Can My Facial Asymmetry Be Fixed?

Q: Dr. Eppley, I am interested in facial asymmetry correction. My face is crooked, particularly my chin and jaw. When I smile my chin pulls to the left and makes the jaw asymmetry look worse as it points to the left. The rest if my face on the left side is also uneven. My left eye and eyebrow are lower and my cheekbone seems smaller. When I look in the mirror I don’t look too bad but it looks much worse obvious in pictures. Can my facial asymmetry be fixed?

A: Like many cases of facial asymmetry, it rarely is just one area of the face. What you are describing is a more complete unilateral or one-sided facial underdevelopment. This is evidenced by a lower eyebrow and eyeball position, a flatter cheek and a shorter jawline distance from chin back to the jaw angles. In essence the vertical length of the face is shorter on your left side than your right. The jaw asymmetry in particular is magnified when you smile as the soft tissue of the chin is pulled back and deviates to the less developed side.

There are a variety of facial asymmetry procedures that can be done from the eyebrow down to the jawline.  What you would do depends on how much of the facial asymmetry you want to treat. The chin/jawline often displays the most severe aspects of facial asymmetry and is often the most important area for many patients to correct. This can be treated by a sliding genioplasty to realign the bony chin to the midline. This can be possibly combined with a small jaw angle implant in the back to completely lengthen the entire jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Will Custom Jaw Implants Fix My Facial Asymmetry?

Q: Dr. Eppley, I am interested in jaw implants to help correct my facial asymmetry. Although it is not noticeable to others,  if taking a picture straight-on and in certain lighting, it shows that my face is extremely asymmetrical. I was wondering if this would best be corrected with asymmetry surgery or could be corrected with customs jaw implants. Also- if corrective asymmetry surgery was performed, could you also add custom jaw implants at the same time to provide the most optimal facial makeover?

A: In looking at your pictures, your facial asymmetry is caused largely by a significantly deviated chin position. This has also has caused some jawline and jaw angle asymmetry although not as significant as that of your chin. There are two approaches to correcting your jaw asymmetry.

The first technique is to correct the chin by a sliding genioplasty that moves it back to the midline. Then the jawline and angles behind it could be augmented by standard jaw angle implants.

The second approach is to go completely with custom implant designs, leaving the chin bone where it is. Computer designing can make jawline-jaw angle implants for each side (that are obviously different but designed to create symmetry) that attach to the sides of the chin.

Either approach can make a big difference and each one has it advantages and disadvantages.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Facial Asymmetry Be Improved With A Jaw Implant?

Q: Dr. Eppley, the left side of my face is different from the right side. It seems to be missing jaw bone. Is it possible to even up my face with the jaw implants? I have attached a picture.

A: Thank you for sending your picture. It is not the best picture (from an angle standpoint) but it does show that you do have significant facial asymmetry which appears to affect the jawline the most. It would be optimal if I had some different picture angles of your face that had your chin more upward and not pointing down. But to provide some basic answers, some form of a jawline implant is needed. Whether this could be a done with a stock preformed implant or would be best done with a custom implant would require a little more in-depth information with some x-rays. At the minimum a panorex x-ray is needed, more ideally a 3D CT scan is best. That information will answer what type of implant is needed and how it would be done. Also, fat injections to fill out the overlying soft tissues is always needed as well as the facial asymmetry is caused by more than just a bone deficiency. Think of improving your facial asymmetry from the bony foundation underneath outward to the skin.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Way To Plan For Revision of My Facial Implants?

Q: Dr. Eppley, I have a slight asymmetry that affects most of my face, though the only place I noticed it was in my lower jaw. My chin grew too far to one side, and that side was under developed. I had implants put in to make the developed side fuller, my chin was filed down and capped to make it symmetrical. The problem was that after the surgery the side of my face didn’t have implants put in then looked very small. My dad said I looked like the “Janis” Roman coin with a different face on each side. I saw the same surgeon for a corrective procedure where he took out the chin piece almost entirely and only added a piece to make it symmetrical on that side. The result was a very odd look. I think because the jaw implant was designed to go with the chin implant, when the chin implant was gone it no longer worked. I look like I have constant swelling on one side of my face. This was all five years ago. I didn’t have the heart to ask my parents to pay for another surgery. I have been saving since then and I think that I can afford it now. I recently started orthodontics again and can send you current photos of my face and can send you x-rays that show the implants. 

I have several concerns, which you will probably need to see these pictures to answer. The first is, do I have unreasonably expectations. I think that I could expect to have symmetry, and a face I don’t try to grow a beard to hide, but I don’t have your experience. This is a tremendous amount of money for me and I won’t have the money to try again if this surgery is unsuccessful so I would rather not go for it if I can’t expect good results. I imagine the previous implants are grown in, I don’t know what that means for your surgery. 

