Can My Facial Asymmetry Be Corrected?

Q: Dr. Eppley, My concern is my facial asymmetry. My one side of my face did not develop normally, my left eye sets lower than the right.  Also my left cheek bone is under developed.  I want to know if it can be corrected. I have attached some pictures so you can see what I mean by one side of my face being different than the other.

A: Thank you for sending your pictures. You have a left-sided form of facial asymmetry due to some underdevelopment of various facial structures. This is probably a minor variant of hemifacial microsomia. I can see in looking at your pictures you have some orbital dystopia (lower eye socket) with malar (cheekbone) hypoplasia as well as some chin asymmetry. (shift towards the underdeveloped left side) The best treatment approach would be orbital floor augmentation, medial z-plasty canthoplasty, cheek augmentation and a chin straightening genioplasty. But probably what bothers you the most is the cheek-eye area which is what you see and look at the most.

I believe the eye and cheek area could be significantly improved but I wouldn’t use the term ‘correction’ as that implies they could be made perfectly normal which they can’t can’t. It is just a question of how close to normal can they be made.

Dr. Barry Eppley

Indianapolis, Indiana

What Can be Done To Make My Face Look Less Crooked?

Q: Dr. Eppley, I am 22 years old. My question is in regards to my face which is crooked. It does not have the best shape. The right side of my face is not equal with the left side. (see attached picture) Because my face does not look good, I have no confidence. Please suggest to me what I am supposed to do.Your advise is highly appreciated.

A: Your picture shows that you have significant facial asymmetry. The left side of your face shows hemifacial hypoplasia (hemifacial microsomia) as demonstrated by significant left chin deviation, a flattened left cheek and an inferiorly positioned (low) left eye and eyebrow. There are a variety of facial plastic surgery procedures that can help improve your facial asymmetry. Beginning from the bottom of your face and working up, the chin can be brought back to the facial midline by a sliding genioplasty, the left cheek built up by an implant, the eye raised up by an orbital floor implant with repositioning of the left canthus (corner of the eye) and the lower brow lifted by an endoscopic browlift. While all of them done together will produce the best degree of facial symmetry improvement, treatment of the chin and cheek asymmetries are the most important as well as the most improveable of the facial deficiences.

Dr. Barry Eppley

Indianapolis, Indiana

How Can My Facial Asymmetry From Plagiocephaly Be Improved?

Q: Dr. Eppley, I’m contacting you as I am seeking some comments from yourself in relation to what I suspect is either unilateral coronal synostosis or plagiocephaly. Given the nature of the problems I present I am not to comfortable with sending photographs

If I were to describe my observable problems I would summarize them as follows:

1.       Slight right-sided anterior ear displacement (very obvious asymmetry of the ears)

2.       Mild right-sided occipital flattening

3.       Frontal bossing with excessive protuberance of the upper portion of the squama frontalis over the supraorbital margin – slight right to left cant with the right being more forward

4.       Vertical orbital dystopia – right side slightly higher than the left (I would say the entire zygomatico-orbital bone complex on the right is higher as I have an asymmetry and protuberance in the zygoma region)

5.       Nasal root deviation to the right with deviated septum to the right (What I mean by this is that the entire nasal bone pyramid complex is off to the right)

6.       Chin deviation to the left

7.       Asymmetry in the vertical height of the mandible – left side is higher than the left

8.       Uneven cheek fullness – slightly greater degree of fullness on the right side.

9.       Malocclusion – no functional occlusal contact left side and buccal crossbite right side in centric relation, posterior bilateral open bite in centric occlusion. Mandibular mid-symphysis deviates slightly to the right in centric relation, and slightly to the left in centric occlusion. Left condyle is both posterior and superior in the mandibular fossa compared the right.  There is a slight transverse cant of the maxillary occlusal plane observable in frontal view, which gets more significant as you approach the region of which is inclined.

If I were to describe my visual appearance in worm-eye view I would say that there is a slight twisted effect to the skull from right to left, as can be seen looking at the frontal bone and the supraorbital margin, the nose, the zygoma’s, and the mandible.

I have looked at some photos of myself as a child and it seems quite apparent to me that I had a slight degree of vertical orbital dystopia. I do not believe however that I had the “harlequin eye” deformity looking at these photos.  

Do you have any comments or advice, and what treatments may be available to tackle my asymmetry?
A: Your description is fairly classic for this deformational type of skull deformity. Usually the best camouflage approach is to level out the chin and jawline by osteotomy/implant, correction of lower orbital dystopia by cheek augmentation, building up the floor of the eye and adjusting the ipsilateral lateral canthus and possible brow bone contouring. Rhinoplasty to straighten a deviated nose may also be useful. If the ear sticks out on the more anteriorly positioned side, an otoplasty may also be done. Usually I leave the occipital skull deformity alone unless it is really flat.

Dr. Barry Eppley

Indianapolis,Indiana

How Can My Facial Asymmetry Be Improved?

