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Background: Facial asymmetry is common and most of us have it to some mild degree. Some would say that a certain amount of asymmetry makes the face uniquely different and provides character to it. But only each individual can say whether they consider their degree of facial asymmetry, if present, of aesthetic benefit or not.

But when the degree of facial asymmetry is more significant or is disturbing to the person regardless of its magnitude, the facial asymmetry needs to be fully evaluated. Most facial asymmetries often encompass the entire side of the face if one looks closely enough. There may only be several asymmetric features that stand out. But it is more often than not that the whole side of the face is involved to varying degrees. In addition most facial asymmetries are caused by underdevelopment (hypoplasia) of the involved side. It is much more rare that overdevelopment (hyperplasia) accounts for the cause of the facial asymmetry.

In assessing facial asymmetry of any significance, a 3D CT scam of the face is needed. This will identify any bony asymmetries and correlate that to what is seen on the outside. From there a treatment plan can be devised which may include custom facial implants if so indicated as a foundational component.

Case Study:  This young female was bothered by her right hypoplastic facial asymmetry which could be seen from a lower eyebrow down to a smaller jawline. A 3D CT scan showed, besides a general twist of the facial skeleton to the right side, a flatter cheekbone all the way along the arch to a smaller jawline starting right behind the chin back to the jaw angle.

Custom cheek and jawline implants were designed by making a mirror image of the deficiency from the left to that of the smaller right side. It could be seen how much surface area they cover even though no thickness of any of the two implants was greater than 3.5mms.

Under general anesthesia and through three intraoral vestibular incisions (one for the cheek under the upper lip and two for the jawline implants near the chin and back by the molars), the two implants were placed. One should not let the thinness of the implants fool one as to their ease of placement. With thin edges that cover a broad bone surface it is challenging to get the implants into the right position and laying flat on all edges as well. Screw fixation is essential.

When looking at custom facial implants for facial asymmetry it is most noteworthy how much surface area they need to cover for a complete bony correction. And they are often not very thick. This speaks to the frequent historic occurrence of persistent or worsened asymmetry when the a surgeon ‘eyeballs’ the asymmetry and picks a standard implant style or hand modifies an existing implant to try and correct it. This is usually too thick and does. not cover enough surface areas to be effective.

It is important to point out that no one procedure, even custom facial implants, provide the complete correction of any facial asymmetry. Other overlying soft tissue procedures may be needed as well. But without creating a more symmetric bony foundation, any overlying soft tissue work would be less effective than it otherwise would be.

Case Highlights:

1) Many hypoplastic facial asymmetries have a significant skeletal basis to them which serves as the foundation for improved facial symmetry.

2) The best diagnostic assessment of facial asymmetries is a 3D CT scan which allows for proper treatment planning.

3) For hypoplastic facial skeletal asymmetries, custom implants can be designed which often covers large surfaces areas but are often quite thin as well.

Dr. Barry Eppley

Indianapolis, Indiana

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