Dr. Kenneth Kim has collaborated and worked with leading facial bone surgery experts in South Korea including Dr. Jae-Yoon Seol to improve facial proportion and balance with facial bone sculpting in Los Angeles.
Introduction
The fundamental aspect of facial aesthetics starts with the facial contour. This is because all of the soft tissue on our face rests on the facial bone structure. The ideal face shape is an oval shape like that of an egg. There are many cases where people have cheekbones that tend to be wide and/or the mandible or jaw that flares out. In addition, the chin may be retruded or recessed. These features can make the face appear wide or larger than desired and flat, producing a more masculine and disproportionate appearance. The central aspects of the face (eyes, nose, and mouth) can appear smaller on these types of faces. Facial bone contouring surgery in L.A. addresses these underlying issues and helps restructure the bony architecture to create a more aesthetic and proportionate facial bone shape.
The left image depicts an egg cut in half with a flat surface. The cheekbone surgery converts the face into a 3-dimensionally curved oval shape, similar to a complete egg as seen on the right.Since the advent of facial bone surgery in the 1980s, this procedure has been especially popular in Asia. There have been many surgical innovations over the past 40 years that have increased the safety of the procedure and the speed of recovery. With the development of new technology and innovative techniques, bone contouring surgery can be performed with ease and convenience to patients. In the past, facial bone surgery was performed with limited visibility and no access to soft tissue restoration. In terms of new techniques that have emerged in more recent years, incisions can now be made to maximize surgical exposure allowing for more precise bony manipulation and overlying soft tissue repositioning, which prevents facial sagging/drooping. In terms of technology, we now have advanced surgical instrumentation that allows for ultra-precision cutting that does not disturb the underlying non-bony structures. With all of the innovations, the surgeries can now be performed safely under local anesthesia while the patient is awake. Therefore, the patient is not subject to the risks and postoperative complications that come with general anesthesia.
Ultra-precision facial bone surgery using local anesthesia allows for utmost patient safety and fast recovery.
Cheekbone Reduction (Zygoma / Malar Reduction)
Much of facial beauty is determined by proportion and balance.
The shape of the cheek is under-acknowledged but integral in defining facial beauty. When you look at beautiful faces, one unifying trait is that they tend to have high and oval cheekbones vs wide and outer-flaring cheekbones. Whether the person has double eyelid folds, small or large nose, or overall smaller or larger face, the one key feature that a beautiful face tends to have is an oval facial skeleton. This is because wide cheekbones can make the other facial features appear disproportionate. Wide cheekbones can make the temples appear hollow making one appear older as this is one of the facial characteristics of aging. In addition, wide and flaring cheekbones can make the eyes appear narrow relative to the facial shape and the nose appear smaller and flatter. The reason is when the cheeks protrude outward and forward, it makes the nose appear smaller. The traditional (intraoral) method of cheekbone reduction involves making an incision inside the upper part of the mouth and operating through this opening. The advantage of this approach is that it is a faster procedure for surgeons; however, it can have serious limitations and complications. The main issues with this approach is the limited access to the full zygoma (cheekbone) and inability to reposition the soft tissue. With the intraoral approach, the surgeon can only cut a smaller segment of the zygomatic complex which is from the zygomatic arch to the outer aspect of the zygomatic body. This is because the intraoral approach does not permit access to the inner side or the body of the cheekbone for a larger cut that needs to be mobilized to create an oval face shape. As a result, the smaller cut segment will produce a square and flat cheekbone rather than an oval curve. Additionally, because the access is through the mouth with the intraoral method, the bone fixation can only be placed on the lower aspect of the zygoma. The issue with a low fixation is that it is unstable. Following surgery, movements made with the mouth such as chewing can further destabilize an already weak low fixation causing postoperative complications. When chewing, the force of the masseter (muscle involved in chewing or mastication) pulls on the upper part of the zygoma and can loosen and displace/separate the cheekbone after surgery causing it to flare laterally. The inadequate fixation can also make the cheekbone prone to fracture upon traumatic impact as well as limit mouth opening.
The Advantages of Dr. Kim’s Approach
1. Osteotomy (Cutting of the bone)
Dr. Kim’s technique ensures that a more aesthetically favorable medial (towards the middle of the face) and larger segment osteotomy is made so that the resultant cheekbone has a soft curve oval shape. Whereas the traditional approach involves a more outward, smaller cut which results in a flat and square/angular cheekbone.