Q: Dr. Eppley, I have an asymmetric face, jaw, and bite and looking to even things out. The left side of my face is bigger. I’m seeking to make my jaw and cheekbone on the left side smaller to match the right. Also, my right eyelid and eyebrow are lower than the left.

A: I have taken a look at your frontal facial photo and looked at making changes that would provide the best benefit. These

would include a left cheek narrowing vertical osteotomy, a left jawline/angle narrowing ostectomy and a right endoscopic browlift. I don’t know your age and you mentioned a bite that is off so there is the possibility of orthodontics and orthognathic surgery as well which would always need to be done first. If you have never had an orthodontic workup this would be a good evaluation to do so you at least know your options.

Facial asymmetry is usually very difficult to get the best symmetry when only one side is done. This is why there remains the option of a

small high right cheek implant or even a small right jaw angle implant…as the bigger left side can never be made quite as small as the opposite smaller right side.

Dr. Barry Eppley

Indianapolis, Indiana

What Does Facial Asymmetry Surgery Cost?

Q: Dr. Eppley, I am only just researching these procedures. I have lived my entire life with an asymmetrical face and flat head, being told that one half of my face looks young and the other like an old man. I’m 23 years old. This deformity is my biggest most unavoidable insecurity which has hindered my confidence since my teenage years. I don’t wear baseball caps or winter toques. I avoid having my picture taken as much as possible and I keep my hair long in front to cover my very uneven eyebrows. My question is will I ever be able to afford a surgery like this?

How much generally is a surgery like this? Any support and advice on this would be so much appreciated.

A: Facial and skull asymmetry takes on many variations. It is impossible to say what procedures would be beneficial without seeing pictures and talking to the patient about their concerns. Every patient must create a priority list of their concerns and then a surgery plan is made around that list. Cost of surgery follows making that listyso it would be impossible to provide any estimates at this point.

Dr. Barry Eppley

Indianapolis, Indiana

Can Facial Implants Do A Good Job Of Correcting Facial Asymmetry?

Q: Dr. Eppley, I am interested in implants to correct my jaw asymmetry. My jaw angles are very asymmetric and I feel I would be more attractive if my facial asymmetry was corrected. I have always been curious about art with respect to beauty.  What is beauty?  I’ve concluded that beauty is not only in the eye of the beholder but also in the symmetry of the viewed.  When you see a symmetric butterfly, it looks beautiful.  When you see the symmetry of a supermodel, it is beauty.  So this is something that I have become aware of over the years… and others have as well.  In fact, there is now an iPhone app that can rate your attractiveness by measuring your symmetry…  and guess what actor ranks the highest…  It’s Brad Pitt.  His left side of his face is exactly like his right side.

I have read your comment about not being able to reach a perfect match on anyone’s facial asymmetry, but instead improving on it.  I like that realistic goal.  I personally would be highly satisfied if I used a string that was measured and cut to reach from the corner of my left outer eye to the corner of my left corner back jaw (mandibular ramus) and have that string reach the same distance on the right side of my face as well.  It currently does not match.  But if it did, I would be a happy man.  And I also understand that even if I had this result, the symmetry would not be perfect since the position of the corner jaws may be different in the 3-D x-y-z coordinate system.

A: While I have found that perfect symmetry can be difficult to achieve in facial surgery, that does not mean it is not the goal. There are different methods in trying to achieve that symmetry regardless of the location of the implants. Traditional, and still the most commonly done, method of facial implant surgery is to pick out the implants based on a more or less artistic assessment of the patient’s needs. There is no precise method of matching the implants to the underlying bone shape or knowing exactly what the outward changes will be. As unscientific as that is, it works most of the time when the patient’s facial bones are symmetric and the patient isn’t overly detailed or looking for perfection. When it comes to improving facial asymmetry, however, it is easy to see how an unexact science applied to a variable problem is prone to some degree of a persistent level of asymmetry.

To counter these issues, an ideal approach is to make custom implants off of a 3-D model. When this is economically feasible, it is easy to see why this is better than ‘eyeballing’ it.  

Dr. Barry Eppley

Indianapolis, Indiana

How Would You Treat My Orbital Dystopia?

Q: Dr. Eppley, I am interested in yourresults in treating facial asymmetry. I have a pronounced vertical orbital dystopia (I’m not sure if this is the result of plagiocephaly, though I highly suspect it is given the other imbalances in my face). I would like to know my options for treating this.  I have attached pictures for your review.

A: Thank you for sending your pictures. I can clearly see that you have a mild to moderate case of right orbital dystopia. (5mms of horizontal pupillary discrepancy) The entire orbital box is situated lower than that of the left side, affecting every surrounding structure from a lower eyebrow/brow bone down to an orbital rim-malar deficiency.

