about the outcome of a particular operation. Descent, apparent hollowing and residual asymmetry can occur despite every measure described here. Where a statement is the clinic’s own description of its method, that is said.

No. Whether descent occurs, and how noticeable it is, depends on how much retaining ligament had to be released, how much deep cheek fat is present, and how elastic the skin and SMAS are. It is a probability that can be influenced, not an inevitability.

No approach removes the possibility. The stated measures are to release only as far as the planned movement requires, and to address the deep cheek fat where it is contributing. Those change the likelihood; they do not promise a result.

Not in the first weeks. The judgement is made once swelling has substantially resolved, and that timing varies between people. An asymmetry obvious at two months is frequently smaller at six.

CT shows the position, thickness and union of the bone, and whether the two sides differ. Examination shows how far the soft tissue has descended and how it responds to being lifted by hand.

Not necessarily. The cause is established first, and the degree matters. Where the bone is in an acceptable position and the descent is mild, observation may be reasonable. Where it is significant and soft tissue in origin, a lifting plan is discussed.

Often, yes, but adhesion changes the dissection and the planning. Imaging and examination come before the plan is fixed, and where adhesion is extensive the sensible order may be to address the injected material first.

The tissue over the bone does not move with it immediately, and some of it never takes up the slack. Part of the difference is swelling and resolves. Part is the envelope, and how far that follows depends on age, elasticity and how much was released.

ReferencesKang CM, Han DG. Objective Outcomes of Closed Reduction According to the Type of Nasal Bone Fracture. Arch Craniofac Surg. 2017;18(1):30-36.PMID 28913300Reduction of nasal bone fractures graded on CT by fracture type in 313 patients. Cited for the method of grading a bony result on imaging rather than by impression. It examines nasal bone, not the zygoma.Kang CM, Han DG. Correlation between Operation Result and Patient Satisfaction of Nasal Bone Fracture. Arch Craniofac Surg. 2017;18(1):25-29.PMID 28913299The same 313-patient cohort from the other side: the CT outcome and the patients’ own satisfaction correlated. A second analysis of one cohort, not a second cohort.Kang CM, Shim JS, Park SH, Jeong YJ, Seol KH, Kwak SG. Volume Change of Muscle and Fat Portions of Latissimus Dorsi Myocutaneous Flap after Breast Reconstruction. Plast Reconstr Surg Glob Open. 2021;9(4):e3536.PMID 33868878Sixteen patients after breast reconstruction; muscle and fat portions of one flap changed volume at different rates. Methodological background only, not evidence for any facial operation.ContinueAdjacent workFaceliftMaterial that has sat in a face for years holds tissue in a position it would not otherwise hold. Take it out and…The surgeonDr. Chang Min KangCleft lip and palate, reconstruction, facelift, and the removal of material injected into a face years earlier. The…The surgeonThe Measured PracticeSix peer-reviewed papers on the breast, the buttock and the nasal bone. The subjects have almost nothing in common.…