Your Questions

Q: Dr. Eppley, I am inquiring about orbital asymmetry surgery. I suffered a zygomatico-maxillary complex (ZMC) fracture six months ago and have since had noticeable asymmetry of the orbits. The right orbit (injured side), is now noticeably higher than the left orbit. The right orbit was slightly higher than the left prior to the injury, but not to the current degree seen in the attached image. The medial portion of the eye is at an upward slant compared to the left eye which is more level.

A: Such orbital asymmetry would suggest an impaction type ZMC fracture. This could create an inward translocation of the inferior orbital rim/zygomatic body. This would then cause a buckling of the orbital floor upward, creating the changes you see now. But the etiology of these changes is best assessed by a 3D CT scan which would clearly show whether any asymmetry exists between the two orbital floors.  If orbital floor asymmetry exists then lowering of the raised part of the orbital floor may be beneficial as an orbital asymmetry surgery. This could be done through a lower blepharoplasty incision to allow complete access to the entire orbital floor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital asymmetry correction. I have attached several photos. I believe my right eyeball is smaller in size than my left. I also believe my right eyeball is further back in the eye socket and more deeply set than the left adding to the asymmetry I have. This is probably causing my right brow to drop a bit too. If you look at photos you will see my left eye looks different than in other photos. (same eye just pictures were taken at different times) This only happens from time to time, especially when am really tired I don’t know whether its the muscles in the eyelid reacting or what but as you can probably see it looks very odd. I know am never going to be symmetric but if I could find a solution to help minimize the orbital asymetrys then it would help me massively. Let me know what you think Doctor Eppley and thank you for your time.

A: Thank you for sending your pictures and describing your orbital asymmetry concerns. What you have is rather classic right sides facial asymmetry that affects the entire right orbito-malar region. Your right eyeball is likely not truly smaller than the left but it appears so for the following reasons: 1) the right brow bone sits lower than the left, 2) the right eyeball sits further back in the eye socket than the left, 3) the right upper eyelid has redundant eyelid skin (from the eyeball sitting back further), and 4) the right cheek/infraorbital rim one is smaller than that of the left. The skeletal components of your orbital asymmetry can be demonstrated/proven by a 3D CT scan.

When it comes to treating your orbital asymmetry, the most efficient approach would be the following: 1) right brow bone reduction (raise the lower rim of the brow bone by shaving it), 2) right upper blepharoplasty (use this same incision for the brow bone contouring), and 3) right cheek-infraorbital rim implant augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m not sure what is wrong with my face. My eyes seem misaligned and not symmetric. The thing is when I look in the mirror I can’t see much wrong with my face it’s only on photos. I’m not sure if the pictures make it 10x worse or if the mirror makes it look like nothing is wrong. I don’t really know the aspect in which people see me. I have a great deal of anxiety due to this and i’m not sure what’s wrong or how it needs to be corrected. What can you recommend ?

A: I think there is no question you have a significant orbital dystopia of the right eye. In the perfectly oriented facial photo, you can see that the right eye is lower than the left as well as the eyebrow on that side is also lower. This is somewhat masked in your other pictures because you tilt your head to the right side, probably as a subconscious reaction to mask the facial asymmetry as it makes it appear more symmetric than it really is. The difference in the horizontal pupillary levels is about 5mms lower on the right than the left. Also you can see that your nose is deviated to the right, one side of the chin is slightly longer on the affected side and the eyelid on that side has some laxity with a more ‘droopy’ position. If you had a 3D CT scan of your face you would see how different the right orbital ‘box’ is compared to the left.

All of the most significant signs of orbital facial asymmetry could be improved by a collect of procedures done around the eye. These would include orbital floor augmentation, right lateral canthoplasty and a right eyebrow lift would be helpful for improved facial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana