Q: I have a severe asymmetry in my face. I was born with a condition called plagiocephaly which has twisted by face and skull around in a weird fashion. My eyes are at two different levels and this really makes my face go to one side. I had a browlift performed locally but it did not make ay difference in how I look. I have attached some pictures. What do you think can be done?
A: Thank you for the facial pictures. On evaluating them it is important to realize that the apparent orbital asymmetry is not the basis of the problem. It is that the entire facial skeleton below the orbits is severely rotated to the left. This makes the orbits seem much further asymmetric than they really are. There are some differences in the forehead and orbital shapes but the real problem is what lies below.
Such facial asymmetry is best improved by doing total facial skeletal repositioning that can open up right facial vertical length and shorten the longer right side. In essence, to derotate the face back to the right. This would be done by preparatory orthodontics followed by orthognathic surgery to change the entire position of the maxilla and mandible. (LeFort I osteotomy and mandibular sagittal split osteotomies) I don’t know if that has ever been discussed with you or whether is a viable option for your consideration.
If orthognathic surgery is not in the future, then there are a variety of what I call camouflage procedures to attempt to achieve one similar goal…lengthen the left side of the face. Camouflage procedures can not be done that will really shorten the right facial skeleton. These would include a chin osteotomy with a shift of the chin midline to the right with lengthening of the left side of the chin and shortening of the right side of the chin. This would be combined with a left cheek and jaw angle implants to provide further left facial fullness. A rhinoplasty coule be done to narrow the tip and move the nasal midline back to the right. The left nasal alar base would be rotated down and around to be level with the other side. Lastly, a right brow release would be done with the intent of lowering the brow on the right side. This combination of fairly standard facial procedures combined into a single operation would help the facial asymmetry considerably. This still leaves the smile line tilted up to the left but this is virtually unchangeable.
I have attached a frontal view of the proposed changes that would occur. These are done conservatively and may likely be more significant in real life. The photo has been leveled at the eye level to demonstrate that the real problem is the rotated facial skeleton below the eyes. You undoubtably have a head tilt to the left side as well but that can not be changed.
Dr. Barry Eppley