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Dr. Barry Eppley

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Case Study – Custom Implant for Vertical Orbital Dystopia


Background: Few faces are perfectly symmetric and most of us have some noticeable differences between the right and left sides. Such facial side differences are usually well tolerated or may not even be known. We all recognize that ‘no one is perfect’ and everyone has a little bit of facial asymmetry which is seen within the range of normal.

But asymmetry of the eyes is often different because it is so easily recognized and almost impossible to visually ignore. While there are different types of eye asymmetry, many of which are related to the eyelids, one of the most recognized causes of is that of orbital dystopia. Orbital dystopia is bone-based with the orbital bony box being at different levels between the two sides. The most common type of orbital dystopia is vertical and the affected side is almost always lower than the normal side.

In vertical orbital dystopia, the affected eye sits lower which can be seen and measured by the horizontal positioning of the pupil of the eye.  The eye sits lower because the orbital floor, including the circumferential orbital rims and cheek bone, sit lower. In more minor cases the orbital dystopia is isolated to the eye area. But in more significant cases the entire side of the face from the eyebrows down to the jawline is lower.

Right Orbital Dystopia 3D CT scan Dr Barry Eppley IndianapolisCase Study: This 43 year-old male presented for cheek augmentation for which a custom designed approach was chosen. He had always been by a mild degree of eye asymmetry as well which was most apparent in pictures. A 3D CT scan shows that the affected eye had a vertical dystopia of around 3mms. The lower infraorbital rim and malar eminence as well as more inferiorly positioned orbital floor could be seen as the bony origin of the vertical dystopia.

Orbital Dystopia Orbital Floor Implanty with Custom Cheek Implants design Ddr Barry Eppley IndianapolisCustyom Cheek Implants with Orbital Floor Implant design Dr Barry Eppley IndianapolisHis custom cheek implants designs included a component on the affected side that wrapped over the infraorbital rim and onto the orbital floor to create the needed amount of globe elevation.

Orbitozygomatic Implant placement for Facial Asymmetry Dr Barry Eppley IndianapolisCustom Orbitozygomatic Implant Placement incision closure Dr Barry Eppley IndianapolisUnder general anesthesia and through a subciliary eyelid incision, the custom orbital floor-rim-cheek implant was placed and secured to the orbital rim with two microscrews. An orbicularis muscle rsuspension and lateral canthopexy was performed at closure.

Orbital Floor Augmentation result front view Dr Barry Eppley IndianapolisHis one year after surgery results showed improvement in the symmetry between the eyes. As is often the case in vertical orbital dystopia raising up the eye reveals the other components of the dystopia including the more inferiorly positioned upper eyelid and eyebrow. These are planned for adjustment in the future. (right upper blepharoplasty with ptosis repair and transpalpebral browlift.


  1. One cause of eye asymmetry is a malpositioned orbital box which causes the eye to sit at a lower horizontal level than the normal side.
  2. Orbital floor and infraorbital rim augmentation is one technique in the treatment of vertical orbital dystopia but it will not correct every aspect of the eye asymmetry.
  3. The orbital floor-rim augmentation implant is best made from a 3D CT scan in a custom implant fashion.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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