Your Questions
Your Questions
Q: Dr. Eppley, Would a zygomatic osteotomy work on an individual with cheek asymmetry due to hemifacial microsomia? I am considering orthognathic surgery to fix my jaw and masseter muscle. I am also considering a procedure to enhance my cheek symmetry. I have heard implants can be unnatural when placed unilaterally even when custom made. I thought a zygomatic wedge osteotomy may be better. Because the eye and cheek are interrelated it could make eye look smaller?
A: What is best for your cheek symmetry would really require evaluation by pictures of your face and review of a 3D CT scan. But as a general statement, a zygomatic expansion osteotomy (which is what you mean by ‘zygomatic wedge”) only affects one dimension and that is cheek width. It can not change any other cheek dimension. In my experience in the hemifacial microsomia patients, the dimensional changes need to the cheek area are more than just that of width. Plus the bony edges of a zygomatic osteotomy and the plates and screws to hold it would ultimately be able to be felt and many be able to even be seen through the skin. It is not true that a custom implant would look unnatural and, because it is custom made and fits the bone in a smooth transition manner, would probably look more natural than any osteotomy/bone grafting procedure.
Any cheek augmentation procedure, by definition, may make the eye look smaller no matter what technique is used. Although that degree of orbital change may be aesthetically negligible.
These are general statements which are made with no specific knowledge about your case.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am scheduled to have an old cheekbone fracture reapir procedure by you in a few weeks. The two procedures you will perform on me are: (21407) treatment of fracture of orbit except blowout with implant Left side and (21270) augmentation of cheekbone left side. My questions are what exactly will you be doing as far the actual repairs? Will it require breaking the bone? If screws are used anytime in the procedure, will that negate my ability to have an MRI of the head region in the future because of the metal? Will I feel the implants and screws in my face when I rub it? Lastly, how durable will the implants be if I get hit in the face playing basketball? Thank you for being able to help me restore my features after so long of an injury. I trust you and your reputation and I feel I am in the best competent hands possible.Thank you for your time.
A: Your old cheekbone/infraorbital rim fracture is going to be treated by a camouflage technique to build out the depressed bone and lower eyelid and cheek facial areas. This would be a combined cheek implant and infraorbital rim implant. Any implants used would be screwed into place with very small titanium screws. (about the size of eyeglass screws) They do not interfere with any type of x-rays. With such an old and healed facial fracture there is no benefit to breaking the bone and repositioning it. That would be very traumatic and less effective at this point that building out and filling in the obvious facial indentations/asymmetry. These implants are very durable and would pose no problems playing contact sports. In some ways you can think of them like placing protective bumpers on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a cheek implant. I was in a car accident ten years ago and had reconstructive surgery on right side of face. You can see that my fave is fuller along the jawline and lacking fullness on the apple of my cheek. I’ve had fillers for years to temporarily fix the problem area but I hate it. I’m ready for a permanent fix so I can feel beautiful. You can see in my attached pictures my facial asymmetry problem.
A:Thank you for sending your pictures. You have the classic cheek deformity that often occurs after a zygomatico-maxillary (cheekbone) fracture where the projection of the cheek is ultimately lost from inward translocation of the arched cheek bone complex. Given your naturally very high cheekbones (as seen on your left side) it would be easy for such a fracture and even its repair to match the naturally high cheekbone projection that you have. You are correct in that there is a simple fix to that concern by placing a cheek implant on top of the most depressed portion of the bone. This is done through a small incision inside the mouth.The key is both the proper cheek implant shape and size.
Dr. Barry Eppley
Indianapolis, Indiana
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
Q: Dr. Eppley, I am 28 year old female.When I was12 whenever I opened my mouth very wide the left side of my face clicked under my ear. Therefter it became more painful to open and I had great difficulty in eating chewy foods. By the time I was 18 my face looked obviously asymmetric. My jaw is not properly aligned. I have been to an orthodontist and was told that I would need corrective jaw surgery which I can not afford and he also said it may not necessarily make my face look straight even if my jaws were better aligned. What can I do to straighten out my face?
A: Your face is significantly asymmetric due to an underdeveloped left side. That extends from the cheek bone down to the jawline with a significant left chin deviation.Your non-major orthognathic surgery options include a combined procedure by repositioning the chin bone (opening wedge genioplasty), a left cheek implant and fat injections to the left side of the face. These three procedures will help fill out the left side of the face and straighten it by aligning the chin with the midline of the face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 19 years old and have developed a problem with my face. It looks crooked and I don’t know why. I saw pictures of me before about 6 years ago and my face wasn’t crooked. So I’m kind of worried about what made it crooked. So can it be fixed?
