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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘facial asymmetry’

Plastic Surgery’s Did You Know? The Science of Facial Beauty

Sunday, July 1st, 2012

The concept of beauty has changed over time and does vary amongst different cultures. But the basic tenets of beauty, proportion and symmetry, are timeless and unchanging. Thousands of years ago Nefertiti was considered the most beautiful of all women with her arched brows, high cheekbones, and slim nose. In the 1950s, Grace Kelly was viewed as a natural beauty because of her very symmetric and proportioned facial features and small slightly upturned nose. Leonardo Da Vinci was the first to apply scientific and mathematical analysis to the study of the face. Contemporary studies have confirmed the importance of symmetry and balance of facial features. If a line is drawn done the center of one’s face and mirror images are of made of each half, the closer these two reconstructed faces match the more attractive one is deemed. The classic example is that of Denzel Washington whose two facial halfs look remarkably similar. Lack of symmetry and proportion is a major reason why many patients seek plastic surgery for facial appearance improvement.

Corrective Surgery for Lower Facial (Jaw) Asymmetry

Saturday, November 21st, 2009

Facial asymmetry is generally the norm, not the exception. The same may be said to be true for any paired body part. Few people have identical facial halfs but most such asymmetries are minor and essentially undetectable. With the asymmetry becomes more than minor (greater than five millimeters or more), however, it may become apparent to more than just the casual eye.

One of the most common reasons for facial asymmetry is the mandible or lower jaw. In my experience, I consider it the most likely facial bone to develop differences between the two sides during growth. This most likely is because of its hinged or joint attachments (TMJ) to the skull where jaw growth is highly influenced by condylar development. Any injury, even minor, to the condyle during growth can cause bone developments differences between the two sides.

When the lower jaw is not symmetrically developed, it can be quite apparent with obvious facial asymmetry and a potential malocclusion. (poor bite) More frequently, however,  the face and jaw may be asymmetric but one’s occlusion has good interdigitation. There are many known causes of mandibular asymmetry including a superior altered cranial base (craniosynostosis, torticollis, deformational plagiocephaly), condylar deformities (fractures, hyperplasia, hemifacial microsomia, arthritic degeneration) and external compressive deformation from overlying tumors causing a mass effect.

Most commonly, however, I see mandibular-based facial asymmetries in adults which do not have a clearly identifiable cause. Regardless of the reason, known or unknown, the diagnosis only matters from the standpoint of understanding where and how the mandible is asymmetric. While 3-D CT scans make great pictures and clearly show the problem, I find that a panorex film is just as helpful. It allows for tracing and precise measurements of the vertical height of the ramus, the differences in the inferior border of the mandible from side to side, and the symmetry of the two chin halfs.

When mandibular asymmetry exists with a bite discrepancy or significant cant to the face, strong consideration should be given to a combined treatment plan of orthodontics and corrective maxillary and mandibular osteotomies. This will produce by far the best long-term solution. However, for those patients that do not want or are not capable of going through this program or for more minor asymmetries, a camouflage treatment can be done.

Camouflage treatments for any form of facial asymmetry is largely based on using bone implants for augmentation or removing bone for reduction.  For the short posterior (back part) of the mandible, the use of jaw angle implants can be very useful to made it wider or longer…often both are needed. Those jaw angle implants which extend or wrap around the lower border are particularly useful as well as more stable. When the ramus is too long, jaw angle and inferior border ostectomies (bone removal) can be done to better match the other side. Both approaches are done intraorally.

When the asymmetry involves the chin implants are not usually the best option. Cutting and leveling the chin bone (one side reduction or expansion) is usually more effective and a better long-term solution.

Significant correction of mandible-based facial asymmetries can be done by a combination of jaw angle and chin manipulations. Choosing the best options can be done through a good facial analysis and patient discussion as well as a tracing assessment of a panorex.

Dr. Barry Eppley





Correction of Facial Asymmetry in Adults from Occipital Plagiocephaly

Monday, October 19th, 2009

Occipital plagiocephaly is a well known congenital malformation of the back of the head marked by an oblique slant to the main axis of the skull. It is commonly corrected today by the early institution of either static or dynamic cranial orthotics or helmets. In rare cases if the skull is significantly deformed and does not respond to external molding influences, cranial reshaping can be successfully done.

Plagiocephaly is well known to affect how the face develops. What happens in the back of the skull will influence how the front of the skull and face looks. This occurs in a diametrically opposite manner. The side that is flat on the back of the head will be protrusive on the front….and vice versa. Even in cases where helmet therapy or even surgery has made a well rounded back of the head, the face may still show some of the residual effects as it develops resulting in facial asymmetry. When plagiocephaly goes untreated or was not adequately treated at a young age, this facial asymmetry may become quite apparent.

