True symmetry cannot exist in nature. There is always a degree of asymmetry in everything. It can be so mild that it cannot be noticed or it can be severe enough to be easily noticeable. Every human face is slightly asymmetric. In most cases, it is barely perceptible and is not disfiguring. However, when it is cosmetically disfiguring or causes functional problems, it needs to be corrected through surgical procedures. A wide range of surgery procedures and cosmetic procedures have been developed over time to correct this disfigurement.
One of the signs of aging is the increase in facial asymmetry. This can be the result of loss of tone in the soft tissues. The degree of facial asymmetry caused by old age is negligible and needs no treatment.
Board certified plastic surgeons are the specialists who deal with these problems in the United States. Oral and maxillofacial surgeons also offer this treatment in India. There are components of functional as well as cosmetic correction in these surgeries. Trauma to the temporomandibular joint is one of the most common causes of lower face asymmetry in the world. Direct impact to the chin can result in trauma to the jaw joint, which can ultimately result in ankylosis of the joint.
Release of ankylosis of the jaw is usually accomplished through interpositioning of the temporalis muscle in the joint. Mobilization of the TMJ is done early. Muscle relaxants are given if there is spasm of the jaw muscles and physical therapy exercises that aid in increasing mouth opening are performed to aid in quick recovery of the patient.
Development of TMJ ankylosis from a childhood trauma
The patient is a 23-year-old girl from Erode, India who fell down and sustained a direct injury to her chin as an infant. Her mouth opening gradually began to decrease until it finally became very limited. This led to difficulty with feeding and speech. There was also deviation of the lower jaw to the left side as she grew older. Around eight years ago, it reached a point where it made functioning difficult for her and her parents visited a dentist for consultation. He diagnosed her to have ankylosis of the left temporomandibular joint and referred her to our hospital for TMJ ankylosis surgery. Our hospital is renowned for TMJ surgery in India.
The first surgery at our hospital
Dr SM Balaji examined the patient and obtained imaging studies, which confirmed the diagnosis of left TMJ ankylosis. He then explained to her parents that she needed surgical correction of her ankylosed left TMJ. He proposed performing a gap arthroplasty with temporalis muscle interpositioning to release her ankylosed joint. Her mouth opening improved greatly after surgery, but her facial asymmetry persisted.
Her facial asymmetry began to gradually worsen as she grew older. She also developed a retruded mandible. This began to affect her day to day life and she lost self confidence. She isolated herself inside her house and refused to socialize. This worried her parents a great deal and they brought her again to our hospital for comprehensive treatment.
Referral to our hospital for surgical management of her facial asymmetry
Upon examining her, Dr SM Balaji, facial cosmetic surgery specialist, examined the patient and ordered a 3D CT scan of the patient’s mandible. This revealed that the mandible had shifted to the left side because of the TMJ ankylosis. Clinical examination revealed an obvious facial asymmetry with the presence of an occlusal cant. The right side of the mandible was also longer than the left side.
Even though the defect was observed on the right side clinically, the patient would need to undergo treatment on the left side to correct the facial asymmetry through the use of mandibular distractors. A mandibular ramus distractor would be fitted on the left side to increase the length of the mandible. A Le Fort I would also be performed on the maxilla for correction of the patient’s occlusal cant. This was explained to the patient and her parents in detail who agreed to the procedure and signed the surgical consent.
Mandibular ramus distractor fixation surgery performed on the patient
Under general anesthesia, an Incision was first made in the left mandibular retromolar region with elevation of a flap. Bone cuts were then made in the mandible and the mandibular ramus distractor was fixed on the left side using titanium screws.
A sulcular incision was then made in the maxilla following which a Le Fort I osteotomy was performed for mobilization of the maxilla. The left posterior maxilla was then fixed using transosseous wires.
Mandibular distraction performed for correction of facial asymmetry
Intermaxillary fixation was then performed. Following a latency period of about a week, a distraction of 1 mm was performed everyday for a total of 19.5 mm. Distraction was terminated after achieving satisfactory lengthening of the left side of the mandible. A titanium plate was then used to stabilize the maxilla after correction of the patient’s occlusal cant. The distractor will be removed after consolidation of bone at the site of distraction.
Patient expresses satisfaction
The patient and her parents were extremely happy and expressed their complete satisfaction before discharge from the hospital. They will present again after three to four months for removal of the distraction device from the mandible.
Patient with inability to open mouth following depressed zygoma fracture
The patient is a middle-aged man from Hassan, Karnataka. He suffered a comminuted zygoma fracture from a road accident. Improper reduction elsewhere had left him with a depressed zygoma and trismus. The depressed zygoma led to facial asymmetry and impingement of the coronoid process. This resulted in a mouth opening of only 1 cm for the patient. The patient had complaints of inability to eat well as well as impaired speech. He was becoming withdrawn and avoiding social interaction.