A: Thank you for sending your pictures. My assessment shows that your facial asymmetry is caused by a left-sided orbito-zygomatic deficiency. This is evident by a slightly lower eyebrow, a small amount of redundant upper eyelid skin, a lower globe (eyeball) position, a lower positioned lower eyelid and a small cheek bone on that side. This is caused by the underlying cheek and eye socket bones (orbito-zygomatic skeleton) being more underdeveloped than the right side. This makes the overlying soft tissues, including the eyeball, are positioned lower than the other side.
While this is a common facial skeletal deformity seen in cheek bone fractures, yours is clearly development and just grew that way. It has probably only become more evident as you are now nearing full facial skeletal development.
The facial asymmetry could be treated by a combination of procedures including a transpalpebral browlift through an upper eyelid incision (to lift the brow), orbital floor augmentation (to push the eyeball up), lateral canthoplasty (to reposition the outer corner of the lower eyelid) and a cheek implant. (to build up the smaller cheek area) I have attached some imaging which shows the predicted effect of those changes.
Dr. Barry Eppley
Indianapolis, Indiana
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
Q: Dr. Eppley, I have an untreated zygomatic fracture after trauma from 3.5 years ago. My cheek is about 2mm flatter than the other side. The position of the eye looks normal and I have very little compression of the infraorbtial nerve, so little that I think it’s still “fully alive”. The feeling of the V2 nerve area its completely ok with maybe a little paresthesia when I push on it. I am now in the process of doing a CT and EMG of the nerve. As soon as i will get the results of the tests I'm going to consider surgery. What about the infraorbital nerve issue during surgery? Possibility of permanent damage? Is it better to have 90% of feeling without surgery than 0-10% after operation?
A: If I interpret your condition properly you have minimal displacement of the zygoma and 90% to 95% normal function of the infraorbital nerve. (minimal nerve compression) With these minimal ‘problems’ I would question why undergo any surgery at all for these minor potential improvements. But if you were to do something, the treatment should match the magnitude of the problem. The zygomatic deficiency would be treated with a very small cheek implant not an osteotomy. The nerve would be released from around the foramen by a small foraminotomy. These two procedures have little risk of worsening the problems while providing the potential for correction of the aesthetic and neurological sequelae from your initial injury.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had my cheekbone broken two years during an assault. At the time, I did not have it fixed by having plates inserted and it has since healed. My cheekbone is flatter on this side and my face is slightly asymmetrical and uneven. Since then, my friends misinterpret my facial expressions thinking I am smirking or grimacing when I am not. I am sensitive about my facial asymmetry and am wondering if it is worth the time and effort to repair. Thank you so much.
A: Cheekbone or zygomatic fractures display a classic pattern of displacement when fractured. The body of the cheekbone rotates down and inward with partial displacement into the maxillary sinus. This reduces the prominence of the cheek bone by this inferior rotation, making the cheek flatter and the face asymmetric. Primary surgical repair repositions the cheekbone back into place and holds it there with plates and screws. But once the fracture is healed, this is no longer a good option in most patients. Rather than moving the bone, it is usually better to treat the facial asymmetry with an implant to restore fullness to the cheekbone. This is a far simpler surgery than major zygomatic osteotomies and repositioning. A one-sided cheek implant is a simple surgery that takes 30 minutes of surgery and improves much of the aesthetic asymmetry of the fractured but healed cheekbone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My cheekbone injury is over 8 years old. I know doctors are leary of healed/mended cheekbones. Should have initially went to hospital but because of lack of insurance and being raised to believe a black eye is just that. I was even getting carded at 30, took only about 8months before that ended. So now I am 38 and skin is creased/hollowed only on that side. I went to a plastic surgeon but they don’t know what I am talking about.
A: Many untreated depressed zygomatic (cheekbone) fractures will eventually show a malar or cheek flattening once all the swelling has subsided and the tissues are retracted. For many only the cheek is flatter but in more severe cases the shape of the eye may have changed and the corner of the eye tilted slightly downward. Yours sound like it has malar involvement only. A small cheek implant can usually make a significant improvement. Placed through the mouth on just one side, this can provide a simple and immediate fix to your cheek flatness/hollowness.
Dr. Barry Eppley
Indianapolis, Indiana
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
Q: Dr. Eppley, I had a zygomatic surgery four weeks ago. My right cheekbone was broken. The swelling has not completely gone down yet, but I can not understand the asymmetry in my face. My question is when these swellings will go away completely? I feel very anxious about if my cheekbones will have good symmetry again. It seems like I still have a collapse in my cheek bone even though there still is swelling present.
