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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
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
Q: Dr. Eppley, I want a consultation about my profile. I am confused as to what I may need. My bite is not bad and I have never had braces. My dentist told me my upper teeth forms a c-shape. I think my jaw line is asymmetric, my chin points to the left and my right side profile looks concave or flat. This had been bothering me for a while but I don’t know what will be the best to make my face look more symmetric and balanced. I have attached some pictures so you can see what I mean.
A: When looking at a face there are two views to consider. The patient themselves sees the frontal view and, understandably, often considers it to be the most important. The profile and oblique views are what other people see and how the patient will usually see themselves in photographs. In your description of concerns, you mention both the profile and frontal view concerns.
As you have described in your frontal view, the chin and jaw angles are asymmetric (right chin deviation and left angle deficiency), and the right cheek is flatter or less pronounced than the left. If you look at other features of your face, you will see that there is an overall right facial deviation compared to the cranial base. This rotation is also why the right facial profile seems flatter in the cheek area.
I can not speak for your bite (occlusion) as it is not contained in any of the pictures you have sent. However, I doubt if your bite is severely off or misaligned and I don’t think it has any contribution to your facial asymmetry.
To improve your facial asymmetry, you have to think of ‘camouflage’ procedures for improvement. I would recommend left jaw angle and right cheek implants and either an asymmetrically-placed chin implant (with minimal horizontal increase) or a chin osteotomy with rotation and shifting to bring the chin point in the midline.
Dr. Barry Eppley
Q: Hi I would like to inquire about information for the correction of facial asymmetry. I have been irritated by the clear tilt in my cheeks and jaw for sometime. My head just doesn’t appear to sit on my neck correctly. After reading your artilesl very carefully I feel I may be a candidate for this. I must stress I understand perfection is unobtainable, however, this has bothered me for sometime. I hope someone can get back to me.
A: The origin of many facial asymmetries is developmental, the facial skeleton is rotated based on a skull growth issue. In craniofacial biology, it is well recognized that how the skull forms through plate expansion and underlying brain growth has a major inflence on how the facial bones develop. If the skull is twisted to any degree so will be the face. This can affect everything resulting in asymmetries of the forehead, brow bones, orbits, cheeks, nose, and jaw.
This facial asymmetry can be camouflaged, or made less apparent, by making adjustments to any of the facial prominences/flattenings. This could include bony reductions or shavings or augmentation through the use of implants. It takes a careful analysis to choose a balance of bony reductions and augmentations to achieve the look of improved facial asymmetry. What procedures would be of most benefit to any particular patient would depend on their individual anatomic issues. Common procedures include forehead augmentation, brow bone reduction, cheek implants, chin osteotomies and jaw angle implants.
Dr. Barry Eppley