Facial Asymmetry

Q: Dr. Eppley, I have what to me is extreme facial asymmetry, and have wondered all of my life if anyone could correct my face. I destroy all pictures of myself I am so ashamed of what I look like. Is there anything you can do for me? If I take a reverse picture using a mirror, I look pretty normal ( pictures attached). Is there a way I can look like that without using a mirror to reverse my image? Thank you very much. 

A: Thank you for your inquiry and sending your pictures for assessment of your facial asymmetry. In critically looking at your pictures, I see four very specific difference between the two sides of your face. They include the following and are based the way I am seeing the picture (which may well be reversed in real life based on how the picture was taken)

1) Cupid’s bow asymmetry of the upper lip. The right of the cupid’s bow is lower than the left. (correction – cupid’s bow vermilion advancement)

2 Nostril asymmetry. The left nasal base is wider and more elevated than that of the right side. (correction – left alar base lowering and inward relocation)

3) Left eye asymmetry. You have a significant left lower eyelid ectropion/sagging) This is probably the one facial feature that is the oat obvious. (correction – lateral canthoplasty and lower eyelid repositioning)

4) Left eyebrow asymmetry. The left eyebrow is lower than the right. (correction – left endoscopic browlift)

When these four facial asymmetries are out together it can create a rather significant facial asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, What if anything can be done for my orbital and overall facial asymmetry? Its clearly affected the entire side of my face not just my eye. I have to tilt my face for pictures and even then its way off. Thoughts? The second pic is with my head tilted…I am tired of having to do so and has really hindered my confidence my entire life.

A: Thank you for your inquiry and sending your picture. Eye asymmetry (orbital dystopia)  rarely occurs in isolation and is often part of an overall facial asymmetry. The brow bone, cheek, nose and even the jawline may be lower or deficient on the ‘lower eye’ side. Tilting the head helps ‘lift’ the deficient side to make it more even. The key is this type of facial asymmetry is to pick the procedures that would make the greatest difference. The hardest choice is deciding what to do with the eye as this is the most important part of the facial asymmetry correction. The eye must come up as well as the outer corner of the lower eyelid. One caution here is to keep an ‘eye’ on the position of the upper eyelid so the raised eye does not get buried under the upper eyelid creating a pseudoptosis appearance.

Vertical brow bone reduction, cheek augmentation and jawline reduction/widening and a straightening rhinoplasty are all other options to consider in facial asymmetry correction.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Reshaping

Q: Dr. Eppley, I am interested in facial reshaping. I absolutely hate my face and how it looks different on both sides. What would I need done to make myself look more symmetrical. I only like the left side. I hate people even looking at my right side and I wont ever take face forward shots. I attached a picture to show you. I just really hate it and very insecure. I feel like everyone can notice that one side of my entire face is higher than the other and that one eye is bigger than the other.

A: Thank you for sending your picture and expressing concerns. I can clearly see the differences between the two sides of your face and most, if not all, of the asymmetry is in the periorbital region. (around the eye) Because the picture you sent may be inverted (mirror image) I am not sure which is the right or the left. But there is one side where the eye is bigger and the brow bone and cheek bone on that side are more developed. While the opposite side has a smaller eye and a slightly lower brow bone edge and smaller cheek.

When it comes to facial asymmetry and facial reshaping surgery that involves the eye, the bigger eye or higher side can not be lowered. Only the smaller side can be made more open or raised. Thus on the smaller side the brow bone can be shaved to raise it, the cheek augmented to make it fuller, the eyeball raised to make the pupil more even with the other side and the upper and lower eyelids raised to expose more of the white of the eye.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Dr. Eppley, I am interested in facial asymmetry surgery. I have an an asymmetrical face due to irregular growth of the jaw bone. Will the chin reduction on the right side correct it? I also notice that the right side of my face has less soft tissue so will the jaw angle implant balance out my face? Thank you.