This became a hindrance to normal functioning in day to day life. His friends searched for the best hospital to get his asymmetry corrected. They took him to a local oral surgeon who studied the case in depth. Findings were somewhat complicated and needed an experienced surgeon. He was then referred to our hospital for correction of his complaints.
Various aspects of correction of facial asymmetry
No human face has perfect symmetry. Perfect symmetry is impossible in biological organisms. There is always a small degree of asymmetry present in all structures. The human face is no exception to this law of nature. This facial asymmetry is imperceptible in 99.90% of the population. It is only in a small minority that there is noticeable asymmetry. This asymmetry could be congenital or acquired. Congenital facial asymmetry could be the result of birth defects or injuries. Improper use of forceps during delivery can result in facial asymmetry.
Cleft lip and palate deformities result in severe facial deformities. Correction of this requires the services of an experienced cleft surgeon. The majority of acquired facial asymmetry is through trauma. An asymmetrical face can lead to psychological problems. The patient becomes very self conscious and withdraws from social interactions.
Types of presentation of asymmetry of the face
Facial asymmetry can involve the soft tissues alone or can involve the hard tissues also. Treatment options depend upon the location and degree of asymmetry. The main aim of treatment is to restore facial symmetry. We are one of the premier hospitals for facial asymmetry correction in India. Correction of the asymmetry of his face will undergo correction here. Jaw surgery is among the most common asymmetry correction surgeries performed in India. Orthognathic surgery can also correct facial asymmetry. Both maxillofacial as well as craniofacial surgeons perform these surgeries.
Treatment planning explained to the patient in detail for correction of problems
Dr SM Balaji, a premier facial deformity correction surgeon in India, examined the patient. He specializes in all manifestations of facial asymmetry. A world renowned cleft surgeon, all types of facial asymmetry undergo correction here. Facial asymmetry due to paralysis is also corrected at our hospital. Patients undergoing rehabilitation are able to lead a completely normal life after surgery. Their ability to smile restored, they are able to face life with dignity and self confidence.
Clinical examination revealed impingement of the left coronoid process during mouth opening. The patient had a mouth opening of only 1 cm. There was a depressed left zygoma with resultant facial asymmetry. He explained the treatment planning to the patient, which included a left coronoidectomy. This would enable good mouth opening again for the patient. The patient was in agreement and consented to the facial deformity correction surgery.
Left coronoidectomy performed on the patient to enable mouth opening
The patient underwent fiberoptic bronchoscopic intubation for general anesthesia. This was due to his inability to open his mouth for oral intubation. A tracheostomy would have to be performed otherwise. Once under satisfactory general anesthesia, a left retromolar incision was first made. The coronoid process was then accessed. A coronoidectomy was next performed and the coronoid process removed. The patient’s mouth opening was then demonstrated to be about 5 cm. This falls within the parameters of normal mouth opening. The incision was then closed with sutures.
Depressed zygoma elevated and fixed with plates for facial asymmetry correction
The depressed zygoma was next addressed. It was impinging on the coronoid process during mouth opening. This was preventing full opening of the mouth. Zygomatic bone was then approached through two approaches. They were through the maxillary vestibular incision and lateral canthal incision. The zygoma was first refractured to set right the depression. It was then fixed in an elevated position with the use of plates. Both incisions were then closed with sutures. The patient expressed his total satisfaction at the results of the surgery.
Parry Romberg syndrome is a rare neurocutaneous syndrome of unknown origin. It causes progressive hemifacial atrophy. This is often sporadic in its course. It leads to shrinkage of tissues underneath the skin. Only one side of the face is often affected. It also rarely extends to other parts of the body. Females are most commonly affected by this disease. Onset is often between 5 to 15 years of age. Other associated morbidities include those of a neurological, ocular and oral nature. Severity of this condition varies between patients.
Patient with Parry Romberg syndrome referred to our hospital
This middle aged male from Tirupati presented to our hospital for management. He has undergone previous surgeries elsewhere. The patient presented with nose, lip and chin asymmetry. He desired establishment of symmetry to the face.
Treatment planning and surgery explained to the patient
Dr SM Balaji examined the patient and ordered diagnostic studies. He explained that fascia lata graft from his thigh needed to be harvested for this surgery. The patient agreed to the treatment planning and consented to surgery.
Successful surgical correction of the patient’s facial asymmetry
Under general anesthesia, an S shaped incision was first made on his lateral thigh. The incision was then closed after harvesting a fascia lata graft. Attention was next turned to the chin asymmetry. A vestibular incision first made in the anterior mandibular region. Dissection was then carried down to the chin and an osteotomy done. The osteotomized piece of chin bone was then repositioned and screwed in place. This resulted in establishment of chin symmetry. The incision was then closed with sutures.