A: There is no question that zygomatic fracture repair can be associated with a large amount of eye and cheek swelling, particularly if it required a combined intraoral and eyelid incisional approach. Less swelling occurs from a more simple intraoral reduction. Since I don’t know the classification and magnitude of your cheekbone fracture and how it was treated, I can not say with any certainty about when most of the swelling will subside. But six weeks is a good time period to judge the results even though it may take until three months for all swelling and tissue contraction to occur.
However if in the face of swelling a cheek bone fracture repair shows persistent asymmetry, it may well be that the fracture repair was inadequate or not stabilized ideally. If this is the case, it is still possible at six to twelve weeks after surgery to do a revisional fracture repair with an improved outcome. (secondary facial fracture repair) Very delayed zygomatic fracture repairs may require camouflage procedures such as a cheek implant and/or combined with an orbital floor implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a facial asymmetry problem. Even though I know that everyone has a little asymmetry to their face, mine is not that little. It is quite visible. My cheek bone on the right is a little higher than that of the left. So is the eyeball area above it. I also don’t like my very bushy eyebrows and my left eyebrfow is lower than my right side. My left ear is lower than my right one and that makes it difficult to wear glasses or sunglasses comfortably. I am attaching a frontal picture for your assessment and recommendations. I am leaving this up to you as there seem to be few doctors that know how to treat facial asymmetry and because of your good reviews plus you can help me in all my problems.
A: Thank you for sending your picture and expressing your specific concerns. Your overall issue is one of facial asymmetry with the left orbito-maxillary region as a unit being lower on the left side. The lower positioned left ear would be part of that overall problem. As a general concept to gain better facial symmetry, the lower facial side has to be raised rather than trying to lower the higher side as that is surgically more possible.
With the objective of raising the left sided facial issue, I would make the following recommendations/thoughts. The left ear could be raised somewhat through suspension sutures from the cartilage to the fascia. A slight setback of its protrusion (sticking out) may be considered. This would be done through an incision on the back of the ear. A left eyebrow lift could be through an upper eyelid approach (transpalpebral browlift) which is the most common approach in men. I would remove a slight amount of left upper eyelid skin (blepharoplasty) which also serves as the access for the browlift. The lower eyelid marginj could be raised slightly on the outside with a lateral canthopexy/lid wedge excision. Raising the eyeball, even a few millimeters, can be difficult but a small orbital floor implant could be placed for a slight lifting effect. A small cheek implant would be used to provide some upper cheek fullness. Eyebrow waxing can be done to reduce fullness and are a good start to determine if their thinning is aesthetically advantageous. If so, you can then consider laser hair removal which is best done locally due to the need for a series of regularly spaced treatments to get some permanent reduction.
Although all of the individual surgeries are small in nature, they can collectively make a noticeable difference. All os this is said with the understanding that your facial asymmetry can be improved but a perfect match to the right side is not possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested to find out if you could help me to reduce my facial assymetry. What would you actually perform as I am not able to even guess that, but it seems that my halves are different in jaw and forehead shape. I want to make my face more symmetrical and I want to reduce and minimize the difference of my jaw and forehead. Please advise what kind of procedure do you recommend and what would be the estimated cost. Attached is the photo so you can see and assess the treatment.
A: In looking at your frontal view photograph, I see four isses that are making your face asymmetrical. The first is the difference in the sdie of the jaw angles between the two sides. The right is bigger than the left. That could be addressed by either a right jaw angle reduction or left jaw angle augmentation depending upon which side you like better. Secondly, there also appears to be left cheek deficiency which is less prominent than the right. That would be compatible with the left side of your face being smaller than the right. That could be improved by a left cheek implant. Thirdly, the right upper eyelid has more skin which hangs down onto the lashline. That could be removed by an upper eyelid blepharoplasty. Lastly, your nose is deviated towards the left side with a broader tip. That could be improved by a rhinoplasty. I think the combination of these four procedures would go a long way to improving your facial asymmetry.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley I need your help with my cheek. Several years ago I was involved in a fight and got struck on the left side of my face. At the hospital they diagnosed me with a cheekbone fracture but I never got it fixed since I didn’t have insurance at the time. The left side of my face is asymmetric now to the other side and I want to get it fixed. I will describe the problem as I see it. If you look at about an inch down from my left eye, that area from the middle of the top portion of the cheek toward the edge of my nose is flattened. It has no definition like my other cheek. The flatness extends down toward the middle portion of my ceek also. It appears to me as the complete area is shaped like a sideways triangle toward the rear. Also in the same area about an inch under my left eye, right on top of the upper portion of my cheek, it appears as if that area has dropped down. Do you think the bone needs to be rebroken to be fixed or can some type of implant be used to fix it? Thanks for your time.
