Patients who had previous conventional reduction malarplasty but were dissatisfied with the results seek secondary operation for further improvement as the zygomatic body and the inferolateral orbital rim continued to appear prominent. Some patients who complain of prominent cheekbones, which were assessed as difficult to be reduced by using conventional methods, are also proper candidates of orbito-malar complex reduction surgeries. All patients are analyzed by physical examination, along with clinical photographs and radiographic studies. Zygomatic arch view and three-dimensional computed tomography images are used for radiographic inspection to assess the extent of change before and after surgery. All patients have a detailed consultation with the surgeon to discuss their requirements and to understand the practical goals of the procedure before surgery.

All patients are given general anesthesia. Orotracheal intubation is preferred at ID hospital, but nasotracheal intubation can be used. Intraoral, preauricular and subciliary, or transconjunctival approaches were universally applied. Intraoral and preauricular incisions are equal to those of conventional reduction malarplasty described at the previous chapter. Through these incisions, the soft tissues are elevated superiorly and laterally at the subperiosteal plane to expose the anteroinferior portion of the maxilla, zygomatic body, infraorbital foramen, and zygomatic arch with care taken to prevent infraorbital nerve injury. In contrast with conventional reduction malarplasty, dissection aims at exposing the zygomaticomaxillary suture as the osteotomy is performed along this suture line. For the subciliary approach, a skin incision is made inferior to the lower eyelashes, almost along the full length of the eyelid. To reach the orbital rim, a skin-muscle flap is elevated inferior to the lower eyelid. Preseptal transconjunctival approach is also useful especially in patients favoring invisible scars as possible. Lateral canthotomy can be considered to minimize the risk of periorbital tissue injuries and secure lateral orbital rim exposure. After the periosteum is incised, subperiosteal dissection was performed to expose the lateral and inferior aspect of the orbital rim. The extent of dissection of the lateral orbital rim is narrower than in conventional tripod osteotomy surgery, and the usual exposure of the zygomaticofrontal suture is not mandatory as the level of osteotomy and burring is inferior to the location of the suture.

Conventionally, there are two surgical methods described for improving the prominent inferolateral orbital rim: one, shaving the orbital rim with a burr and, the other, mobilizing the orbital rim by tripod osteotomy. The shaving method is less invasive, but the rasping and burring of the orbital rim may be traumatic to the periorbital soft tissue, and the degree of improvement achieved may be inadequate. The tripod osteotomy, though more invasive, is considered to be more effective and reliable in achieving the desired improvement. Surgeons should make a decision which method is effective and efficient.