There are two fundamental strategies for dealing with these orbital discrepancies. The first is a complete orbital box change. Dealing with changing the fundamental problem through an orbital box osteotomy is too extreme is my opinion for the magnitude of your dystopia.  Therefore, I would recommend an alternative approach of multiple camouflage procedures. At the minimum, I would use an orbital floor-rim implant with hydroxyapatite cement which could be extended out on to the lower cheek bone. One could also use other types of implants such as Medpor or Gore-Tex which can be custom carved to fit during surgery. Ideally I would get a skull model fabricated from a 3-D CT scan to make an exact implant that reconstructs the bone levels to the opposite side. The lower eyelid would then be resuspended/tightened  which would move the lower lid level up, particulalry the outer half. One could also treat the upper orbit through either an endoscopic browlift approach with brow bone modification  through an upper eyelid approach. You can see with this camouflage approach it is a function of how far you want to go in treating all components of your orbital dystopia.

Dr. Barry Eppley

Indianapolis, Indiana

What Procedures Do I Need To Improve My Facial Asymmetry?

Q:  Dear Dr. Eppley, I was born with a condition known as right hemifacial atrophy, also known as Romberg’s syndrome. I was operated on two years ago with corrective orthognathic surgery. Both my upper and lower jaws were cut, leveled and my bite put back together. The result is good but I still have some right facial asymmetry. I want to reshape my right cheek bone, nose and orbital region. I would appreciate if you can give me some advice on what procedures I need. I have attached some pictures and x-rays from my surgery.

A: Thank you for sending your pictures. You have made good improvement from your orthognathic surgery. To further improve your hemifacial hypoplasia/asymmetry, I would recommend the following right-sided facial reshaping/augmentation procedures:

 1) Right orbital floor-infraorbital rim implant

2) Right lateral canthoplasty

3) Right cheek implant

4) Rhinoplasty

5) Right jaw angle implant

6) Opening wedge genioplasty (right side lengthening) – I was little surprised they did not do this during your orthognathic surgery

This would be my optimal plan to address all of your right facial issues. While all of these procedures do is to lengthen and expand the shorter right side of your face. I think you would get as good, if not even better, aesthetic improvement than you have had from your prior orthognathic surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Facial Asymmetry Be Improved By Fillers Or Implants?

Q: Dr. Eppley, I am interested in creating a more symmetrical look to my face via fillers and eventually implants. As a result of my jaw being asymmetrical, the right side of my lower face appears fuller and more defined than the left. I have attached some pictures for you to see.

A: Thank you for sending your pictures. I have taken a careful look at them and the fundamental issue is that the two sides of your face are different. The asymmetry is that the entire right side of the face is lower than that of the left. This can be seen from the eyebrow down to the bottom of the lower jaw. the right eyebrow is lower, the right orbital box and eye is lower as well as the lower eyelid, the cheek is lower and more recessed and the inferior border of the mandible is more inferiorly positioned. In short, you have a classic case of facial asymmetry where the two halfs have developed differently. For the sake of any correction, you have to take the position that the left side of the face is the good side or the objective for the right side to try and achieve. No form of injectable filler can make any significant difference in such facial asymmetry. A variety of surgical procedures can be considered from top to bottom including right endoscopic browlift, right orbital floor-infraorbital rim implant, right lower eyelid tightening by canthopexy, right cheek implant and right inferior border mandibular shave reduction.

Dr. Barry Eppley

Indianapolis, Indiana

What Can Be Done To Correct My Facial Asymmetry?

Q:  Dr. Eppley, Ive come to highly respect your opinion, especially regarding the lower face as you’ve done some beautiful work.  I have an asymmetric face. In seeing an orthodontist,  he said I am not a candidate for jaw surgery. I think he is wrong. I think jaw surgery is probably the only real solution that will properly address my lower face. My jaw is clearly longer on one side than the other in both the ramus and the condyle, its visible in X-rays. The cheekbone is also visibly lower on one side both externally an by Xray.

My questions aside from obvious rhinoplasty and chin augmentation, can anything at all be done to address this “tilted” look to my face and eye area? It bothers the heck out of me . Your feedback would be highly appreciated. I think surgery is my real need and only true solution.

A: I do not have the advantage of seeing any x-rays so my comments can only relate to your photographs. The most significant component of your facial asymmetry is in the orbits with the one being lower than the other. That is potentially improveable through a brow shaving procedure through the upper eyelid and a lateral canthopexy corner of eye tightening procedure done on the lower orbit. That is relatively low risk and is an operation commensurate with the magnitude of the problem.

Straightening your nose through rhinoplasty is of obvious benefit as well as chin augmentation, via an implant or osteotomy, as you are already aware.

As for jaw surgery in terms of orthognathic repositioning…no. Your orthodontist is correct based on what I see in the photographs. I have no clue as to what your occlusion is but this would involve a major effort and years of orthodontic work. There would have to be a major malocclusion to justify that effort. You are far better off camouflaging the jaw asymmetry with chin augmentation and possibly a lower border shave/ostectomy on the elongated side.

Dr. Barry Eppley

Indianapolis, Indiana