The traditional osteotomy involves a more outward cut so that only a smaller segment of the cheekbone is repositioned. The area in red represents the limited osteotomy of the intraoral method. In contrast, Dr. Kim’s method allows him full access to the cheekbone so he can cut and reposition an optimal, larger segment (entire yellow area including the red) which effectively reduces the larger body of the zygoma.
The traditional osteotomy involves a more outward cut so that only a smaller segment of the cheekbone is repositioned. The area in red represents the limited osteotomy of the intraoral method. In contrast, Dr. Kim’s method allows him full access to the cheekbone so he can cut and reposition an optimal, larger segment (entire yellow area including the red) which effectively reduces the larger body of the zygoma.
Preoperative before photos on the left. The frontal view of the patient’s face shows a wide and lateral flaring zygoma. Postoperative after photos of the coronal approach on the right show narrowing of the cheekbone. The coronal approach not only decreased the width of the cheekbones but changed the curvature of the cheekbone from square-shaped (below left) to a more oval shape (below right).
Following Dr. Kenneth Kim’s technique, the postoperative x-ray on the left and the CT scan on the right show a smooth, oval-shaped curve of the zygoma.
2. Bone Stabilization
Additionally, Dr. Kim addresses the issue of inadequate bone fixation by securing the cut cheekbone in a biomechanically favorable position. He achieves a high fixation of the zygoma which secures it in the most stable manner. With the intraoral approach, the fixation of the cut cheekbone is made lower on the body of the cheekbone and is prone to postoperative bone separation and/or inadequate healing which may require revision surgery by the coronal approach.
3. Soft Tissue Elevation / Support
The third issue of facial drooping is solved by the inclusion of soft tissue re-suspension during cheekbone surgery. Any facial bone surgery including cheekbone reduction surgery in Los Angeles involves detachment of the overlying soft tissue of the bone in order to manipulate the bone. Once the soft tissue has been detached, the loosened soft tissue is no longer held in place. Over time, gravity pulls the detached tissue so that it descends, making the patient look older. We can use the analogy of a tent pole to better understand this. Think of the zygoma (cheekbone) as the tent pole. When the soft tissue (tent) has been detached from the bone (tent pole), the tent becomes loose and after the zygoma is repositioned inwardly (tent pole is lowered), the tent lowers further. The traditional method only targets bone cutting without addressing the detached soft tissue, resulting in midface drooping and premature aging after surgery. This will require additional surgery such as a facelift or a coronal midface lift to correct. Dr. Kim’s method not only readjusts the bone in an aesthetically favorable position but also lifts and suspends the detached soft tissue so that the patient appears more youthful. Going back to the tent analogy, when Dr. Kim repositions the zygoma (tent pole), after moving it inwardly, he then moves the bone superiorly (upward) which maintains the tension in the tent. In addition, the detached soft tissue is repositioned upward as well to keep the tent taut.
The muscles and soft tissue are left detached with the intraoral approach, making them less taut and descend downward following surgery (right).
Midface soft tissue drooping is a significant complication with intraoral reduction. Compared to the preoperative midface (left), the postoperative photo on the right shows facial drooping in the midface and jowls which occur when the zygomatic muscles and soft tissue are detached.
Dr. Kim re-elevates and stabilizes the soft tissue and muscles, preventing postoperative facial drooping.Dr. Kim’s method of cheekbone reduction surgery entails cutting the arch and body of the zygoma and repositioning it in 3 directions, 3-dimensionally: inward (posterior), medial (towards the middle of the face), and upper (superior). The traditional approach to this surgery repositions the bone in only 2 directions, inward and medial. After the zygoma has been repositioned, Dr. Kim will smooth the edges to soften the curvature of the cheekbone stabilize the bone, and resuspend the soft tissue.
Dr. Kim’s approach to zygoma reduction effectively converts wide, flaring cheekbones into a narrow, oval-shaped facial contour. In addition, his soft tissue support prevents facial drooping so that the patient appears youthful.
V-Shaped Jaw Reduction Surgery
Mandible or jaw reduction surgery aims to reduce the lateral flaring jaw bone. A wide jaw bone can make a person appear more masculine and square shaped. For those seeking a more feminine jawline, a V-shaped jaw reduction surgery can help you achieve those results.
This surgery involves removal of the flaring/protruding angle of the mandible (jaw bone). Jaw reduction surgery in particular can be a high-risk bone surgery. One reason is the negative sequela which is postoperative soft tissue drooping. The other is more serious which is significant bleeding or even life-threatening bleeding.
