Is Malar Augmentation Required to Correct Malar Deficiency With Le Fort Advancement?

Petersen C¹, Miloro M²

¹Resident, ²Professor and Head

University of Illinois at Chicago, Department of Oral and Maxillofacial Surgery, Chicago, Illinois

Statement of Problem: Many patients with anteroposterior maxillary hypoplasia may also have significant malar deficiency. As a result, preoperative planning for maxillary advancement surgery often includes consideration for simultaneous malar augmentation, but patients who have Le Fort advancement without malarplasty do not usually complain of malar deficiency postsurgically, and rarely undergo subsequent malarplasty. The aim of this study is to compare pre- and postoperative profiles of subjects who underwent orthognathic surgery that included Le Fort I advancement, with and without malarplasty, to assess the subjective perception of malar eminence projection alterations.

Materials and Methods:Subjects who underwent maxillary advancement, with and without malarplasty, at a single center by one surgeon (MM) from January 2013 to October 2015 were assessed. The non-malarplasty cohort served as the control group. Pre- and postoperative photos with questionnaires were created and assessed by two groups: oral surgery faculty and residents (professional group), dental assistants and ancillary staff (layperson group). The photos were arranged randomly and participants were asked to score each photo using a visual analogue scale (VAS) to assess the malar region (range: 1 = deficient to 5= excessive). In a second questionnaire, pre- and postoperative photos were shown side by side and participants were asked to indicate which subjects they perceived to have undergone malarplasty.

Methods of Data Analysis:Data from the surveys were recorded and averaged. Changes in perception of malar eminence projection were analyzed and correlated with the presence or absence of malar implants, the amount of maxillary advancement, and patient demographic data to determine significance (p<0.05).

Results:Of 43 patients that underwent maxillary advancement surgery, a total of 23 met the inclusion criteria. Seven of the 23 subjects received malarplasty at the time of maxillary advancement. The average age of all patients was 18.2 years (range 14-28) and 52% were female. Preoperative photos were taken within one month of surgery and post-operative photos were obtained between four and eight months postoperatively. There were 27 survey participants including 15 professionals and 12 laypersons. On average, 100% of subjects were perceived as having an increase in malar eminence projection postoperatively. In the non-malarplasty cohort, laypersons noted an average increase in projection (based upon the 1 (deficient) – 5 (excessive) VAS scale) from 1.90 to 2.50 and professionals noted an increase from 2.14 to 2.59 (p<0.05). In the malarplasty cohort, laypersons noted an average increase in projection from 1.86 to 2.69 and among professionals an increase from 1.96 to 2.73 (p<0.05). In the second questionnaire, laypersons tended to overestimate the number of malarplasty subjects. Alternatively, professionals were better able to accurately assess when malarplasty had not been done.

Outcomes Data:The perceived change of the malar area following Le Fort I advancement, with and without simultaneous malarplasty, was the primary outcome variable according to the VAS scale used. Additionally, the amount of maxillary advancement was correlated with perceived subjective changes in the malar region.

Conclusions:The decision for malar augmentation at the time of maxillary advancement should be considered on an individual basis since this study indicates there will be subjective improvement of the malar region with Le Fort advancement alone without malarplasty.

References:

1. O’Ryan, F, Lassetter, J: Optimizing facial esthetics in the orthognathic patient. J. Oral Maxillofac. Surg 69:702-715, 2011

2. Robiony, M et al: Simultaneous malaroplasty with porous polyethylene implants and orthognathic surgery for correction of malar deficiency. J. Oral Maxillofac Surg 56:734-741, 1998