Q: Dr. Eppley, I am interested in brow bone augmentation as well as orbital floor augmentation. But I don’t want to use any synthetic implant materials to do so. Can Bio-oss (bovine hydroxyapatite) be used for orbital augmentation and brow bone augmentation?
A: Any hydroxyapatite granular material can be used to augment a confined space like the orbital floor or a more open surface like that of the brow bones. Whether a bovine hydroxyapatite will persist or develop any significant bone ingrowth as an onlay material is a matter of debate. (it works best as an inlay bone substitute material) But from a handling standpoint, it can be used for either craniofacial application. Applying the material to the orbital floor is very straightforward. Applying to the brow bones, however, is a bit challenging because access to the brow bones is more restrictive. The ideal way to use it in brow bone augmentation would be an injection technique that uses a brow incision to do so.
While the concept of hydroxyapatite granules is understandably appealing, there are prone to irregularities and asymmetry when applied as an onlay graft. This would be particularly evident when introduced as an injection as the material does not have a smooth linear flow when injected out of a syringe.
Dr. Barry Eppley
Q: Dr. Eppley, I have sent you a lot of pictures and will try to explain my questions! I definitely have some skull asymmetry. The back of my head is kind of flat and it looks really weird when I have s short haircut. I also feel that the space between my chin and neck is very small.
I also have facial asymmetry and one side is bigger than the other. One eye is than the other although I feel both sides of my face are not matched. My neck on the lower eye side also feels tight and I can’t move my head straight.
It’s a mess and doctors here say I was born like this but it has gotten worse over the years.
Thanks for reading this. Hope to here from you.
A: By your pictures and your description of symptoms and physical findings, you appear to have a relatively classic case of craniofacial scoliosis caused by occipital plagiocephaly as an infant. There are three potentially improvable craniofacial problems:
- The back of head flatness can be corrected fairly well through skull augmentation by either bone cements or a custom skull implant.
- You asymmetric eyes (orbital dystopia = one eye lower than the other) is improveable by orbital floor augmentation with or without eyelid elevation. Fortunately the eyebrow appears to be in a symmetric position.
- The tightness in your neck may be unsolveable. Unless there is a very distinct and palpable band (cord) along the sternocleidomastoid (SCM) muscle (i.e., band torticollis), the tightness may be a function of congenital shortness of the neck muscles. If there is a band, then it can be surgically released although this would be an unusual finding in an adult. One non-surgical option to consider is Botox injections into the tightest area of the SCM muscle.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking to have an orbital floor augmentation procedure. My left eye is placed about 3mm lower than the right and I am searching for different methods to correct this, trying to find the least invasive method possible. Is it technically possible to correct the orbital dystopia with injections? I mean, using some kind of injectable cement or even fat that would be injected for orbital floor augmentation. I have searched the internet but I haven’t found much information about a possible injectable orbital dystopia correction procedure. What would be the risks of such hypothetical procedure?
A: Injecting any material, even fat, into the orbit would be neither safe nor effective for correcting orbital dystopia. The most severe risk of this procedure would be blindness or visual field loss. The safe and effective procedure would be orbital floor augmentation done through a standard lower eyelid/blepharoplasty incision. Bone cement can be placed to build up the orbital floor to the desired level. This is not really much more invasive than a lower blepharoplasty procedure. It would be good to see before surgery an orbital 3D CT scan to see the exact location and extent of the orbital floor differences. A custom orbital floor implant can also be made from this same 3D CT scan.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in orbital floor augmentation to raise up my eye which is about 2 to 3mms lower than the other side. Regarding the graft material, I’d prefer to go with natural ear cartilage if that’s something you’re comfortable using. Have you used ear cartilage for orbital floor augmentations before? I also have several more questions about this procedure…
1. Could raising the eyeball via the orbital floor (as opposed to reconstructing the entire orbit in a different position) result in pressure on the upper part of my eye?
2. Is there any chance of this procedure affecting my vision?
3. How long would I have to abstain from wearing my contact lenses?
4. Could this result in unintentional horizontal movement, in addition to vertical movement? Is there any chance of ending up with a cross-eyed look?
