Facial asymmetry often involves the lower jaw. Since the lower jaw defines the border of the face to the neck, any differences between the two sides of the face can be clearly seen. It is usually not difficult to determine which is the normal side and which is the affected side although this is ultimately determined by patient preference.
In cases of facial asymmetry caused by either excessive lengthening or a more inferiorly positioned bony half of the face, the inferior border of the lower jaw is too long. This is most clearly seen in a simple panorex x-ray where the entire lower jaw is laid out in a flat 2D fashion. It is also clearly seen in a 3D CT scan with a side view showing the different heights of the lower border of the mandible.
Removal of the lower inferior border of the mandible is done by a saw cut based on measured differences between the two sides. This usually needs to run from the chin back to the jaw angle. This bony cut is most easily done from a submental incision where it becomes a straight line with the best visualization. While this can be done from an intraoral approach, this makes it much more difficult and has a greater risk of injury to the inferior alveolar nerve.
The straightness of the bony cut (mandibular inferior border shave) from a submental incision can be seen in this before and after x-ray assessment.
Fat loss in the face is referred to as facial lipoatrophy. While some people have it occur naturally with aging or weight loss, for others it is a medication side effect. While retroviral drugs have extended the lives of patients with human immunodeficiency virus (HIV), one of its well know side effects is the loss of the facial fat compartments. This has become known as facial wasting since it is an abnormal and active process. In facial lipoatrophy terms, there are various degrees of it classified as I through V. Many HIV positive patients have advanced type IV and V facial lipoatrophy appearances.
While facial wasting affects all fat layers in the face, its biggest impact is on the buccal fat pad. With its numerous fingers of fat that extend throughout the face and up into the temple region, loss of the buccal fat pad creates a skeletonized and hollow facial appearance. In its fullest extent, it makes one look ill and unhealthy and carries the social stigmata of someone who has the disease.
It has been shown that thymidine analogue drugs are the cause of this facial lipoatrophy effect. Recovery of some of the lost fat can be achieved with a switch to nucleoside reverse transcriptase inhibitor-sparing therapies but it is slow and never complete.Various forms of plastic surgery are needed to create a more dramatic and immediate facial change.
Facial rejuvenation procedures for facial wasting is focused on volume restoration around the periorbital region (eyes), specifically that of the cheeks and temple regions. The temple hollowing is a pure soft tissue deficit while that of the cheek area is a combined bone and soft tissue deficit. This is not to say that the cheek has lost bone but that it has become very skeletonized adn looks withered, thus cheek (malar = bone) and the area below the cheek (submalar = soft tissue) needs building back up.
While there are injectable treatments available to treat facial wasting, synthetic (Sculptra) and natural (fat), they have favorable degrees of effectiveness. Sculptra injections are for those patients who are definitely opposed to surgery and have the patience to wait until their fill effect is seen…and then have it repeated 18 to 24 months later. Fat injections are problematic both in harvest and persistence. Many facial wasting have little fat to harvest and its ability to survive in tissue beds with very little subcutaneous fat is precarious at best.
A facial implant approach can be very successful and create an immediate volume restoration with long-term stability. The temple hollowing is treated with new soft silicone elastomer temple implants that are placed below the fascia but on top of the muscle. This camouflages the implant edges and is a remarkably simple procedure to insert them with no postoperative pain, little swelling and a very quick recovery. They are far superior to any injectable filler because they are so effective. They key in using them is to not pout in a size that is too big which is very easy to do in a very skeletonized temporal region.
The cheek area requires a very broad-based implant, part of which is placed below the cheek bone on the masseter muscle. Proper implant placement actually puts at least half if not more of the implant below the bone. While once submalar cheek implants were exclusively used, I have found that larger combined malar-submalar shell implants do a better job of midface volume restoration. Because these type of cheek implants are substantative in size, screw fixation is useful to keep them in the desired location as they heal.
One area that is left out with temple and malar-submalar shell implants is the intervening area over the zygomatic arch and immediately beneath it into the lower face. A complete facial wasting surgery includes implantation of this area as well but has to be done with either fat injections or preferably a dermal-fat graft placed through a limited facelift approach. Without filling in this area there can be a step-off in the face behind where the malar-submalar shell implant ends.
Facial wasting treatment is one specialized form of facial reshaping surgery. These procedures allowing for volume restoration of the face hopefully to a level that is close to what they looked like before starting their anti-viral drugs. With a more ‘plump’ face, one self-confidence is improved, they look healthier and they will be encouraged to stick with their long-term drug therapy.
Every elective cosmetic facial procedure that a plastic surgeon does is to create a more beautiful or attractive face. Many patients that undergo aesthetic facial plastic surgery today have a very clear idea in their mind as to what deficiency they have and what procedures they think will give them the improvement they are seeking. Some may ask if what they are seeking will create a more attractive face and others may ask what else or what the plastic surgeon may suggest.