There are vessels, specifically the retromandibular blood vessel, that is situated at the back/posterior to the mandibular angle. When approaching this area from the mouth (intraoral), the surgeon cannot see the vessel. Therefore, during cutting, the saw instrumentation can cut the vessel or during the bone detachment after the cut, the vessel can rupture because it has not been fully mobilized from the bone. The inadequate vessel mobilization occurs because the vessel cannot be seen and the angle of the intraoral approach makes it difficult to detach the vessels. Both possible scenarios (saw cutting the vessel or tearing of the vessel during bone removal) can cause significant bleeding that is difficult to stop due to the lack of exposure and visibility. The only way to stop this type of bleeding is to pack it and let it stop over multiple hours of bleeding as it cannot be cauterized. This can lead to significant blood loss requiring a large amount of blood transfusion and can even be fatal. These complications still occur annually since its inception in South Korea and the rest of Asia where jaw reduction surgery is most often performed. Among the plastic surgeons in South Korea, a small percentage perform mandible surgery due to the risks and complications.
Dr. Kim believes that all elective surgeries should be safe and performed without taking these types of risks.
His surgical technique is designed to avoid these complications. He accomplishes this by having direct visualization of the vessels and surgical region and fully mobilizing the soft tissues and vessels away from the bone that is to be cut. After cutting and removal of the bone, the mobilized soft tissue and vessels are undisturbed. Hypothetically, if there is bleeding, because Dr. Kim has a direct view of the vessels, the bleeding can be stopped. Furthermore, the advanced instrumentation he uses also ensures that nothing but the bone is cut by the saw. What this means is the state-of-the-art technology will not cut soft tissue or vessels, thus ensuring another margin of safety.
The traditional approach to jaw reduction involves operating through the mouth and detaching the soft tissue from the bone. When the reduction occurs, the soft tissue remains detached and therefore starts sagging following surgery. Once the soft tissue has been detached, the aging process accelerates postoperatively. Over time, the patient will appear older than their age group and essentially lose the effect of the jaw reduction because the detached soft tissue will descend, creating a rounder, fuller jawline, going against the desired V-shape. Dr. Kim’s approach to jaw reduction surgery entails not only reducing the flaring jaw bone but also repositioning the soft tissue so there is no soft tissue descent or drooping and the patient maintains a V-shaped face.
Genioplasty (Chin Augmentation)
There are two options for those seeking chin augmentation surgery: one is a genioplasty which involves cutting and moving the chin bone forward and the other is placement of an implant which does not require any bony cuts. The advantage of a genioplasty is that it can also improve the appearance of a double chin and create a sharper neckline. In addition, patients who snore can see improvements in snoring as the advanced chin can further open the airways during sleep. For patients who only require chin projection, an implant can suffice. A genioplasty candidate would be a patient who not only wants chin protrusion but also improvement of the neck contour. If indicated, Dr. Kim will obtain radiographic images to further plan your surgery.
Consultation
Every facial plan is unique and tailored to your facial anatomy. During your consultation, Dr. Kim will review before and after photos with you and discuss the variable factors involved with the surgery, so that you fully understand the procedure and can confidently make the decision that is right for you.
Choosing an Expert
Bone surgery requires precision, an aesthetic eye, and a thorough understanding of bone biology and biomechanics. Dr. Kim performs the most advanced surgical techniques that he has received extensive training on and has further developed throughout his career. He understands bone regeneration and healing at the molecular and cellular levels.
As a Howard Hughes Medical Institute fellow, Dr. Kim conducted research on growth factors such as bone morphogenetic proteins (BMP) and transforming growth factor beta (TGF-β) and published numerous peer-reviewed scientific publications on the subject of bone healing at the molecular and cellular levels. In addition, Dr. Kim has worked with the top biomechanical engineers in Switzerland as an AO Research and Development fellow, the first U.S. resident to be inducted as a fellow at the AO headquarters in Switzerland. During his fellowship, he designed and developed instrumentation and surgical processes for facial bone reconstruction utilizing minimally invasive methods.
He worked with the leading craniomaxillofacial reconstructive surgeons in Europe, North America, and Asia. He was also an instructor at the AO Institute, teaching surgeons the fundamentals of facial reconstruction. Furthermore, he received advanced training as a facial trauma and reconstruction fellow at UC Davis Medical Center where he acquired the skill set to perform complex bone reconstruction. He conducted research and pioneered utilization of real-time 3D CT image guided surgery on facial bone to improve surgical precision. He also designed the method to build customized implants for craniofacial defects with ultra-high resolution 3D renderings.
Furthermore, he has trained and collaborated with numerous pioneers of bone surgery in South Korea, where bone surgery originated and where innovation occurs most. Dr. Kim serves as a clinical instructor at Seoul National University and is conducting research on innovative approaches to bone contouring, detailed anatomy of facial nerves and vessels, and improved safety in bone surgery.