A: Your description of the left cheek/midface deformity is exactly what one would anticipate from an incomplete zygomatic or cheekbone fracture. As the zygomatic complex, when fractured, can only rotate downward and inward toward and into the maxillary sinus you will lose some cheek and underlying anterior maxillary projection. Because you have described no changes in the eye area or numbness of the cheek and teeth (infraorbital nerve impingement) your original zygomatic fracture is incomplete and less severe than a fully displaced fracture. Given the age of the injury and the now healed bone, a modified cheek implant placed across the anterior maxillary wall and up onto the anterior zygoma should do nicely to restore the bone fullness lost. Given the modified position of such a cheek implant, it would need to be secured by multiple screw fixation.
Dr. Barry Eppley
Indianapolis Indiana
Q: All my life I have had depressions under my eyes. It’s a hereditary thing as I have no cheekbones at all. It makes me extremely self-conscious. Although I don’t need glasses, I wear them all the time to hide this problem. I have been thinking about getting cheek implants. Do you think that will help me? I have seen some cheek implant results and they look really fake to me. How do you avoid cheek implants from looking unnatural and even making my eyes look too sunken in?
A: There is no doubt that well-defined cheekbones are an important facial component of what can make a man or a women good looking. Cheekbones help define the face by highlighting the eyes, adding balance to the other facial prominences and contributing to a look of youth and vitality.
Cheek implants can really help those whose midface is deficient. But cheek implants come in different styles and sizes. There is more to cheek implants than just choosing a size. The cheekbone is a curved structure that has dimensions of a frontal, central, posterior and inferior considerations. Different styles of cheek implants highlight these areas differently. Patients have different types of cheekbone deficiencies and that is the reason so many cheek implant styles exist. In addition, how the implant is placed along the bone and what size is chosen will influence how it will look after surgery.
Probably the biggest consideration in avoiding an unnatural cheek implant result is to not use too big of an implant. The cheek area is very aesthetically sensitive and trying to make too big of a change or use the implant to lift sagging cheek tissues can quickly make for a peculiar looking result. There are some good celebrity illustrations of this exact problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a fracture in my right cheek bone from a fall. There is a dent in bone. Is there anything that could be done to fix it. I’d like to send a picture of me to you.
A: Thank you for sending your picture. What it shows is the sequelae of a a cheek or zygomatic infracture. When the cheek bone is struck with enough force it will fracture the ‘legs’ of bone which support it. When the cheek bone loses this support, it will always fall down and inward impacting into the maxillary sinus. This is known as a rotation fracture. When this happens the prominence of the cheek is lost, causing an indentation of the cheek. That indentation will appear just below and to the side of the eye. It is the prominence of the cheekbone which is lost.
Secondary of uncomplicated cheek fractures can take two approaches depending upon the degree of displacement and if there are other associated symptoms. Rebreaking the bone (cheek osteotomy) is only indicated when the amount of displacement is severe and there may be some nerve pain or numbness and alteration of the corner of the eye. If the indentation is the only problem, however, a cheek implant will usually suffice.
Through an intraoral (inside the mouth) incision, a cheek implant can be easily placed. It is important to have the right shape of cheek implant and that it is accurately positioned over the loss of prominence for the best correction.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had cheek implants placed over10years ago and an oral and maxillofacial surgeon told me one of them is infected. It started with a visit to the dentist.I had 2 fillings done in my upper molars.The freezing was in the same area the implants are and this somehow caused one of them to get infected. It is swollen and I am upset it happened and worried about the infection. I have been on antibiotics for about a month.I know infection is rare but I got unlucky and I was wondering how many times you’ve had to take one or both implants out?
A: You are correct in that infections with cheek implants are rare, but they are not unheard of. It has been reported that cheek implants can get infected with local anesthetic injections during dental treatment. An upper vestibular or intraoral nerve block puts the needle very close to a cheek implant and could very easily, unknowing to the dentist, touch or penetrate into the implant. This would be a source of bacteria brought into the implant capsule from the needle track.
Once a cheek implant, or any facial implant for that matter, gets infected, it is likely that it will eventually require surgical treatment. An implant is an avascular surface, that once contaminated, can not easily get rid of an infection. Antibiotics are a logical first choice but they will tend to only suppress it for the duration that you are them. Once off, the swelling and infection usually returns. If this does not work after a month or so, I would re-operate, remove and clean off the existing implant and either replant it or replace it with a new one. This approach will work. The opposite cheek implant is at no risk from the infection of the other one.
Dr. Barry Eppley
Indianapolis, Indiana