Fourth nerve palsy has gone undiagnosed for 36 years. This has caused eyelid and facial asymmetry. Is there help? (Photo)

I was finally diagnosed with fourth nerve palsy in my left eye this week. After a lifetime of vision disturbances, chronic neck pain and embarrassment by my "wonky" floating eye, I'm finally on the path to having it corrected. My question is this, after the surgery to my eye muscle, is there anything I can do to correct the eyelid and facial asymmetry?

Doctor Answers 4

Tough question

I used to live in Louisville so I am glad to help. Your fourth nerve palsy sounds like something for our eye colleagues and I am glad someone is helping you with that. As far as the asymmetry goes, there are changes that can be made. Your photo is not full face frontal so it is a little hard to comment and I also cant tell if the asymmetry is at rest, when moving, or both. Movement asymmetry can be improved with botox, at rest asymmetry can be improved by volumising if it is soft tissue. I suspect however that there may be a skeletal element to your asymmetry. This will require a CT scan and a review by a craniofacial surgeon if it is the case. Hope this helps and that I haven't made your situation more complicated with my answer. 

Good luck.

Adam Goodwin

Amazing things happen when distracting aspects of the face are corrected.

You have a head tilt.  Presumably this will be improved with the strabismus surgery.  It is important that you weight a full 6 months after the surgery to let your head posture adjust to the new surgery.  It will be much easier to judge what is going on at that point.  Best of luck to you and please repost when you have healed.

Kenneth D. Steinsapir, MD
Los Angeles Oculoplastic Surgeon
4.9 out of 5 stars 23 reviews

Facial Asymmetry

It is extremely common for patients to have facial asymmetries.  In these cases, injections with dermal fillers can help improve the asymmetry and camouflage some of the issues.  In reviewing your pictures, I would recommend you start with non-surgical and conservative options.  I hope this helps.  

Facial asymmetry

You really have more than a fourth cranial (trochlear) nerve defect.   You have significant bony craniofacial asymmetry involving the cranium and facial  bones judging from the photos.  A complete workup would involve extensive studies and craniofacial surgery that is probably not advisable.  Several things including fillers can be used to help partially camouflage the asymmetry.  I recommend that you get a second opinion from a plastic and reconstructive surgeon before doing anything.    You are an attractive, well-groomed person.  Some time, less is better.

Richard O. Gregory, MD
Orlando Plastic Surgeon
5.0 out of 5 stars 11 reviews

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