Initial consultations with patients are a great time to get to know patient motivations.  One topic that has come up recurrently (especially within the past month), and has been mentioned by people of every age group that I treat, has been about facial asymmetry.  It is usually not the first thing mentioned, but when the mirror is out, I have the patient looking at themselves in the mirror, and they start telling me their story, it comes out eventually.  

In the ideals of beauty, facial symmetry is seen as something that adds to the attractiveness and is associated with things ranging from personality to mate selection.  I don’t think this is on the mind of my patients when they talk to me about it; rather, they are talking about things that make them pause when they look in the mirror.  I do not minimize this complaint, as it is a real concern of patients.  However, I don’t think that all asymmetries need to be treated.

Static Facial Asymmetries

When I think of static facial asymmetries, I am looking at the anatomy of the relaxed face.  I feel the position of the bony prominences of the face, their relative projections, heights, and shapes.  Then I take a step back and look at the patient at rest.  This is my soft tissue exam.  I am looking at how the muscle, fat, and skin drapes over the bone.  To try to figure out how much of the asymmetry is from the muscle as opposed to the fat, I feel the tissues and also have the patient smile and animate, as muscle “flexes”, or contracts, while fat does not.  

Dynamic Facial Asymmetries

After evaluating static facial asymmetries, I look at how the face moves and is supported.  This exam is actually done before the static exam, as it usually takes place during the patient interview, though I think about static asymmetries before dynamic ones.  Does the right upper lip raise higher when smiling?  Is the left “smile line”, or nasolabial fold, deeper than the right when speaking?  Are the crow’s feet or forehead furrows deeper on one side than the other?

To Treat

My first discussion about facial asymmetries is usually about how we are all asymmetric.  Nobody is microscopically symmetric, and we do not need to be.  However, static asymmetries can be troublesome for people, and they may prefer to be photographed on their “good side”.  Sometimes these are easy to treat.

The easy cases are ones where there is a static asymmetry of the cheek that can be evened out by filler, or the asymmetric placement of filler.  If both cheeks have lost volume, but the left side has always been “thin”, then we can place more filler on the left side, giving a more symmetric look.  I find that many patients have one tear trough deeper than the other, and asymmetric placement gives great results (and more importantly, happy patients).  

When Not To Treat

Dynamic facial asymmetries, I feel, give your face a certain “character”.  I usually discourage treating these.  If your lips look symmetric at rest, but when you smile, one half looks a little more full or elevates a little less than the other side, you will find me talking you out of trying to “balance” this with filler or Botox.  Your facial muscles may be weaker on one side than the other.  Your mouth has a characteristic right corner that raises when you smile.  Great!  This is one of your unique facial signatures.  Your friends may not tell you, but this is one of the things they love about you!

Think twice before you treat these.  After you have thought twice, think twice again.  Have you ever looked in a “true” mirror that flips your view so that you are looking at yourself as the world sees you rather than a flipped mirror image?  Were you kinda freaked out by this?  What you are seeing is your dynamic asymmetry flipped.

Facial Asymmetry in My Practice

Most of my patients that have tried treating these dynamic facial asymmetries in the past have had results that they did not like.  Not all of them can pinpoint why.  A few have had good results.  Given these odds, my first instinct is to try to talk people out of this.  Why would I try to do a treatment with great odds of freaking a patient out?  

Let me give you a better option.  Enjoy these facial asymmetries, and know that you are better off for having them.