Management of Facial Asymmetry
For facial asymmetry, camouflaging techniques using cartilage grafts are the preferred first-line approach because they are more conservative, less destabilizing, and more predictable than realignment procedures, though severe skeletal asymmetries require orthognathic surgery. 1
Initial Assessment and Classification
Begin by systematically categorizing the asymmetry into one of six recognized patterns 1, 2:
- Left-right facial width differences 1
- Orbital level discrepancies 1
- Rotational displacement of upper jaw/piriform aperture 1
- Isolated lateral placement of piriform aperture 1
- Non-horizontal alar base 1
- Pronounced asymmetry with cheek flattening and midface slanting (category f) 1, 2
Divide the face into horizontal thirds (upper, middle, lower) and examine each third relative to the midline vertical, which should intercept the glabella, nasal dorsum, nasal tip, columella base, philtrum, upper incisors, and menton 1, 2
Diagnostic Workup
Obtain 3D-CT maxillofacial scan to accurately assess skeletal discrepancies and soft tissue deficiency, particularly for progressive cases or those with suspected structural abnormalities 2, 3
Measure dental midline discrepancy: asymmetries greater than 3mm with concomitant occlusal asymmetry indicate medical necessity for surgical intervention 3
Assess occlusion plane by having the patient bite on a tongue depressor—it should be horizontal; a tilted plane suggests off-horizontal upper jaw positioning 1
Treatment Algorithm
For Mild to Moderate Asymmetry (Non-Progressive, <3mm Discrepancy)
Use camouflaging techniques as first-line treatment 1:
- Fill depressions with thin cartilage wafers to create the illusion of midline position 1
- Apply onlay grafts extending over the nasal dorsum to hide crooked contours 1
- Supplement with contralateral dorsal rasping or cartilage shaving for reduction where needed 1
- These techniques achieve volume enhancement rather than architectural shifts, adding postoperative stability and preventing drift to malaligned states 1
For Severe Skeletal Asymmetry (Progressive, >3mm Discrepancy)
Proceed directly to orthognathic surgery 2, 3:
- LeFort I osteotomy corrects transverse, vertical, and anteroposterior maxillary dimensions 3
- Mandibular reconstruction addresses mandibular asymmetry and establishes proper occlusion 3
- Remove third molars at least 6 months prior to allow proper bony healing 3
For Nasal Component Asymmetry
Apply modern rhinoplasty techniques using autogenous cartilage grafts for repositioning, reinforcement, recontouring, and reconstruction of nasal skeletal components 1
Correct septal deviations first—"as the septum goes, so goes the nose"—since severe dorsal and caudal septal deformities determine nasal shape and position 1
Critical Pitfalls to Avoid
Do not rely on camouflaging alone for progressive cases—structural correction is necessary when asymmetry worsens over time 2
Balance volume added with grafting against unesthetic nasal width and potential graft visibility—excessive grafting creates new aesthetic problems 1
Recognize that patients with facial asymmetry have complex three-dimensional discrepancies—careful surgical planning with detailed imaging is mandatory 2, 3
Account for compensatory head positioning—approximately 10% of patients maintain a preferred head position off the Frankfurt plane, which complicates facial balance determination 1
Distinguish between true anatomical asymmetry and functional asymmetry (such as compensatory head posture from strabismus), as this affects treatment planning 4
Special Considerations
For congenital/developmental causes (hemifacial microsomia, unilateral clefts), genetic consultation and specialized craniofacial referral are indicated 4, 5
Address patient expectations directly—complaints vary from unrealistic expectations to lack of concern even with large deviations, requiring careful counseling 5
Monitor progression closely in pediatric cases, as conditions like hemifacial microsomia show increasing asymmetry with growth 4