Attention was next turned to the upper lip. A midline incision was then made on the inner aspect of the lip. The fascia lata strip was then tunneled from the corner of the lip on the left to the midline incision. This was then sutured and secured. This resulted in establishment of lip symmetry.
Attention was then turned to the nasal asymmetry. Intranasal incisions ensured absence of any visible scars. Lateral osteotomies were then performed of the nasal bone. The medial cartilage was then partially excised from the nasal septum. This resulted in good nasal symmetry.
The patient recovered from general anesthesia without event. He expressed his happiness at the results before final discharge from the hospital.
Patient with nasal asymmetry and sunken right eye presents for surgery
The patient is a young man who presented to our hospital for nasal asymmetry correction. This was from a road traffic accident six months ago. The patient had already been first operated on elsewhere. That surgery had failed. He also complained of having a sunken right eye. This condition has been present for a very long time now.
The treatment plan was explained to the patient
Dr. SM Balaji examined the patient and formulated a treatment plan. This was then explained to the patient in detail who agreed to the surgery.
Surgical correction of nasal asymmetry
Under general anesthesia, intranasal incisions were first made to correct the nasal asymmetry. This would ensure the absence of any visible scar formation. Through an intercartilaginous incision, the nasal septum on either side was first exposed. The upper nasal cartilage was then identified, and interdomain ligaments split. Medial and lateral osteotomies were then done on either side. The nasal base asymmetry was thus corrected
Medpor implant used to correct right enophthalmos
Attention was next turned to the enophthalmos correction of the right eye. A transconjunctival incision was first made in the right eye. This allowed for access to the floor of the orbit. A Medpor implant was then shaped to fit into the floor of the orbit. The implant was then screwed in place and stabilized. This resulted in the complete correction of the patient’s enophthalmos. The transconjunctival incision was then left open for spontaneous healing. The patient now had a symmetrical face.
The patient expressed his utmost satisfaction with the results before discharge.
A neurofibroma is a benign nerve sheath tumour of the peripheral nervous system. This is an inherited disorder of the nervous system. It adds to the bulk of the tissues and can be very disfiguring and distressing to the patient. This causes facial asymmetry.
Patient with neurofibroma presents for bulk reduction surgery
The patient here is a young man who developed this condition from birth. This had led to extensive right sided facial disfigurement of the patient. He had undergone surgeries elsewhere, which left behind residual scars. The disfigurement had reached a level where it was beginning to affect the patient’s day to day life. His parents conducted extensive Internet research for the best facial reconstruction surgeon. Their search had led them straight to our hospital.
Treatment plan explained to the patient
Prof SM Balaji examined the patient and ordered imaging studies. Studies revealed that the patient also needed reduction of the lateral orbital rim. It also revealed that the patient needed reduction of his chin and the maxillary bone. The patient also had ectropion of the left eye. Correction of the ectropion would be through lateral tarsorrhaphy. The patient and his parents agreed to the treatment plan.
Asymmetry of ears corrected with removal of excess tissue
Under general anesthesia, markings were first made on the excess ear tissue. Excision of the excess tissue would lead to symmetry of the patient’s ears. The excess tissue was first removed and the wounds were then closed with sutures.
Maxillary bulk reduction with mandibular chin reduction
Attention was then directed to the chin reduction procedure. The chin was next approached through a labial sulcus incision of the mandible. Dissection was then carried down to the chin. An osteotomy was then done at the lower border of the chin. The bone was next shaped and screwed back on the mandible. Incision was then closed with sutures. Maxillary vestibular incision was next done to access the hypertrophic right maxilla. Neurofibromatosis tissue was then excised and removed. The maxilla was then reduced until it was symmetrical with the left side. The incision was then closed with sutures.
Ectropion correction with lateral tarsorrhaphy
An incision was next made over the right eyebrow in the temporal region. Bulk reduction was then done with excision of excess tissue. The incision was then sutured. Attention was next turned to the ectropion correction. Markings were first made in the supraorbital region. This was then followed by excision of the excess tissue. The tissue was then sutured close. An incision was next made extending distal from the lateral canthus of the eye. A temporalis flap was then raised. Dissection was then carried down to the lateral orbital rim margin. The bone was then trimmed with a bur. Holes were then made in the bone for the sutures to pass for lateral tarsorrhaphy. This was to correct the patient’s ectropion. The sutures were then passed through the holes and tightened for ectropion correction. Excess tissues were then trimmed and incisions closed with sutures.
The patient tolerated the procedure well and recovered from general anesthesia.
