Facial Asymmetry Surgery

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Lack of proportion

Extensive research has found that there is a certain optimal ratio of the distance between the main features on the face that makes a person’s face look attractive. According this optimal ratio, also known as the “golden ratio”, the ideal face is around one-and-a-half times as long as it is wide. 

The three key facial measurements that are required for determining how close a person’s face is to meeting the “golden” proportions are as follows: Face divide in 3 parts from forehead to chin

Deviation of the lower face is more frequent and greater in length than that of the upper and midface. Deviation of the chin being the most remarkable feature of asymmetry. A possible explanation would be the longer lower jaw (mandibular) growth periods, in addition to the upper jaw (maxilla) being rigidly attached to the stable region of the cranial base.

Because of their developmental origin Aesthetic Facial Asymmetries occur in patterns which can be divided into complete and incomplete types.

Incomplete facial asymmetries are where just one facial feature is affected. The single most common incomplete facial asymmetry is that of the lower jaw. The upper two-thirds of the face are symmetric but the lower jaw is asymmetric.

Complete facial asymmetries are when the entire side of the face is involved and they typically present in two types, a top to bottom pattern (superior facial asymmetry) or a bottom to top pattern. (inferior facial asymmetry). In both types the most affected facial features are either at the top or the bottom of the face and their degree of involvement fades in severity as one moves away from the more severely affected area.

In the superior facial asymmetry, the eyes are seen as the major asymmetric feature. The eyes are at two different levels as judged by a horizontal line drawn through the pupils. Almost always the affected side is the lower eye. But close inspection of the facial features below it can show a downturned mouth corner/lip deviation, nostril asymmetry or even the entire nose pulled toward that side and lower, a fuller jowl on that side as well as chin/jaw lengthening on the asymmetric side. 

In the inferior facial asymmetry the lower face is the most serenely affected by chin/jaw deviation or decreased fullness from the other side. The occlusal plane  may be level (often because of orthodontic treatment) or even slightly tilted upward on the asymmetric facial side. Similarly the nose will show a nostril that is asymmetric but higher with some slight deviation of the nose. 

So while facial asymmetries can involve a wide variety of feature differences between the two sides of the fade (chin/jawline deviation, vertical facial shortening, cheek retrusion, orbital floor/eye displacement, eyebrow lowering, forehead and brow bone protrusion or retrusions and nasal deviations) they generally follow patterns that can be explained by their embryologic development

Facial Asymmetry is usually caused by the combination of differences in facial length, underlying soft tissues (muscles, fat) and skeletal shape, muscular size and activity, as well as underlying structures. Facial asymmetry must be assessed by thorough and judicious analysis conducted by means of a first interview, extra- and intraoral clinical examination, as well as supplementary diagnostic examination such as radiographs, 3D CT Scan and MRI.

These assessments are necessary to determine what exact procedure(s) would be beneficial and which ones would have the greatest impact on improving facial symmetry. A list of all structures contributing to the asymmetry is made and ordered in priority of importance to the patient. Then the appropriate procedures are matched to the diagnosis list. 

The patient then gets to choose which procedures they value and feel will make the greatest amount of improvement. In some cases, all selected procedures may be done at once and in other cases the patient may choose to do only a few or do a staged approach awaiting the outcome of the most important procedures first.

• Although a mild non-pathological facial asymmetry is in many cases imperceptible and is often considered normal, its clinical importance cannot be easily determined, since facial aesthetics are completely subjective. Therefore, the degree of acceptance of this malformation will depend largely on the region of asymmetry and the perception of the patient's imbalance.
• That is why not all patients who have facial asymmetry are candidates for surgery, but only those who have a degree of facial asymmetry evident for their social, professional and family environment or that disturbs their peace of mind.
• An asymmetrical face is considered to be unique, charming and attractive. But decision to correct facial deformity is your own. Do you love your asymmetrical face? If not, then you are a candidate for facial asymmetry correction treatment.

Following are some of the reasons for facial asymmetry correction treatment

1. People for whom the center line dividing the upper and lower lip is non-straight.
2. People who have a non-straight line between the center of the nose and middle of the lips.
3. People who have two different chin or jaw lines (left & right).