5. Approximately how long will it take for my eye to settle in its final position, about 2mm higher than where it is now?
6. Approximately how long will the procedure take and how long will I be under anesthesia for?
7. Is there any way to do before/after 3-D imaging for this procedure? I think what I’m seeing in my head is a complete relocation of my entire eye – I’m having some trouble visualizing what it would look like just to have my left eyeball raised, while my eyelids, lashes, etc. remain in the same position.
A: Cartilage can be used for orbital floor augmentation and certainly would be a natural material. I am all for using a natural material when possible. Cartilage has the advantage somewhat similar to a synthetic implants in that it should not undergo any resorption. The only issue with ear cartilage is that the amount of graft material is fairly limited. Ear cartilage is great for the nose but the front part of the orbital floor is much bigger. Thus the only caveat is that the ear graft size may be somewhat insufficient for its intended purpose. In answer to other questions:
- This amount of orbital floor augmentation will not put any undue pressure on the eye.
- There is no risk of vision loss with this procedure.
- You can wear your contacts as soon as you feel comfortable and can get them in.
- The procedure will not result in any unintended horizontal movement.
- The final results from orbital floor augmentation can be critically judged 6 weeks later. Always the eye will look a little higher than the ‘normal’ eye for awhile.
- This is a one hour procedure done under general anesthesia.
- Computer imaging can be done of the eye moving up but it will create a distorted view. Computer imaging can only show more or less of what is already present. Thus moving the eye up should show a similar amount of iris exposure but it will look elongated and will not show a natural iris to lower lid margin relationship. I am happy to do it but you will probably not find it helpful.
Dr. Barry Eppley
Q: Dr. Eppley, I have orbital dystopia that I want corrected. Here are a few photos and you can see that my left eye is noticeably lower on my face. As you may also notice from the top view, you can see that the left eye also protrudes forward a bit. My nose and chin also are off the center line and lean to the left as well but my eyes have always bothered me the most and the others I can live with. Again, this is something that has made things difficult for me and i’ve just reserved myself to the idea that I have gone this long and I may as well just live with it….until I shaved my head due to hair loss that is. Now my eyes are the very first thing that people notice and they stand out much more now. Any thoughts/guidance would be much appreciated.
A: I have seen your photos and the amount of orbital dystopia in the left eye seems to be about 2 to 3mms at most. That can be improved with frontal orbital floor augmentation and possibly orbital rim augmentation as well. That will bring up the vertical level of the eye but it will not change the more forward projection of the eye as seen from the top view. The key question in any case of orbital dystopia is what happens with the position of the lower eyelid for that is not a bone-based structure and thus will not change. With the eye coming up and if the lower eyelid position remains the same, some slight amount of increased scleral show may result. That is why a canthopexy is usually done to provide a bit of lower lid tightening/lift as well with the change in eyeball position.
Dr. Barry Eppley
Q: Dr. Eppley, I am seeking orbital floor augmentation. I have a mild case of orbital dystopia of my left eye. It is about 2mms as judging by the position of iris of the eye to the lower eyelid compared to the other side. How would orbital floor augmentation be done. Would there be any external scarring?
A: There are numerous options of how to do orbital floor augmentation. There are two choices to make in orbital floor augmentation, incisional access and the choice of augmentation material. Because your orbital dystopia problem is fairly slight (1 to 2mms), your young age, and your asian skin, I am loathe to consider any type of open procedure that involves an external lower blepharoplasty incision. While that is how I would normally do it, I just don’t think your amount of orbital floor augmentation justifies that degree of invasive surgery. That leaves either a transconjuncival approach or a purely injectable technique. Because it is the eyeball and for safety purposes, I would not do an injectable method. That leaves us with the transconjunctival approach. (internal eyelid) The next issue is the augmentation material. This is a choice between a natural material (like fat or cartilage) or a synthetic implant. This is a classic debate in orbital floor augmentation and just about anything will work. It just depends on your thoughts of a graft harvest (ear cartilage or fat harvest) or a synthetic material. (like a bone cement or gore-tex (PTFE) floor implant. There is also the issue of how much access the transconjunctival approach offers and the ability to get the augmentation material through it.
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 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