Assessment Of Asymmetry And How To Best Manage This

It is well known that most faces are not entirely symmetric. The notion that the establishment of symmetry is necessary to achieve optimal results is also an historical and philosophical fallacy. Some of the most attractive people demonstrate marked facial asymmetry. Interestingly, asymmetries are well tolerated and often unnoticed in youth and much less tolerated and more obvious with age. More often, patients are unaware of their facial asymmetry but might be more keenly observant of this after surgery due, in part, to their obsession with the mirror. During the evaluation of the patient, I will usually determine this and discuss this with the patient during the treatment planning. Although not perceived by the patient, the asymmetry is sometimes a large component of their displeasure with facial aging. The assessment of asym¬metry must extend far beyond the simple evaluation for blepharoptosis to achieve maximum benefit through the surgical encounter. For instance, relative or asym¬metric brow ptosis may be discussed. At times, the brow position is influenced by the upper eyelid (especially in those who reflexively elevate their ipsilateral eyebrow in response to blepharoptosis) and the upper lid ptosis is only apparent when that brow is digitally depressed by me examiner to determine me true upper eyelid position. A patient with brow asymmetry for any reason, may also sense a greater relative amount of 'excessive' skin on the brow protic side and if this relates to brow ptosis, this should be discussed to explain the rationale for the treatment and how it relates to the chosen procedures. The side with brow ptosis is also usually the small side of the face. This must be considered, especially if the parient is having lower eyelid, mid-, or lower facial surgery. Canthal dystopia and lower eyelid position asymmetry (even in the surgically naive patient) is also common and also more often unnoticed by the patient. The 'big eye-small eye' phenomenon is also far more common than previously appreciated6 and aesthetic remedies may or may not be selected to address this. The 'big eye' is also usually on the large side of the face. When I detect this I ask patients what they see when they look at pictures of themselves (often this is exactly what brought them into your consulting room, but they simply have not realized this or simply can not verbalize their exacr reasons for unhappiness with their appearance). Surgical and non-surgical maneuvers may be performed to lessen the asymmetry in the patient who is desirous of this approach. Caution must be used however with any attempt to alter the natural asymmetry in selected patients. Although an independent observer (and surgeon) might consider the subjective improvemenr in doing so, at times the patient feels as if they appear 'out of balance' much like looking at a photograph of oneself (in the days when we actually used film!) where rhe negative had been reversed for the prinring. There is no question that this is the patient (in the photo) but the relative asymmetries that they have been accustomed to their whole life have now been altered. In general, I find the evaluation of periorbital asymmetry most useful to determine how I might titrate procedures to optimize results by either maintaining the asymmetry, or improving symmetry so rhat the asymmetric appearance does not become more obvious after surgery.