Correcting facial asymmetry can have many benefits, such as:

• Enhanced aesthetic appearance
• Greater self-confidence
• More youthful appearance
• Better facial function

Whatever the extent of your facial asymmetry, you should ALWAYS consult with a trusted, board-certified Maxillo-Facial Surgeon before making any treatment decisions. Such a professional can evaluate the extent of your facial asymmetry and recommend treatment options that suit your specific needs.

The solution of facial asymmetry, like all surgical procedures that we perform at the Nuface Clinic, solves at the same time aesthetic problems, such as lack of harmony in the factions, and functional, such as pain in the temporomandibular joint or discomfort when chewing , in addition to greatly improving patient self-confidence.

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There are a number of surgical and non-surgical options when it comes to correcting facial asymmetry. The type of procedure you go with typically depends on what your surgeon recommends based on your specific desires and situation.

Condylar hyperplasia, which is also known as mandibular hyperplasia, is over-enlargement of the mandible bone in the skull. The mandibular bone has two condyles. The condyles are known as the growth centers of the mandible. When the growth in the condyle exceeds its normal time span, it is called condylar hyperplasia. The most prevalent form of condylar hyperplasia is unilateral condylar hyperplasia. In this case, one condyle grows beyond the other condyle which results in facial asymmetry. There are two different categories of condylar hyperplasia, which includes hemimandibular hyperplasia and hemimandibular elongation. An estimated 30% of people who have facial asymmetry have condylar hyperplasia. These two anomalies can be clinically present in a singular form or in combination with one another.

Type 1- Hemimandibular elongation

- Chin deviation towards contralateral side

- Midline shift towards contralateral side

- Posterior crossbite on contralateral side 

- Excessive growth in the horizontal vector

- Enlarged ramus, normal condyle

Type 2 - Hemimandibular hyperplasia

- Sloping rima oris with minimal chin deviation

- Supra-eruption of maxillary molars on affected side

- Open bite

- Midline shift (minimal to none)

- Excessive growth in the vertical vector

- Excessive growth in the condylar head 

Type 3 - Combination of both

- Chin deviation towards contralateral side

- Possible open bite

- Sloping rima oris with possible chin deviation 

- Combination of excessive growth in both vectors

Condylar hyperplasia has an unknown cause. One theory states that an event of a trauma leading to increase in number of repair mechanism and hormones in that area may lead to increase in growth of mandible on that side. Another theory states that an increase in loading of the temporomandibular joint  can lead to increase in expression of bone forming molecules. Condylar hyperplasia predominantly affects women with 64% of patients being women. 

The diagnosis of asymmetry can be completed through a variety of different methods. PA cephalometry, panoramic radiograph and nuclear imaging are a few of the techniques which can be used for a diagnosis. Primarily nuclear imaging techniques like single-photon emission computed tomography (SPECT), positron emission tomography (PET) and bone scintigraphy are collected along with other data prior to diagnosing a patient with Condylar Hyperplasia. In SPECT imaging, an increase uptake of the isotope is found on the affected side when compared to the non-affected side indicated active growth of condyle on that side. Treatment plan is decided depending on growing status of condyle.

There are numerous treatment options for condylar hyperplasia. In some cases, orthognathic surgery can be performed once the active condylar growth has completed. In some cases mandibular bone reshaping such as lower border reduction and angle reduction, is required along with orthognathic surgery.  The goal of this surgery to wait while the condyle is growing and complete surgery once the condyle stops growing. This helps reduce the chances of any worsening of facial asymmetry lessens. One downside to this option, however, requires a person to live with their facial asymmetry features until the age of 18 or 19, which can be challenging. 

A procedure called condylectomy can also be completed. Condylectomy involves the removal of part of the growing condyle in order to arrest any active growth. Condylectomy can sometimes be done in conjunction with articular disk repositioning and orthognathic surgery in order to treat patients with mandibular hyperplasia.

The masseter muscle runs through the rear part of the cheek, from the cheekbone down to the lower jaw on each side of the face. The muscle connects the mandible (lower jawbone) to the cheekbone and is known as one of the “muscles of mastication” because it works to raise and close the jaw while chewing.

