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 need some help with an issue. I had an orbital floor fracture repair done a year ago with mesh implant. Since then I now have enophthalmos and nerve damage in my face. I want to know at this point is there anything you can do for me or suggest? PLEASE help me if you can I would greatly appreciate you!
A: I will assume that you had an isolated orbital floor blow-out fracture. When that occurs, the supporting thin bony floor of the eye drops down. If significant enough (greater than a 1 cm floor defect) the eye will drop down. (enophthalmos) In addition, the large infraorbital nerve runs just under the orbital floor so it frequently gets trapped or pinched as the floor drops down. This is a sensory nerve (maxillary division of the trigeminal nerve) that supplies feeling to the cheek, lip and side of the nose. If injured or entrapped, patients may suffer long-term numbness or pain.
During an orbital floor repair, I always check for this nerve and make sure it is not entrapped in the blow-put fracture. Sometimes the nerve may be irreversibly injured, other times it may be entrapped and needs to be released. Reconstruction of the orbital floor can be done by a wide variety of synthetic implants or bone. There are proponents for all approaches and any of them can work with good surgical technique. The goal of orbital floor reconstruction is to prevent long-term dropping of the eye, known as enophthalmos, due to loss of support.
Since you have enophthalmos and infraorbital nerve dysesthesia, I suspect that further surgery may be beneficial by removal of the mesh implant, exploration and decompression of the nerve and a new floor reconstruction done. The first place to start, however, is with a good CT evaluation. I would get a 3-D CT scan of the involved orbit to first look at the anatomy. Based on that information, surgery can be planned appropriately.
Dr. Barry Eppley
Q: Dr. Eppley, I got punched in the face a year ago and my eyeball has been sinking since. I am pretty sure that I fractured my eye socket but it was never treated. I didn’t go to the hospital when it happened at the time. My eye got very bruised and swollen afterwards and it took about three weeks for all of it to go away. I’d like to know if my eye will keep sinking. Please see the photo and let me know if you think this problem can be fixed. Thank you.
A: The description of your facial injury most certainly sounds like an orbital floor fracture. This is classic for orbital trauma as the thin bone of the floor of the eye blows out and downward as a decompression mechanism for protection of the eyeball. When displaced and untreated, the eyeball will sink downward afterwards as the floor that supports it is lower. After a year, the eyeball should sink no lower as the soft tissues under the eyeball has fully settled into the hole in the orbital floor. The level of your eyeball can be restored by orbital floor reconstruction. The scarred soft tissues under the eye can be freed up and the bony hole rebuilt/covered with either thin synthetic materials or bone grafts. This will bring the horizontal level of the eyeball up to its preinjury position.