Facing me, my right side is too full,

my chin is too weak. I would ideally like to pull out the chin implant that is there now and create a new implant that wraps from (facing me) my left side to the implants on the right side. This would lengthen the chin so I wouldn’t have the fat face effect. It would also add filling to the left side so I wouldn’t have the janis effect. Hopefully, it would be symmetrical. Because my whole face is off slightly I worry that a 3d rendering of my jaw may allow for a perfectly symmetrical jaw, that does not look symmetrical. I am sure you could address that.

A: When you have a significant facial asymmetry that has failed previous attempts at ‘simplistic’ correction (estimating the amounts of augmentation), one can assume that this is partly a function of the planning stage. While one can never predict with absolute certainty as to how any bone surgery will create a change on the outside,  it is reasonable however to strive for optimal facial symmetry. This is best done with a 3-D CT scan and model fabricated to properly diagnose the problems and design/fabricate custom facial implants that would best correct them.

Dr. Barry Eppley

Indianapolis, Indiana

What Can Be Done To Improve My Left Facial Asymmetries?

Q: Dr. Eppley, my left orbital and the left side of my jaw are fairly asymmetrical. I am interested in possible left cheek implant, andleft jaw/chin implant. I would actually also like to build out the left side of my nose and frontal bone if possible and fix my eyebrows as they are different heights. Also if you have suggestions I would like to hear them. I saw two plastic surgeons already, both said they could not help me . They did not actually look at me for more than a couple of seconds before they said that though.

A: Thank you for sending your pictures and indicating your objectives. To  summarize your facial asymmetry concerns, I list the following items:

1) Left jawline asymmetry (based on the arrow in the drawing this is located at the prejowl area which is the junction of the back end of the chin and the body of the mandible

2) Left cheek deficiency

3) Left brow bone-nasal deficiency

4) Left eyebrow excessive elevation

I don't know if any of these are from prior facial injuries or just your natural facial development. But either way, I can make the following comments/treatment recommendations:

1) It is not possible to improve your eyebrow asymmetry by lowering the higher left side. There is not a procedure that can accomplish that movement. Eyebrows can be lifted but they can not really be lowered

. It is certainly possible to do an endoscopic periosteal release of the supraorbital tissues and see of that will accomplich some lowering (and there is little to lose by so doing) but I can't guarantee if that would really be effective.

2) The medial brow bone and upper nasal deficiency (which is bone based) can be built up by the onlay of a material through an upper eyelid (blepharoplasty) incision. While a wide variety of materials exist, I would opt for either an hydroxyapatite cement or a mersilene mesh onlay.

3) The cheek bone deficiency could be augmented by the use of a cheek implant placed through an intraoral incision.

4) The jawline deficiency (unless I am misinterpreting what your concerns are) appears to be a 'spot' area along the left jawline. I would build up that area with a mersilene mesh onlay to fill in the prejowl deficiency through an intraoral approach.

The three select facial skeletal deficiences (jawline, cheek and left brow-nasal) could be assessed in exact anatomic detail and custom implants made off of a 3-D skull model, but I don't think we have to go to that extent to get a good result. It may be ideal but I don't consider it absolutely necessary in your case.

Dr. Barry Eppley

Indianapolis, Indiana

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How Can The Asymmetry Of My Face From Positional Plagiocephaly Be Improved?

Q: Dr. Eppley, I have some skull and face asymmetry from positional plagiocephaly. The main issue is that the right side of my forehead bulges, is it possible to reduce this bulging so my forehead doesnt have such a broad appearance when viewed from one side? Also the left side of my face is less prominent, maybe you could say “weaker” than the right. Would some sort of implant help with the asymmetry and make the left side as prominent as the right?

A: Plagiocephaly produces the exact face and skull asymmetry that you have described. Your right-sided forehead protrusion and smaller left face are common. Although I have not seen any pictures of you, your theory for improvement in facial symmetry would be the correct approach. Reduction of the right forehead bulging and augmentation of the left face, most likely that of the left cheek and jaw angle, could offer visible improvement. I would need to see some pictures of you, particularly a straight-on frontal view, to confirm if this approach would be helpful.

The left facial implants can be placed from inside the mouth so there are no scar trade-offs for those improvements. That can not be said for the forehead reduction in which the scalp scar trade-0ff must be considered very carefully, particularly in the a male patient.

Dr. Barry Eppley

Indianapolis, Indiana

Would A Jaw Angle Implant Help Improve My Facial Asymmetry?

Q: Dr. Eppley, I am a 37 year old female with microtia of the left ear. I have thought long and hard about pursuing the reconstructive surgery but I have decided not to proceed with it. I think I have become a little more comfortable with the situation just understanding more about the condition and I am also deterred by the uncertainty and expense. I am however interested in any minimally invasive option to improve my facial asymmetry. Are facial implants an option to do so?

