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What is FACIAL ASYMMETRY?

It is important to note that nothing in nature is truly symmetric. All faces have some intrinsic degree of asymmetry. However, when the asymmetry is more pronounced, it may bother the patient. Facial asymmetry has numerous etiologies: congenital, traumatic, iatrogenic, and post-oncologic. In patients who present for improvement of facial asymmetry, the ideal treatment will depend on their physical examination.

Symptoms SYMPTOMS

Severe Asymmetry
Osteotomies are indicated in major cases of facial asymmetry and include jaw movement surgery (orthognathic surgery), jaw reduction or augmentation surgery, and chin surgery. Moving the upper and lower jaws into a symmetric position may be the most powerful tool to correct severe facial asymmetry, but in patients who do not want to undergo surgery of this magnitude, camouflage procedures using facial implants and fat grafting can create an improvement in facial symmetry through less invasive techniques.

When large asymmetric movements of bone occur, the soft tissue response is unpredictable and does not necessarily translate into soft tissue symmetry despite underlying skeletal symmetry. Fat grafting may be considered at the time of surgery in areas where soft tissue asymmetry is anticipated or as part of a revision procedure after swelling resides and soft tissue asymmetries become evident.

Asymmetry of the chin has a profound impact on the symmetry of the face. Many times severe asymmetries can be significantly improved by centering the chin's position and feathering the edges with fat grafting.

Moderate Asymmetry
When the asymmetry is not severe enough to warrant an actually moving the jaw bones, facial implants may be utilized. These can be palced on the cheeks, the lower jaw, or the midface. In many asymmetry cases, the underdeveloped side is a combined skeletal and soft tissue deficiency. When an attempt is made to achieve facial symmetry with a bone graft or alloplastic implant alone, the overlying soft tissue may have an excessively angular appearance when compared to the opposite side. It has therefore been demonstrated that an improvement in skeletal symmetry does not always lead to an improvement in facial symmetry. In fact a mild disparity in size with normal contours and texture may actually be preferable over a "symmetric" skeleton with an angular appearance on one side and a soft tapered appearance on the other. In cases of moderate to severe mandibular asymmetry for example, it is recommended to reduce the size of the alloplastic implant and feather with fat over top to create both good 3 dimensional qualities and the right contour and texture over the overlying soft tissue.

In patients with moderate cheek asymmetry an alloplastic implant is usually used to recreate symmetry. Given the thin skin of the lid cheek junction, fat is a useful tool to reestablish soft tissue volume, thereby enhancing a natural appearance. Visible or palpable edges of implants will compromise the result and give the patient an iatrogenic appearance that may be as unsatisfactory as the original deformity. Fat grafting in this region can be performed at the initial surgery and repeated as necessary in the office under local anesthesia. To minimize surface irregularities, it is important to layer the fat deep to lift the overlying normal tissue rather than add the fat superficially. Our initial injections in this region tend to be just over the periosteum and proceed incrementally superficial to the subcutaneous level.

Mild Asymmetry
In patients with mild to fat grafting alone may appear to be a reasonable strategy for correcting asymmetry. If fat grafting is not an option, dermal filelrs may be used to soften asymmetry. It is our belief , however, that this approach is usually flawed. When approaching a patient with facial asymmetry it is critical to be aware of the components that are contributing to the deformity. In almost all cases both the skeletal and soft tissues are contributing to the problem. In all but the most mild cases, it is na´ve to think that fat grafting alone will correct the asymmetry and provide the optimal aesthetic result. Skeletal problems ultimately require skeletal solutions-replace like with like. Attempting to correct facial asymmetry with soft tissue fillers alone may improve volumetric symmetry, but will likely result in a soft, doughy appearance.

Treatment TREATMENT & MANAGEMENT

Correction of facial asymmetry may require moving bone (osteotomy), adding bone (bone graft), adding an implant (alloplastic implant), reducing bone, adding soft tissue (fat, filler, flap) or reducing soft tissue (liposuction) to create symmetry. While correcting skeletal symmetry the overlying soft tissue may exhibit some persistent asymmetry in contour or texture following these procedures. Autologous fat grafting has been a useful tool to improve the soft tissue results for these patients. Because of the myriad of tools that can be applied to each patient, it is important that you see a surgeon who is facile with all techniques so that your treatment is not compromised by a surgeon's limited skill set.