Between discussions and computer imaging, most of the proposed facial procedures can be determined. But there is no doubt that facial attractiveness is highly subjective and personal factors of age, race and ethnicity influence how attractiveness is perceived. There are large numbers of facial measurements that can be done from anthropometric studies, but in the end the phrase ‘Beauty In The Eye Of The Beholder’ trumps any objective assessment.
While the determination of an attractive face may be subjective, there are well known guidelines that can be assessed and measured to help guide a surgical plan. They include symmetry, proportion and gender specificity.
While no face is perfectly symmetric, the closer the two sides of the face match the more attractive it will seem to be. Most observers, even close friends, do not usually notice many facial asymmetries. But each individual does as they spend a lot more time looking at themselves everyday and many asymmetries can be glaringly apparent in pictures due to their static nature. In my experience creating symmetry, even if never perfectly achieved, is a key feature in improving facial attractiveness.
The concept of facial proportion comes directly from anthropometric work that dates back to DaVinci. The horizontal assessment of facial thirds is the simplest and the most useful facial proportional measurement. Numerous forehead and lower facial procedures (jawline, chin) can be done to affect these facial ratios. The vertical fifths apportionment of the face is equally valid but less easily changed by surgery. There are also lots of facial angle measurements which are helpful to individual features but few are rigidly tied to an absolute attractiveness effect.
Gender association refers to facial features that are clearly male vs female. Overall, a man’s face is simply bigger with larger overall measurements. But many of these important gender features that create attractiveness are not based on pure numbers but underlying skeletal features that have developed due to hormonal influences. For example, the male forehead angles back more, is less convex and has a brow prominence with a visible brow break. Conversely, the female forehead has a minimal brow protrusion, no brow break and a greater convexity that is more vertically inclined. The male nose is higher with a straight dorsal line and a tip that creates nasolabial angle of around 90 degrees. Conversely, a more feminine nose can have a slightly concave dorsal line with a higher tip position and a more open nasolabial angle. The most obvious gender feature between men and women is the jawline where the differences in chin and jawline shapes are well known.
In the end, changing a face with the intent of enhancing attractiveness is a balance between striving for better symmetry, proportion and gender accentuation. How to put these three facial components together in a surgical plan is a mixture of objective and subjective assessments and the procedures needed to achieve them. This gestalt approach to facial reshaping is critical for success and requires a lot of experience to ever develop the amalgamated thinking to optimize facial outcomes.
The facial aging process is one that is well known as everyone will eventually see it on their face. The eyes get heavy, the brows descend, the cheek fall, jowls develop and the neck sags. Women become concerned earlier in the aging process and proceed to do procedures to treat or slow it down in an overall more comprehensive manner. Men take a much more delayed approach to it often waiting until one facial area becomes a major concern or until the facial aging process is fairly advanced.
While the face ages largely similar in both men and women, the facial procedures used to treat them are often done differently. Not as many men have facelifts as their aging neck and jowls are more tolerated. But in men that have facelifts they must be done very carefully, respecting the natural hairlines of the temples and behind the ears and being careful not to displace the beard skin into the ear canal. Incisions must be placed very inconspicously and often less of a tightening result must be accepted to keep the scars hidden. That is not a bad thing as men look better underdone than having their faces pulled too tight anyway.
While men also develop heavy upper eyelid skin and lower eyelid bags just like women, their eyelid lifts (blepharoplasties) need to be done more conservatively. Browlift options in men are more limited due to the frequent lack of adequate scalp hair and a well defined frontal hairline. The most common male browlift method is through the upper eyelid (transpalpebral browlift) using the endotine device to accomplish the lift. This produces a very modest browlift but creates no visible scars and with more conservative eyelid skin and fat removals can avoid overfeminizing the male face and creating an unnatural overdone look.
Men do not engage in as many Botox and injectable fillers treatments as women as some wrinkles and signs of aging are more tolerated. A more natural result for men is one that reduces the worst of the wrinkles but does not eliminate all of them. This is the same reason men, at best, will only do a bare minimum of facial skin care. Many men would rather seek more definitive surgical procedures, or do nothing at all, that engage in non-surgical procedures that require frequent efforts to maintain.
Facial reshaping surgery is vastly different in men than women. Male rhinoplasties must keep a high and straight dorsal line and avoid an overly upturned tip while most women desire a smaller less projecting tip and lower dorsal lines. The shape of the face in men is dominated by a strong jaw and requests for chin, jaw angle and even total jawline enhancements are not uncommon to pursue a more masculine appearance and even the so called ‘male model’ look. Men favor higher more angular cheek augmentations while women prefer a lower more anterior rounded cheek prominence. Men pursue brow bone surgery for either reduction of an overlying prominent one or for augmentation to create a more masculine brow prominence and a more backward sloping forehead profile.
Plastic surgery for men has its own unique requirements both in the type of surgeries and the demeanor of the patients. One should not assume that every plastic surgeon or plastic surgery practice is equally adept about meeting the needs of the male patient. Just like breast reconstruction for women or body contouring after massive weight loss, the male patient presents unique challenges for a satisfying surgical outcome.