The facial asymmetry that results from a plagiocephalic influence appears as that of a ‘twisted’ face if one is looking from above. This is apparent by misaligned ears (the ear on the affected side may be pulled forward and down and be larger then the unaffected ear) and facial asymmetry, with the more forward side of the face having a fuller forehead, brow bone, and cheek. The jawbone will be tilted and one’s occlusion (bite) may have a cant to it. There may be differences in the position and shape of the jaw angles and the chin may be deviated toward the ‘weaker’ or more retrusive side.

When the facial asymmetry is very severe, complete facial bone repositioning incorporating orthodontics and multiple jaw orthognathic surgery is needed. But most of such facial asymmetry that I see in my Indianapolis plastic surgery practice is more mild and in late adolescence or adulthood. Patients are looking for less major methods for improving their facial asymmetry.

When one considers improving facial asymmetry, a careful analysis of the face must be done to determine exactly where the imbalances are. Of even greater importance is input from the patient as to which facial prominences they consider to be the good or the bad side. This is very important because weak areas can be built up with implants which is most commonly done because it is easier. But reduction of bone can be done in certain facial areas if they are too prominent.

Options in facial asymmetry correction include from top to bottom: forehead/brow augmentation, forehead/brow reduction, cheek and orbital implants, jaw angle augmentation or reduction, inferior border mandibular ostectomies, and chin osteotomies or implants. Such an array of procedures requires thoughtful and careful preoperative planning. When more than one of these is done during the operation (which is most common), the effects of facial rebalancing can be quite significant. In my experience, at least two or three facial areas are treated at the same time to get the best result.

 While complete or perfect facial symmetry is not obtainable in any case, significant camouflaging of the facial bony asymmetries can be made. Such surgical improvement provides great psychological relief to the facial asymmetry patient and can usually be achieved in a single operation.   

Dr. Barry Eppley

Indianapolis, Indiana

Treating Facial Asymmetry with Jaw Implants

Thursday, November 20th, 2008

Facial asymmetry exists whenever one side of the face does not match the other in size and shape. The most common reason this occurs is due to different development patterns of the underlying facial bones and is most commonly seen in people who have some facial bone development issues such as cleft lip and palate and other craniofacial birth defects. Sometimes it may just be soft tissue only and the facial bones are fairly symmetric. But aside from these types of patients, some people merely have a light or mild facial asymmetry of which the cause is not obvious or will ever be known. In essence, it is just you.

In many cases of facial asymmetry the most common finding or cause is that the lower jaw is different between the two sides. Because the lower jaw is moveable (the only facial bone to do so) and has an L-shape in the back above which the jaw joint hinges, it is the one facial bone that is most prone to having differences between the two sides. Most commonly, these differences are back at the angle area and along the jawline that comes forward. This can create a very visible difference between the jawlines when looking straight forward. It is the most common type of facial asymmetry that I see. Sometimes I will see someone who has a crooked chin, where the chin point if offline, but the origin of the crooked chin usually comes from differential jaw growth between the two sides.

In cases of facial asymmetry it is initally important to make sure that the jaw asymmetry is not best corrected by actually moving the whole jaw and putting the teeth into a better bite relationship. If one is young and the jaw asymmetry is significant, how the teeth come together will determine if this is the best long-term solution. But assuming that jaw bone movement is not a good solution, the more common approach is to correct it with the placement of implants.

Jaw angle and jawline implants can be fairly simple methods of improving jaw asymmetry. These implants are almost always placed through inside the mouth. Off-the-shelf jaw angle implants exist but there is no off-the-shelf jawline implant. Jawline implants have to be fashioned at the time of surgery, usually out of a block or thick sheet of semi-soft material. (Gore-tex or SAM is what I prefer) The key to success with implant augmentation is to be certain of exactly where the jaw asymmetry is. Implants will do little good if they aren’t in the area of bone deficiency or asymmetry. Sometimes this is obvious by feel, other times it may be better to get a 3-D CT scan and have an exact skeletal image to work off of. In rare cases, I have even had a 3-D model made from the CT scan and custom-fabricated the shape of the implants prior to surgery. This is the most exacting method but also the most costly.

When having implants placed for any type of facial asymmetry it is important to walk into surgery with the understanding that the outcome will be better…but not perfect. Surgical facial augmentation with implants is as much an art as it is an exact science.

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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