Facial Asymmetry Surgery

Q: Dr. Eppley, I am interested in facial asymmetry surgery. I developed facial asymmetry over past five years and it gets worth each year. I have very low self esteem and would want the least invasive procedure to correct this. I am interested in knowing the causes for this and learning more on options to correct. As you can see in this photo the right side of my face seems to droop. It is not as toned as the left side. To me it seems to be pronounced when I talk and less pronounced when I smile. The concern I have is why–about 5 years ago I didn’t notice this extreme droop at all and over the past few years it seems to get worse. I have always had a lazy eye and that never really bothered me but now that it has advanced to my lip it does concern me. What are causes for this? I get my eyebrows done and the technicians have told me it’s hard to get them to match because they are just different that is when I really began noticing. It just seems like the two sides of my face are totally different. I appreciate your time. 

A: Your facial asymmetry is congenital where the entire right side of your face sits lower than the left. Yo have known this inadvertently for a long time because of the eye asymmetry (‘lazy eye’) but it has become more apparent now as the entire right face is dropping as you age. That is why it is much more apparent now and gets better when you smile since smiling picks up the sagging tissues.

There are no ‘minimally invasive methods of facial asymmetry correction. This is a problem that will respond only to surgery. The simplest and most effective approach to your facial asymmetry surgery would be a combined right endoscopic brow lift and right lower facelift/jowl tuck up procedure. This will resuspend the tissues up higher so the right facial droop is corrected and better matches the left side of your face.

Dr. Barry Eppley
Indianapolis, Indiana

Is Facial Asymmetry Surgery Worth It?

Q: Dr. Eppley, I was writing interested in learning more about facial asymmetry surgery. I noticed that one side of my face is a bit fuller than the other. It manifests in the forehead and the jawline. I am wondering if it is advisable to do anything about these types of asymmetries or is it best to just ignore them. I have attached some photos to provide some examples of what I am referring to.

A: The answer to your question about facial asymmetry surgery and whether it is worth it depends on the degree that it bothers you, what would it take to make a correction and what are the risks in doing so. In terms of improving any facial asymmetry it is infinitely easier to add fullness than it is to reduce it. This is particularly true in the forehead due to surgical access. (incision needed to do it) It is less true in the jawline since the incisional access is intraoral. I would need to see better pictures of your face (non-smiling straight on picture) to do a computer imaging analysis to see if you feel such changes would be aesthetically beneficial and what type of facial changes those would be.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Facial Asymmetry Surgery Do I Need As A Result Of Untreated Occipital Plagiocephaly?

Q: Dr. Eppley,  I would like to know what can and cannot be done about untreated plagiocephaly in terms of facial asymmetry surgery procedures. I am still young (19), which is why I want to explore my options now so I can put this ongoing struggle in the past. I have very noticeable facial assymetry, particularly evident in my cheeks and jaw angle. I also have some forehead assymetry as well due to the soft spot on the left back side if my head. Regardless of this, the area of immediate concern is my cheeks and jaw. The left side of my face is much more prominent and “fuller” due to the Plagiocephaly. My eyes are also assymetrical because of the different orbital positions making it seem as if I have a lazy eye when looking in certain directions. Another area of concern for me is my flat midface; it seems as if I need at method to someho w “pull out my face.” My face needs to gain a more 3D look so my eyes don’t seem deeper than they actually are. Also, as you can tell from the pictures, not only do both halves of my face look drastically different from the side, my head lacks length from the front of my head to the back, as well. I would like to gain your input on what would be the most effective methods to improve my facial features.

A: What you are describing are very typical facial findings from congenital occipital plagiocephaly. While there is a long list of facial and skull changes that can be done for our facial asymmetry surgery, the question is which ones have the greatest value and are the most economically efficient. You have pointed out the most important to you currently and that is the flatter and more deficient cheek and jaw angle on the affected side. A cheek and jaw angle implant will help in that regard. But it is important to point out that the eye on the same side is also a major focal point and addressing it with orbital floor augmentation and a corner of the eye adjustment would also be important. ideally the best way to treat all three facial skeletal issues would be a 3D CT scan to make the implants match the facial structures on the opposite side the best.

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Facial Asymmetry Surgery Do I Need?