A: Your facial asymmetry correction surgery approach certainly appears to be the correct one. Based on your pictures, the right side of the chin is longer and the width of the right jaw angle is more narrow than those two jawline areas on the left side of your face. So a right vertical chin reduction and right lateral width jaw angle implant should create improved facial symmetry. The only question is whether one wants to make the judgments for the amount of vertical chin reduction an the amount of width needed in the jaw angle up to the surgeon’s aesthetic sense or whether to make a more scientific quantitative assessment of them. That may be best done using a 3D CT scan or, at the least, get a panorex and lateral cephalometric x-rays to make some preoperative measurements.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, I am interested in facial asymmetry correction. My son was born with torticollis. He had physical therapy for a few years but he still is self conscious about his eyes and the fact that his nose and chin don’t align. Is this something that you could improve?

A: It can be seen that he has right sided facial shortening type facial asymmetry. The vertical length of his right face from eyebrow to chin is shorter than the left side. As a result there is a deviation of twisting of the face to his right. Because of his congenital torticollis he may or may not have a chronic head tilt to the left side. My comments will be based on that he does not.

The top and bottom of the vertical facial axis is the key. A right endoscopic browlift with upper blepharoplasty (to create a visible supratarsal fold like the left side) is what is needed superiorly. Inferiorly the chin need to be rotated over to the left with a vertical opening wedge on the right to straighten and lengthen it. I think these would be the two key areas to improve for his facial asymmetry surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry

Q: Dr. Eppley, I am seeking your professional opinion on how to treat my facial asymmetry. What do you think can be done? When I was 17 I underwent double jaw surgery to correct sleep apnea. I believe the right side of my face is lower than my left, my smile moves predominantly to the right, and my left eye is higher than the right. I do not know exactly what has caused this. I would like to know what is your diagnosis and what is a possible treatment. Thank you so much.

A: What you have is facial asymmetry with your right facial side being overall lower than that of the left side of you face. This is evident from the eyebrow down through the jawline. Given the fact that your facial asymmetry is not severe (I know it is to you but in the big picture it is not) any corrective procedure options should be considered from the perspective of what can be done with the lowest risk of aesthetic complications. (trading off one problem for another)

The most visible part of your facial asymmetry, as it is in a lot of facial asymmetry patients, is around the eye area. An endoscopic browlift on the right side with orbital floor augmentation (to raise up the eye)  and lateral canthoplasty (change the location of the corner of the eye to a higher position) would make the greatest improvement in your facial asymmetry. Possibly a small cheek implant as well, I would leave your jawline along and there is no surgery that can be done to improve your smile asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Asymmetry Correction

Q: Dr. Eppley, I have had two prior facial asymmetry correction procedures on my jaw. I had an implant placed on my right jaw only which is the side that is imbalanced.  It is imbalanced both in width and in depth/length if that makes sense and the surgeon only corrected the width – which he did in excess.  Hence I still have the depth discrepancy and it really is simply imbalanced now to the opposite direction it was initially.
The revision was to shave down the initial implant as it was far too large.  The revision did not do much and was done poorly – the end of the implant now has a lump that is obvious. I’ve attached pictures for you to review.  Please let me know if you need additional or different angles.  One of the things that really bothers me is that the fullness is such that my left side often has shadowing that my right does not which almost emphasizes the asymmetry the doctor created.

A: What your case illustrates is how hard is to do facial asymmetry correction surgery by the doctor ‘winging it’. (that is not a criticism of him per se) It is very hard to just eyeball the facial asymmetry and place an implant and have it be right. That rarely is a successful strategy. It often leads to revisional surgery which still doesn’t solve the problem. Also you can see how just a few millimeters one way or the other can make a big difference on the outside of the face. When one has had a failed attempts at facial asymmetry correction along the jawline, it is best to get a better view of the problem. A 3D CT scan is the best way to really see the bony asymmetry, see where the implant is situated and what it looks like and then design a better implant that is matched to the bone on the other side and fits the jawline intimately.

Dr. Barry Eppley
Indianapolis, Indiana

What Procedures Do I Need To Correct Craniofacial Asymmetry?