Dr. Kim’s Principles to Facial Bone Surgery:
Facial Aesthetics: A surgeon must have a keen sense of aesthetics and be able to operate on all aspects of the face and body. The facial skeleton is in proportion to the frame of the body and our distinguishing features (eyes, nose, and lips) sit on the dimensions of the facial skeleton. A surgeon must be able to distinguish whether to contour the facial bone or to improve the appearance of other features such as the eyes, nose, lips, and facial fat and muscles to achieve desired and optimal results. A plastic surgeon must be able to operate on all aspects of the face and body to create balanced proportions and the most beautiful face for the patient.
Biomechanics: Facial bone exists not only for aesthetics but also as a foundational pillar for the soft tissue and as protection for the brain and vital structures of the face. Therefore, facial contouring surgery which involves cutting the facial bone and reconstructing it must be done in a biomechanically stable form. A plastic surgeon must have extensive knowledge on biomechanical engineering in order to reconstruct the facial skeleton in the most stable manner.
Soft Tissue: Bone surgery without addressing soft tissue is an incomplete surgery. In order to have access to bone for any type of bony manipulation requires degloving or detachment of the surrounding soft tissues (i.e. muscles, fat, vessels, and nerves). Traditional facial bone surgery has been focused on only bone manipulation. Thus, the negative sequela of bone surgery have been early aging due to drooping of the soft tissue. A plastic surgeon must address soft tissue re-elevation in order to have a complete result, where the patient’s face becomes more aesthetically pleasing and more youthful.
Bone healing: Contrary to popular belief, bone is not a static structural entity. The bone is made up of living cells and undergoes constant remodeling which means it goes through growth and degeneration. A facial bone surgeon must have a deep and thorough understanding of the physiology of bone cells and its growth to ensure that they maintain their natural progression of cellular life cycle after bone cutting and reconstruction. In standard bone cutting, tremendous heat is produced during cutting which can burn and kill the living bone cells. A surgeon must use state-of-the-art technology where bone cutting does not deliver additional heat so the bone cells are not negatively affected. In addition, a surgeon must understand how growth factors that the bones release are altered during the healing process and must optimize the bone physiology for rapid and stable bone healing.
Safety: Bone contouring surgery just like any other plastic surgery is an elective procedure. Therefore, a patient should not take chances with safety. Surgical risks include (1) anesthetic risks and (2) surgical complications that arise from the technical aspect of surgery. Dr. Kim places the utmost emphasis on patient safety and designs his surgery from beginning to end with patient safety in mind, so the patient does not need to experience unnecessary risks and complications. Dr. Kim accomplishes this by using local anesthetic, thus avoiding the need for general anesthesia or IV sedation, and by practicing ultra-precision surgery leading to minimal bleeding, thus providing for clear visualization. With safety in mind, facial bone contouring surgery can be performed with ease and comfort for the patient and provide rapid recovery.
Medical Publications
A Comprehensive Assessment of Soft-tissue Sagging
after Zygoma Reduction Surgery through Artificial
Intelligence Analysis
Received for publication March 4, 2024; accepted June 21, 2024
Background: Overdevelopment of zygomatic bones often results in protrusion and flaring of the midfacial region. This makes the face appear squarer than the more favorable oval shape. Therefore, zygoma reduction surgery has become a commonly performed procedure in patients seeking to obtain an ideal facial shape.
Facial soft-tissue ptosis is one of the main complications of zygoma reduction surgery. Previously, the evaluation of cheek soft-tissue ptosis was subjectively based on patients and surgeons. Our study aimed to provide an objective evaluation of softtissue sagging in the cheek region after zygoma reduction surgery using artificial intelligence (AI).
Optimizing Esthetic Outcomes and Bone Stability:
Chin Advancement Through Inverted V
Osteotomy
Received February 24, 2024.
Accepted for publication April 3, 2024.
Abstract: Traditional horizontal osteotomies for small and short chins often yield suboptimal results due to limited bone advancement, resulting in deep labiomental folds and heightened bone resorption risks.
The Rationale of Coronal Approach to Malar/Zygoma Reduction
Received for publication July 24, 2023; accepted August 16, 2023.
Background: Malar/zygoma reduction is an effective procedure to change a broader, flatter facial appearance to an oval facial shape. Of the intraoral and coronal approaches, the intraoral is the more commonly used technique than the coronal, due to the perception that complications with the coronal approach are significant, and intraoral results are satisfactory. We compared the postoperative
effects of both approaches.