Q: Dr. Eppley, I am interested in facial asymmetry surgery to even out the two sides of my face. As you can see in these pictures my right side of my face is lower, along with my right eye. I was wondering if it is somehow possible to have my eyes on the same level and take that bump from my chin away. And on top of that my head temples are narrowing. Is it somehow possible to fill them and make my head more round. Thank you for your time.

A: You have a complete right facial asymmetry which is lower than the left side of your face as you know. The corrective procedures for your facial asymmetry surgery would include the following:

Right Supraorbital Brow Bone Reduction with Right Transpalpebral Brow lift (all done through right upper eyelid incision)

Right Orbital Floor Augmentation with Lateral Canthoplasty (lift the eye up as well as the corner of the eye)

Right Inferior Border Chin Ostectomy (shave of the lower border)

These three procedures would lift up the lower parts of the right side of the face.

The temporal hollowing could be addressed by temporal implants placed under the temporalis fascia done through a small vertical incision in the temporal hairline.

Dr. Barry Eppley

Indianapolis, Indiana

What Needs To Be Done For My Facial Asymmetry Correction?

Q: Dr. Eppley, the right side of my face looks bigger and more elevated than the other side, and the position of my right eye socket is higher than that of my left one. My jaw is also asymmetrical. When I bite, I can feel that the left side of my upper jaw and lower jaw is higher than the right side. I can also feel that the bone between my right eye socket and.my upper jaw is bigger than that on the left side when I touch. Is it possible to make my right side identical to the other side? If so, could you advise me on what procedures I should take and their costs? Thank you.

A: For your facial asymmetry correction, there are some structures that can and can not be changed.  It is not possible to lower a higher eye socket. (orbital box) A lower eye can be raised somewhat but a higher eye can be lowered. Your maxillomandibular cant (jaw asymmetry) can be corrected by a LeFort I osteotomy to shorten the longer side. (vertical maxillary reduction) To keep your current occlusion (bite) a sagittal split ramus osteotomy is needed to rotate the lower jaw back into occlusion as well as complete the vertical shortening of the right lower face.

Dr. Barry Eppley

Indianapolis, Indiana

What Procedures Would Be Needed For My Facial Asymmetry Surgery?

Q: Dr. Eppley, upon a consultation, the maxillofacial surgeon informed me that
I had facial asymmetry and that my right malar bone was posterior. I had always known there was a serious problem with my facial appearance which has caused me
much emotional distress throughout my life. However until this consultation,I couldn’t
articulate exactly what the problems were. More importantly, it hadn’t even entered my mind until this consultation that it might be  possible that my facial asymmetry could be surgically corrected.

I have attached two photographs that I think illustrate very well the facial asymmetry.  The main problems with the facial asymmetry are that the right malar is depressed and possibly the right eye and brow are slightly too low.

I would really welcome your professional opinion on possible treatment options for the facial asymmetry.

A: I can see quite clearly that your facial asymmetry is based on the right periorbital region and is largely skeletally based. The right orbital box (brow bone, lateral orbital wall and zygoma) are smaller/underdeveloped. This leads to the overlying soft tissues following the pattern of the bones, leading to a right brow and corner of eye/lower eyelid sag and a flatter cheek in that side.

In terms of improvement, you can consider for your facial asymmetry surgery a small right cheek implant. right lateral canthopexy, and right brow lift and possibly brow bone augmentation as well.

Dr. Barry Eppley

Indianapolis, Indiana

What Can Be Done For My Facial Asymmetry?

Q: Dr. Eppley, I have orbital, cheek, jaw and nose asymmetry (see attached picture). Please advise as to what can be done surgically to resolve the facial asymmetry. I would be very appreciative of your answers and expertise.

A: What I see in your picture is a right-sided facial asymmetry which is smaller and deviated to that side. The most visible component of your facial asymmetry is a lower right brow and entire orbital box and eye as well as the cheek bone. Since it is not possible to lower the left brow and eye, facial asymmetry surgery would be focused on the right side. The right eyebrow could be lifted and the brow bone augmented. The right eye can be lifted by orbital floor augmentation and the corner of the eye moved upward. Lastly the right cheek bone could be augmented as well. There are other areas of facial asymmetry, such as the nose and jaw, but I would focus first on the most distracting aspect of the facial asymmetry around the right eye. This would be the most important focus of your facial asymmetry since it is what most people focus on during conversational interactions and in pictures.

Dr. Barry Eppley

Indianapolis, Indiana

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