What is the next management plan for a patient with progressive hemifacial asymmetry and decreased cheek bulk, with initial normal Magnetic Resonance Imaging (MRI) findings?

Management Plan for Progressive Hemifacial Asymmetry with Decreased Cheek Bulk

The next step in management for this 15-year-old patient with progressive hemifacial asymmetry and decreased cheek bulk should be a comprehensive three-dimensional computed tomography (3D-CT) scan to evaluate the skeletal and soft tissue components of the asymmetry, followed by referral to a craniofacial specialist for surgical planning. 1

Diagnostic Evaluation

• A 3D-CT analysis is essential for proper evaluation of the asymmetry, as it provides detailed measurements of skeletal and dentoalveolar relationships that are crucial for treatment planning 1
• The normal initial MRI findings followed by progression of hemifacial asymmetry with decreased cheek bulk suggests a possible diagnosis of progressive hemifacial atrophy (Parry-Romberg syndrome) or hemifacial microsomia 2, 3
• The progression of symptoms during adolescence is consistent with the natural history of hemifacial microsomia, which tends to worsen with growth 2

Classification and Analysis

• The patient's presentation falls into category (f) of facial asymmetries: "More pronounced facial asymmetry sometimes associated with cheek flattening and slanting of the whole midface to one side" 4
• Systematic analysis should divide the face into horizontal thirds (upper, middle, and lower) to better conceptualize the deformity and plan appropriate interventions 4
• Assessment should include evaluation of facial width differences, orbital level differences, rotation displacement of upper jaw/piriform aperture, and alar base position 4

Management Approach

Immediate Steps:

• Obtain 3D-CT maxillofacial scan to accurately assess the skeletal discrepancies and soft tissue deficiency 5, 1
• Refer to a multidisciplinary craniofacial team including maxillofacial surgeon, plastic surgeon, and orthodontist 6

Surgical Planning:

• For significant facial asymmetry with decreased cheek bulk, a combination of skeletal correction and soft tissue augmentation will likely be necessary 6
• If skeletal discrepancy is identified, orthognathic surgery such as LeFort I osteotomy may be required to correct maxillary asymmetry 5
• Soft tissue deficiency in the cheek area can be addressed through:
  • Autologous fat grafting to restore volume 6
  • Free tissue transfer for more severe cases 6

Timing Considerations

• Early intervention is recommended as hemifacial asymmetry tends to be progressive, especially during growth periods 2
• Data from studies on hemifacial microsomia demonstrate that facial asymmetry increases with growth, with angular measurements of facial planes showing progressive deviation 2
• Delaying treatment until after growth completion may result in more severe deformity requiring more extensive surgical correction 2

Potential Pitfalls and Caveats

• Distinguishing between progressive hemifacial atrophy (Parry-Romberg syndrome) and hemifacial microsomia is important as treatment approaches may differ 3
• Patients with facial asymmetry often have complex three-dimensional discrepancies that require careful surgical planning 5
• Camouflaging techniques alone may be insufficient for progressive cases, and structural correction is often necessary 4

Follow-up Plan

• Regular monitoring with serial imaging (every 6-12 months) to assess progression until definitive treatment 2
• Pre-surgical orthodontic preparation may be necessary if dental malocclusion is present 6
• Post-surgical follow-up should continue through completion of growth to monitor for any residual asymmetry 2