The masseter can sometimes become enlarged in people who have a tendency to clench or grind their teeth (bruxism), or who chew gum excessively. This may result in an asymmetry of the face due to unequal enlargement and increased bulk of the muscle, potentially creating an overly-square jawline. Typically women, or those seeking facial feminization, prefer a softer, smoother appearance to the jawline, and therefore seek to reduce the size of the masseter.

Masseter Reduction, or Jaw Reduction, is where the lower muscle of the face termed the masseter muscle is reduced. The benefits of this can be two fold. First of all, patients seeking a softer facial shape can improve facial balance and change the shape of an overly square face

Reduction of the masseter may be performed by either 1) surgical, or 2) non-surgical methods…

Surgery to access the masseter and the mandible (jawbone) is performed through incisions on the inside of the mouth, between the gum and cheek, leaving no visible scarring. Your surgeon then shapes and reduces the bone and masseter muscle to achieve a well-rounded, smoother and more streamlined jawline contour. Once the correct amount of bone and muscle has been removed, the incision is closed with self-dissolving sutures.

Injectable muscle relaxing agents such as Botox work extremely well to non-surgically reduce the masseter muscle and also decrease habitual jaw clenching or teeth grinding (Bruxism). The procedure involves a series of injections of Botox directly into the masseter muscle in small doses over several sessions until the desired appearance is achieved. Depending on the individual, the decreased size of the masseter may stay intact permanently even without further injections.

A common concern with treatment of these muscles with muscle relaxants is that the muscle will freeze and you won’t be able to chew your food. Given the large size of the muscle and the use of other smaller muscles of mastication, chewing is not affected by this treatment, although some people may report feeling a bit ‘funny’ chewing tough foods like steak immediately following treatment.

Craniofacial fibrous dysplasia is a bone disease of the face and skull that replaces normal bone with fibrous-type tissue. This tissue is not as hard as normal bone, and because it is soft and stringy, it makes the bone more fragile and prone to break. Craniofacial fibrous dysplasia is related to fibrous dysplasia, which can affect any bone in the body but most commonly affects the long bones in the legs and arms. The condition, sometimes called facial fibrous dysplasia or fibrous dysplasia of the skull, may affect one bone or multiple bones. Craniofacial fibrous dysplasia may cause shifting of facial features and facial asymmetry, such as incorrect placement of the eyes, misalignment of the jaw, and other problems.

There are two forms of fibrous dysplasia:

·  Monostotic, which affects one bone and is active while the child is growing but often becomes inactive after puberty

·  Polyostotic, which affects multiple bones and may remain active throughout a person’s life

Fibrous dysplasia may appear in childhood, usually between the ages of 3 and 15. Boys are more often diagnosed with fibrous dysplasia than girls, except one specific type of polyostotic fibrous dysplasia — McCune-Albright syndrome — which is more common in girls and affects the bones and skin and is associated with hormonal imbalance and often precocious (premature) puberty. 

While the exact cause of fibrous dysplasia is unknown, recent studies point to a mutation of Gs alpha protein during prenatal development as a contributing factor. Fibrous dysplasia is not hereditary, meaning parents do not pass the condition to their children.

Signs and symptoms of fibrous dysplasia affecting the skull may include:

·  Facial asymmetry

·  Shifting facial structure that can affect any bone in the face

·  Nasal airway obstruction

·  Jaw and bite misalignment, in some cases making it difficult to chew and swallow

·  Visual and hearing problems due to compression of the optic nerve or acoustic nerve

·  Additionally, children with craniofacial fibrous dysplasia may experience symptoms related to bone weakness in other parts of the body, including bone fractures or deformities, bone pain, or bone lesions which may stop growing when the child reaches puberty.

Children with polyostotic fibrous dysplasia may also experience:

·  Endocrine gland problems, such as early puberty, thyroid disorders and related issues

·  Unusual skin patches, called café-au-lait pigmentation, ranging from light brown to dark brown in color

At The Nuface Clinic, your child's diagnostic evaluation begins with a thorough medical history and physical examination. Clinical experts use a variety of diagnostic tests to diagnose facial fibrous dysplasia such as X-rays and CT Scan with constructed 3D images, which are used for intervention planning.

Depending on your child’s condition and symptoms, clinicians may recommend additional testing including blood work and hormone testing.

