Your Questions

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

Indianapolis Indiana

Q: I have read that paranasal implants can be done in local anesthesia. Is this right? Is local anesthesia possible also with malar implants which are placed right next to paranasal implants? Does not the lifting of the periosteum from the bone hurt in spite of the local anesthesia? Thank you very much for your information.

A:  Cheek and paranasal implants are placed from an incision inside the upper lip. Besides the mucosal incision, muscles and the periosteum covering the maxillary and zygomatic bone must be lifted up and a pocket made to place the implants. Given the proximity of the paranasal area to the upper lip compared to the cheek area, it would be ‘easier’ to position paranasal implants under local anesthesia as opposed to cheek implants where greater dissection is needed and the feeling in this area has more contributing nerve endings. You are correct in that it is the periosteum that is the most sensitive part of the surgical dissection. I also prefer to us screw fixation for the implants that I place in the midface which can cause more discomfort from the bone drilling.

 While just about any surgery can be done under local anesthesia, I am not sure if I was a patient that I would ever do it that way. (particularly cheek implants) Unless there is some compelling medical reason why IV or general anesthesia could not be used, it would be more comfortable and slightly less costly to use some form of anesthesia for this type of facial implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am 30 yrs old and am tried of people telling me that I am in my mid to late 40s. Ugghhh! I usually just walk away and cry and I am tried of crying over this and want to get something done about it. I have had a brow lift and a neck liposuction about 2 yrs ago. I would like to see what it would look like with eyelid lift and filler. Would you also recommend something else? Maybe a chemical peel? Thank you for your help! I really appreciate it!

A: Thank you for sending your pictures. Unfortunately computer imaging is good at changing structures of the face but not very good at soft tissue manipulations such as those that you have asked for. An eye lift can not be done as it distorts the whole eyelid. However, I think there is no question you have upper eyelid hooding and you would clearly benefit by an upper blepharoplasty or eyelid lift. Putting in fillers along the nasolabial fold and lips is also not very accurate and often just distorts the lips in trying to image it. You have reasonable lip size so injectable fillers will make them nicely bigger. As you have suggested, a chemical peel is good for skin texture and brightening the glow of the skin and for fine wrinkles as well.

As for other recommendations, I have done some other changes just to look at how to soften your facial features and make your face more ‘youthful’. These have included the following:revisional browlift to lower hairline (reduce long forehead) and correct existing brow asymmetry, rhinoplasty to make nose look slimmer and more narrow and chin reduction to soften chin point and make softer looking.These are structural facial changes which are different than just anti-aging procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I am interested in learning about the cosmetic effectiveness of doing both zygomatic osteotomies with orthognathic surgery. I have seen some plastic and oral surgeons and I am told I have what they call a class 2 malocclusion with a restrusive mandible and maxilla, low sunken zygomas and mid-face with the outer edges of my eyes drooping. I am going to have orthognathic surgery in near future for functional reasons, sleep apnea, tmj problems, snoring, and to improve breathing while I am awake by enlarging the air ways. But cosmetically my cheeks and drooping eyes I would also like to improve. There are multiple modified LeFort osteotomies that help with filling in the face, but I am looking for something that will address the drooping outer edges of the eyes. What are the risks involved for a zygomatic osteotomy? (like double vision) How do you feel about the procedure being performed with orthognathic surgery? How cosmeticly effective is it when both done together? (other opinions suggesting best done separately) Can you achieve symmetric cosmetic pleasing effect? Not too interested in implants due to risks of dislodging and erosion, very active lifestyle, feel it would get in the way.

A: Let me give you some general thoughts about your questions with the caveat that I have never seen your photographs or x-rays and am only working off of your description of your face.

Your orbitozygomatic facial skeletal arrangement is such that the cheek bones are flat and recessed and the lateral orbits may have a little downslanting orientation. (tilted horizontal orbital axis) That problem alone, which occurs commonly in more severe deformities such as Treacher-Collins, requires a combination of  a C-shaped orbitozygomatic osteotomy with bone grafts to improve the total three-dimensional bone problem. Yours may not be as severe but the 3-D problem is likely the same. Beyond the fact that this requires a coronal (scalp) incision to do the bone cuts properly, it would be very difficult to do this simultaneously with any form of a LeFort I osteotomy. Between the scalp scar and the type of osteotonies needed, this treatment is likely too severe for correcting a more mild orbitozygomatic bone problem.