Q: Dr. Eppley, I am on a search to find the right doctor to fix my facial structure problem. I’ve been very dissatisfied with the worsening of this birth defect as I age and skin becomes more loose. I started to notice it when I was in my early teens but was very skinny at that time in my life. I am average weight and I tried just having chin liposuction which helped a little but is back to where it was and never really was even close to enough to fix my issue. It’s not only completely hinged crooked (bottom jaw bone) but I think the top of my skull is also off balance (which might not be a big deal in the end if not fixable with fillers/botox) I need professional analysis and advice. I don’t know how much bone I have on that side but i basically can only take photos on one side or it looks like i h ave a huge swollen tooth (I get asked, it kills my self esteem). I need to do this now. I can’t keep living my life with the constant reminder and pain that comes with it. Not if it’s something that I know can be fixed at least some. I also have an eye issue that will not be something that has to do with this surgery other than the fact that I think my entire face being on a tilt has caused strain on a muscle or nerve causing my limited vision on one side (luckily for me the way I can look straight with both eyes is also the side that I can pose to camouflage the extreme jaw imbalance). Please help! You have a lot of background knowledge and studies that go beyond most others I’ve seen. I need to know the long term problems etc. This is a risky and major surgery but is becoming more common. I was originally told locally that I would have to have my jaw broken, re-aligned, and all my teeth realigned as well which is not something I’m prepared to endure at 31years old. I’m looking for results that aren’t going to take years of adjustments and cost to fix while suffering through the pain. Let me know if you think you can help. Thank you!

A: What I see just in these two picture you have attached is a craniofacial asymmetry of which appears to be a hypertrophy problem on your left side. The first place to start is to make an accurate diagnosis and determine the extent of the facial bone differences between the two sides of your face. While there are a wide variety of facial procedures to help, careful analysis must first be done. This information can be obtained by getting a 3D craniofacial CT scan. This will allow both a visual and quantitative of your craniofacial asymmetry. With that information, treatment recommendations can then be made.

Dr. Barry Eppley

Indianapolis, Indiana

Will Cheek Bone Reduction Fix My Facial Asymmetry?

Q: Dr. Eppley, Hello! I am sending this request with my photos. As you may notice, the right side of my face is “larger” than my left, I feel its mostly the cheek bone. Hence I wanted to inquire about “cheek bone reduction” for my right side. I know it is not that simple, but to not make this very long I am writing in the most general way possible. I understand perfect facial symmetry with surgery is realistically impossible, I just wish to find a way that my facial cheek bones may be more proportioned, (with out the use of an implant or fillers), this cheek bone asymmetry is an insecurity I have when people look at me. I look forward to hearing back and thank you for taking time to read. 

A: I can see the asymmetry in your cheek area and, for now, we will assume this is due to a difference on the zygomatic (cheek) bones between the two sides. Right-sided cheek bone reduction can be done but it would be very important to know where the differences in the bones are so that the right bone reshaping technique can be used. In make that assessment, a 3D CT scan of the face is needed so that exact location and magnitude of the cheek bone differences can be seen and the right surgical plan done. Whether yours would be a ‘typical’ cheek bone reduction (anterior and posterior bone cuts) or just anterior awaits what the 3D CT scan shows.

 

Dr. Barry Eppley

Indianapolis, Indiana

What Can be Done For My Asymmetric Eyes?

Q: Dr. Eppley, I have sent you a lot of pictures and will try to explain my questions! I definitely have some skull asymmetry. The back of my head is kind of flat and it looks really weird when I have s short haircut. I also feel that the space between my chin and neck is very small.

I also have facial asymmetry and one side is bigger than the other. One eye is than the other although I feel both sides of my face are not matched. My neck on the lower eye side also feels tight and I can’t move my head straight.

It’s a mess and doctors here say I was born like this but it has gotten worse over the years.

Thanks for reading this. Hope to here from you.

A: By your pictures and your description of symptoms and physical findings, you appear to have a relatively classic case of craniofacial scoliosis caused by occipital plagiocephaly as an infant. There are three potentially improvable craniofacial problems:

  1. The back of head flatness can be corrected fairly well through skull augmentation by either bone cements or a custom skull implant.
  2. You asymmetric eyes (orbital dystopia = one eye lower than the other) is improveable by orbital floor augmentation with or without eyelid elevation. Fortunately the eyebrow appears to be in a symmetric position.
  3. The tightness in your neck may be unsolveable. Unless there is a very distinct and palpable band (cord) along the sternocleidomastoid (SCM) muscle (i.e., band torticollis), the tightness may be a function of congenital shortness of the neck muscles. If there is a band, then it can be surgically released although this would be an unusual finding in an adult. One non-surgical option to consider is Botox injections into the tightest area of the SCM muscle.

Dr. Barry Eppley

Indianapolis, Indiana