At Nuface Clinic, experts Craniomaxillofacial Surgeon take a team approach to treatment of fibrous dysplasia of the skull. Specialists from Craniomaxillofacial surgery, neurosurgery and ophthalmology collaborate to provide your child with individualized care and the best possible outcomes.

While several surgical options are available to treat facial fibrous dysplasia, your child’s treatment will depend on the location of the bones affected and the severity of the condition.

Surgery is usually done through limited incision approaches and hidden incisions in the hair. This can help reduce visible scarring.

·  If the affected areas of the face are small and easily accessible, treatment usually involves complete surgical removal (resection) of the area and reconstruction using a combination of bone grafts and materials such as titanium plates and screws.

·  If the area affected is too large or too important to be removed, the size of the bone may be reduced to normal using a high speed burr. The procedure is know as cosmetic shaving of bone. If the facial fibrous dysplasia is in an area where it is growing and compressing nerves, removing some of the surrounding bone can decompress the nerve.

·  In some patients, a combination of bone reduction with a burr and bone grafting may be utilized.

·  In severe cases where the jaw is displaced and malocclusion occurs, a combined therapy with orthodontics will utilize osteotomies (bone cuts) to reposition abnormally placed bones.

·  If surgery is required on a particular facial region such as the skull base, your craniomaxillofacial surgeon may work together with a neurosurgeon or ophthalmologist to ensure the most effective treatment. If your child's condition involves the jaw, craniomaxillofacial surgeons will collaborate with orthodontics if needed.

·  Your child may need additional surgeries over the course of treatment for facial fibrous dysplasia. In severe cases, the excess bone may grow back over time and require repeated treatments.

After surgery for facial fibrous dysplasia, your child should expect to stay overnight in the Hospital. Depending on the complexity of the surgery required, your child may be hospitalized anywhere from one to several days.

Your child will need to return for evaluation approximately one to two weeks after surgery. Regular follow-up visit will be needed and are commonly done every three months for the first year, and then yearly, based on your child's condition. 

In cases where the bone has been shaped or contoured — usually to preserve vital structures and because the disease affects a large volume of bone — recurrence of the bony overgrowth may occur and secondary procedures may be necessary.

During follow-up visits, your child’s physician will perform a physical exam and may order X-rays or CT scan of the affected area until your child reaches skeletal maturity. If your child was diagnosed with polyostotic fibrous dysplasia, he may also be referred to an endocrinologist for periodic testing of any endocrine or hormone related disorder.

Outcomes for children treated for craniofacial fibrous dysplasia have been excellent. Because this disease is persistent, continued clinical monitoring is essential in long-term management of the condition.

As with any surgery, facial surgery does pose some risks. These risks include:

·  Anesthesia complications 

·  Bleeding 

·  Bruising 

·  Damage to bone, eyes, ears, nose, teeth, or gums 

·  Infection 

·  Nerve damage 

·  Numbness 

·  Pain 

·  Swelling 

·  Additional surgery may be required to address complications or unanticipated anomalies in healing

·  While facial asymmetry surgery may involve a single procedure, more commonly it includes multiple facial procedures. As a result, the after effects such as facial swelling and bruising vary significantly from patient to patient.

·  Depending on how extensive the surgery is, you may return home the same day or spend a night or two in the hospital. You’ll return home with instructions and medications from your doctor. 

·  Immediately after the operation, your face will feel swollen and tight. It is advised to use ice packs right after the surgery until swelling goes down. Swelling and pain will typically peak a few days after surgery, and then resolve within a few weeks.

·  You need to wear a facial compression band for at least 5 days after the surgery and avoid bending your head down or lying on the stomach.

·  Having normal food is possible two weeks after the surgery. You should avoid smoking and drinking alcohol for at least one month after the procedure.

·  The stitches will be removed after 7-10 days.

·  The length of recovery is not based on pain but rather on swelling and the time it takes to look more normal again. It could take anywhere from two to three weeks for one to feel completely comfortable being in public without having noticeable signs of surgery. 

·  The most important thing to understand is that facial asymmetry surgery is about lessening the degree of asymmetry; perfect facial symmetry is usually not possible. In many patients, it may take more than one surgery to attain the best possible result.