While there are some high modifications of a LeFort I osteotomy, they are restricted in how the zygoma moves and will only bring it forward but not out. (no width improvement) These are interesting operations on paper and in surgical diagrams but have never proven very practical or effective. That is why they simply are not done or rarely attempted.

The conclusion is that any form of an orbitozygomatic osteotomy is too big of an operation, will leaves palpable (able to be felt) bone edges, and also requires bone grafts. This is why the best approach, even if you don’t desire it, is to do some form of a cheek implant with lateral canthal repositioning of the eye. These are far simpler, much more cosmetic effective, have less complications (both short and long term) and can be combined with orthognathic surgery.

Dr. Barry Eppley

Indianapolis Indiana

Q:  Hello, I have a rare problem. I think, although I am not sure, I have always slept on the left side of my face. Ad a result, I have an extremely strong left chin and not hardly a right chin at all. I was hoping for implants on the weak side or a reduction on the strong side whichever is best. I’m fine with what ever as long as I can look more symmetric. I have attached some photos so you can see what I am talking about. Thanks!

A: Thank you for sending your pictures.  Based on your pictures, you do not have chin asymmetry. Rather you have facial asymmetry. The left side of your face is bigger than your right and this is most evident to you along the jawline and at the jaw angle. That is very evident in looking at your side views where the right side lack the prominence at the jaw angle that is seen on the left. Your chin is actually fairly straight. Usually with such facial asymmetry the chin will swing over to the right and be off midline. But this fortunately has not occurred in you.

You would benefit from a right jaw angle implant augmentation to try and get a better match to that of the left side. The jaw angle implant will both lower the angle and add width to it.  The width of the jaw angle implant is actually the most important in your case. This will improve your facial symmetry considerably through this relatively simple jaw implant procedure.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, My droopy eyelids are driving me crazy. While I have always had very fleshy and heavy eyelids, they have gotten worse as I age. After my 40s (I am 55 now), they began to sag badly. Putting on makeup has become very difficult. What’s even worse is that it is making my forehead wrinkle. My eyelids are heavy and they seem to be in the way of me seeing. Without realizing it, I tense my forehead muscles to lift my brows up. This lifts up some of the eyelid skin and makes me see better. All of this forehead muscle tensing has given me permanent creases in my forehead. Should I just have my eyelids done or both my eyelids and my forehead?

A: Droopy and heavy eyelids, besides interfering with you seeing, can make you look sad and tired. Blepharoplasty (eyelid lift or tuck) can open them up dramatically and give you a fresher and more alert appearance. (some call it a youthful change) That is certainly what you would benefit from as you have realized.

A browlift is a good complementary procedure to blepharoplasties if your brows have dropped with age. Lifting one’s brows up can signify that it is either a reaction to drooping eyelid skin or that the brows are too low as well. That is an important distinction to make. I suspect that it is more of a reaction to your eyelid skin issue. Therefore a browlift is not what you really need. More likely you would benefit from Botox injections to ‘detrain’ your forehead muscles from the muscular responses they have now learned to do.  

Dr. Barry Eppley

Indianapolis Indiana

Plastic surgery continues to grow in popularity as evidenced by the statistics from the American Society of Plastic Surgery over the past decade. Surgical procedures as well as non-surgical cosmetic office treatments have increased every year since 2000. With the explosion of the internet and other communication mediums, a tremendous amount of information about plastic surgery is available at the click of a mouse from anywhere in the world.

But like much on the internet, news magazines, and product brochures, what can you believe? How do you separate reality from the marketing hype? How can you decide what are the best treatment options for your facial concerns?

Dr. Barry Eppley, board-certified plastic surgeon of Indianapolis, takes you on a tour of facial plastic surgery. Covering dozens of the most popular cosmetic surgeries and treatments of the face, Dr. Eppley talks plainly about his experience and observations. From facelifts and nosejobs to injectable fillers, Dr. Eppley writes from his own extensive plastic surgery experience of the face, and provides insights into what many cosmetic procedures are, and what they actually do.

The desire to feel beautifully confident at any age is a natural one. Seeking plastic surgery ‘assistance’  is not vain or trivial. It is a major decision that requires forethought and preparation. Whether you are still considering  if plastic surgery is right for your face, have an upcoming consultation with a plastic surgeon, or are planning a procedure in the future, Dr. Eppley prepares you to ask better questions and Face The Facts!