It is not uncommon to hear a patient’s concern about their chubby or ‘fat face’. For some of these patients their face matches their body habitus and some significant weight loss will do wonders for those concerns. But there are people who do have a chubby face that are not necessarily significantly overweight and they may seek a plastic surgery consult to see what their options are.
The chubby face differs from other facial types in that the entire face appears full. From the cheeks down to the neck, the face assumes a definite round shape. Patients with a chubby face will often complain that the shape of their face makes them appear heavier than their body really is.
There are numerous non-surgical facial fat reduction methods that are marketed and sold. I can not comment on whether these work or are effective as they are not used in my Indianapolis plastic surgery practice. But should you try them and find them unsatisfactory, you can consider the following surgical options.
Almost all chubby face patients have thicker and elastic skin. This is a double-edged anatomic consideration. Such skin has the ability to shrink and contract (snapback if you will) which is good for getting better contours, particularly in the neck. Conversely, thick skin is also heavy and is prone to prolonged swelling.
The strategy for the chubby face is not one of overall fat reduction through liposuction. This is not possible in the face contrary to the perception of many. Select or spot fat reduction must be done instead. This would include submental and neck liposuction and buccal (cheek) lipectomies. These are very consistent procedures that are effective but patients should not expect them alone to produce a dramatic facial change. Fat pockets around the eyes and excessive skin can also be helpful if they exist but these are complementary procedures, not a primary modification maneuver.
There are no other fat areas of the face that can be effectively reduced. While significant changes can be made, for example, through a superficial parotidectomy and submandibular gland removals, these are extreme procedures which are not justifiable for cosmetic changes. Attention must be turned to bringing out facial prominences to aesthetically work in the opposite direction.
The cheeks, chin and nose must be carefully look at to see if their accentuation would be beneficial. The chin is the easiest one to assess as a weak chin is readily seen. Chin augmentation, even if it is only a minor amount, can complement the contour pullback from the neck liposuction. Cheek augmentation is more difficult to determine its potential benefits as it is not a profile structure. Unlike the chin, cheek augmentation in some patients may actually make their face look fuller or heavier. A cheek implant to help make a face look thinner must be placed high on the cheekbone and not be overdone in amount and location of projection. Too much anterior or too much lateral projection creates undesired midfacial fullness.
A rhinoplasty with dorsal augmentation and tip narrowing can help make the face look thinner by an optical illusion effect. Thinning of the nose is the one procedure that affects the central face whose appearance is not based on how much fat is present. Patients with chubby faces rarely have a narrow nose or a nose with a high dorsum. Usually they have a broader dorsum with a wider tip to their noses.
To change the appearance of the chubby face, multiple soft and hard tissues procedures are needed. These can include neck and cheek fat removal, blepharoplasty, and facial bone prominence highlighting. Piecing together these procedures into an effective facial surgery plan is as much an art form as any definitive science.
Liposuction is a very effective method of fat removal. While it can be used in almost any location of the body where there is fat, it does have limitations. And when applied to certain fat areas, it may even have the opposite effect of an undesired result.
The face is one such area where the concept of liposuction is largely more theoretical than practical. While the face does have fat below the skin, it is not easily removed like that in the trunk or extremities. Facial fat is more fibrous and has branches of the facial nerve lying deep to it. There are few very discrete collections which can easily be removed with the exception of the buccal fat pad and some of its numerous extensions.
Plastic surgeons frequently advertise and perform neck liposuction. And while the neck is part of the face, most patients do not think of the neck when they envision the concept of facial liposuction.
When you combine what is contained in the buccal space with the subcutaneous tissues in the neck, these are the only two facial areas where contouring can be done through fat removal. The neck can be liposuctioned while the buccal fat pad can be directly extracted through a small open incision. Removal of any other facial fat areas through liposuction is not only ineffective but can cause a lot of tissue trauma and prolonged swelling.
When liposuction first became widely used in the 1980s and 90s, facial liposuction was both advocated and written about. It was used to try and reduce facial fullness in the lateral face and even reduce the prominent mound of tissue that develops above the nasolabial fold with aging. It was proven to be ineffective and has since become largely abandoned as a treatment for facial fullness.
For those seeking to reduce their ‘fat’ face or to deround their facial appearance, liposuction is not the answer. It simply can not do what can be done for the circumference of the thigh or the waistline. One cannot deflate the face so to speak.
Improving the shape of a very full and round face does include some fat removal which is accessible, the buccal and neck fat. But fat removal alone is inadequate as it can only change some of the contour. If a full neck is all that bothers someone, then liposuction alone is a good treatment. But for more total facial sculpting and definition creation, it must be combined with other procedures that bring out or highlight facial prominences such as the chin, cheeks, or jaw angles. Using implants in these facial convexity areas can help bring shape to an otherwise amorphous face.
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.
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 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.