Treatment of Facial Asymmetry
Treatment for facial asymmetry requires an individualized surgical approach combining camouflaging techniques for mild cases and orthognathic surgery for severe skeletal discrepancies, with camouflaging being more conservative and predictable than realignment procedures. 1
Initial Assessment and Classification
Before selecting treatment, systematically categorize the asymmetry into one of six types 1:
- 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 1, 2
Divide the face into horizontal thirds (upper, middle, lower) to conceptualize the deformity and determine which anatomical levels require intervention. 1, 2 The upper third corresponds to the bony pyramid, middle third to dorsal septum and upper lateral cartilages, and lower third to alar cartilages and caudal septum. 1
Treatment Algorithm Based on Severity
Mild to Moderate Asymmetry: Camouflaging Techniques
Camouflaging techniques are more conservative, less destabilizing, and more predictable than realignment procedures and should be the first-line approach for mild asymmetries. 1
Specific camouflaging methods include:
- Filling depressions with thin cartilage wafers to improve or totally correct asymmetries 1
- Onlay grafts extending over the nasal dorsum to hide crooked contours 1
- Volume enhancement procedures that add postoperative stability and prevent drifting to malaligned states 1
- Contralateral dorsal rasping or cartilage shaving to balance asymmetries 1
Modern rhinoplasty has evolved from framework reduction to conservatism with autogenous cartilage grafts for repositioning, reinforcement, recontouring, and reconstruction of virtually every nasal component. 1 These grafting maneuvers increase stability of the realigned cartilaginous framework. 1
Severe Asymmetry: Orthognathic Surgery
For progressive hemifacial asymmetry with decreased cheek bulk (category f), obtain 3D-CT maxillofacial scan to assess skeletal discrepancies, as camouflaging alone is insufficient. 2
Orthognathic surgery is indicated when:
- Dental midline discrepancy exceeds 3mm with concomitant occlusal asymmetry 3
- Class 3 malocclusion with significant skeletal discrepancy is present 3
- Posterior crossbite indicates transverse discrepancy 3
LeFort I osteotomy is the appropriate procedure for correcting maxillary asymmetry, allowing correction in transverse, vertical, and anteroposterior dimensions. 2, 3 Mandibular reconstruction may be required to address the mandibular component and establish proper occlusion. 3
Critical Technical Considerations
Balance graft volume against potential for unesthetic nasal width and graft visibility when using augmentation techniques. 1
Maintain periosteal and mucosal attachments during nasal framework manipulation to minimize destabilization. 4
Autologous cartilage remains the gold standard for grafting procedures, particularly for tip work and structural support. 4
Remove third molars at least six months prior to orthognathic surgery to allow proper bony healing. 3
Common Pitfalls
Patients with facial asymmetry have complex three-dimensional discrepancies requiring careful surgical planning—avoid underestimating the complexity. 2, 3
Traditional correction involving mobilization and realignment is intrinsically destabilizing and carries unpredictability. 1 Modern restructuring with grafting provides superior stability. 1
Approximately 10% of patients have a consistent preferred head position off the Frankfurt plane, which complicates determination of facial balance. 1 Use marker points, rulers, and line drawings on frontal photographs for accurate evaluation. 1
The facial centerpoint halfway between medial canthi is the only consistent reference point in anteroposterior view—all other landmarks may be asymmetric. 1