A: Thank you for sending your pictures. As I suspected in left hemifacial microsomia, the jaw on your affected side is smaller with no jaw angle present. Surprisingly the rest of your face above the jawline has minimal to no effect in terms of underdevelopment. You are correct in assuming that a jaw angle implant would be helpful. An implant could be placed that builds out the left jaw angle and jawline as it comes forward. This implant would be placed through the mouth and then screwed into the existing jaw bone. There are two ways to go about choosing the jaw angle implant style and shape. The ideal way is to custom make an implant off of your jaw model that would be made from a CT scan. While this is ideal, it adds considerable expense to the cost of the surgery. The other way is to use an off-the-shelf jaw angle implant and modify it during surgery to fit. It would not create as good a result as a custom implant but it would still make good improvement for you.

Dr. Barry Eppley

Indianapolis, Indiana

What Procedures Should I Have To Improve My Facial Asymmetry?

Q: Dr. Eppley, am very unhappy with the right side of my face. My face is assymetrical; the right side looks smaller, there is less volume in the cheek, and my right eye and eyebrow are lower than the left. Also, the right side of my lower lip is smaller than the left. I feel that the left side of my face is the “good” side. I am very self-conscious of my appearance and avoid having my picture taken. I also feel that my nose is fairly wide from the front, although my profile is not that bad. Most surgeons in my area seem to focus on anti-aging procedures. I am too young (31 years old) that the right facial volume loss is due just to aging. The fact that I have always slept on my right side probably did not help. Please let me know what procedures you would suggest. I’ve attached a picture of my face straight on and also one of my right profile.

A: I would agree with you that you do have some degree of facial asymmetry. All features you have pointed out I can see and agree that it exists. The question is given the asymmetry what is reasonable to consider to do for improvement. I would also agree with youir three procedures of interest. A small right cheek implant with fat injections to the submalar (buccal space compartment) and the perioral mound area are very straightforward low risk procedures that can occur from visible improvement. While asymmetry issues exist in the eyebrow area, I would live with those for now. From a nose standpoint, a tip rhinoplasty to narrow the tip would work nicely. I would leave your profile and the upper portions of the nose alone.

The only point in which I disagree with you is that sleeping more on the right side of your face would not have caused the problem. This is a congenital ‘deformity’  and is a result of in utero development not from postnatal molding influences.

Dr. Barry Eppley

Indianapolis, Indiana

What Procedures Do I Need To Make My Face More Symmetric?

Q: Dr. Eppley, I want symmetry in my face after a few events that changed it. I want to breathe better. I want my nose to be as it was before trauma, might need cartilage graft on left side. I want my jaw to be more angular and symmetrical with osteotomy after having broken jaw. I want my left eye to look like my right eye, cause could be previous rhinoplasty or trauma involving prolonged eye poke. Here are some pictures of me.

A: Thank you for your inquiry and sending your pictures. I can clearly see your concerns in all three areas. In looking at your pictures, I can give you the following suggestions for these areas as follows:

1) Nose -  a septorhinoplasty is needed to straighten the septum, harvest a septal cartilage graft, decrease the size of the inferior turbinates, and reconstruct the external nose with a right middle vault spreader graft. Your external nose may benefit by other changes but that is as much as I can say based on these two pictures.

2) Jaw – To correct your asymmetric jaw, I would not do a traditional jaw osteotomy. This requires preparatory orthodontics and a whole change in your bite. The asymmetry could be better camouflaged with a sliding chin osteotomy to correct the midline of the chin and jaw angle implants to create a more angular and defined look. 

3) Eye – Your lower positioned eye needs to have the orbital floor built up with an implant and possibly both the orbital floor and the orbital rim needs to be augmented. This would raise the eye up and help bring it more forward as well.

Your pictures are not really adequate to do good computer imaging but I have attached the best I could do with the one picture.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Jaw Asymmetry Be Corrected?

Q:  Dr. Eppley, I am looking for help in fixing facial deformities and asymmetries. I have been to an Oral surgeon and a Maxillofacial surgeon before but they didn’t seem to care. I have a right sided facial deformity that bothers me alot. I would like to find some help for this problem. The right side of my face is under developed and I can see it and even feel it. My left and best side is more fuller and straighter.  My right side is smaller and recessed and less defined. Can an angled tilt in the jaws on one side be fixed? I have attached some pics for you to see.

A: Thank you for sending your pictures. I can see quite clearly the tilt to your jawline and the less full right mandibular angle area. It is not possible to cut the jaw bone and angle it downward without changing your bite on the right side. But it can be more simply and effectively treated by a mandibular angle implant, using specifically a type of jaw angle implant that extends the length of the jaw angle downward as well as making it more full. This would be done through an intraoral approach.

Dr. Barry Eppley

Indianapolis, Indiana