Facial asymmetry exists in almost every aging face. As an esthetic sign, facial symmetry is regarded as an important criterion for evaluating plastic surgery operations. Symmetry is believed to be correlated with facial attractiveness, health, and even genetic quality.1 There are multiple factors leading to facial asymmetry, including the components of the soft tissue and dental and skeletal differences.2 , 3 The different aging speeds of the bilateral face also contribute to facial asymmetry. However, many plastic surgeons focus only on bone problems and ignore the role of soft tissues. Shah and Joshi4 demonstrated that mild skeletal asymmetry could be compensated for by the overlying soft tissue components. Methods that improve facial symmetry by correcting bone or dental deformity are more time consuming and invasive. Additionally, symmetry is not definite after soft tissue coverage. In our opinion, it is sufficient for patients without severe deformities to have facial asymmetry corrected solely by individual treatment of the soft tissue.
Although multiple techniques have been reported, the facelift method is still the most impactful for improving the aging face.5 The primary focus of a facelift is to restore a youthful contour. However, facial asymmetry actually decreases the aesthetic outcome after rejuvenation. The improvement of rhytids and laxity using the facelift technique has already been illuminated in numerous articles, while these improvements are lacking in the treatment of facial asymmetry. This article aimed to explore the ability of the individual facelift technique to improve facial symmetry. In addition, due to the geographical environment and cultural differences, there are many differences between Asian and Caucasian people regarding facial aging signs, aesthetic standards, and surgical expectations.6 , 7 The soft tissue and skeletal support characteristics of Asian people yield fewer rhytids and contribute to discernible facial sagging, compared with Caucasians. Besides, correction of orbital aging problems plays a more important role in facial rejuvenation for Asian people. In this study, the subjects included were all Asian women, which helped us discuss the availability of the individual facelift technique in Asian people. At the same time, a novel method, called the grid method, was attempted as a way to analyze facial symmetry.
PATIENTS AND METHODS
A review of consecutive, individualized middle and lower facelifts that were performed by a single surgeon (the senior author) between April 2009 and December 2016 was conducted following institutional review board approval. A cohort of 58 patients was included. All patients included in this study signed written informed consent and agreed to publish identifiable facial images. All patients were Asian women undergoing a natural aging process. Patients who had experienced disease, trauma, or deformity or who underwent a second rejuvenation were excluded from the study. Further, patients who underwent fat grafting or any other filling procedure were not included. Meanwhile, it was important that no visible facial skeletal asymmetry was observed in the patients selected. The frontal photograph of each patient before and after the operation was used to analyze the improvement of the facial asymmetry by the grid method. Five independent plastic surgeons, aside from the senior author (D.Y.), acted as observers and reviewed the facial asymmetry using a visual analog scale. Ten grades, ranging from 0 to 10, were provided by the observers. A 10-cm line was drawn on the paper. A grade of 0 indicated complete symmetry, while a grade of 10 indicated complete asymmetry. The facial symmetry score was given according to the self-perception of the observer. The facial asymmetry of the patients was analyzed using these scores. In addition, postoperative complications were also recorded.
Individualized Facelift Technique.
The individual facelift technique was first proposed by Rohrich et al. in 2009.8 In this study, the individual facelift technique was adopted, and some improvements were made according to the characteristics of Asian people. Compared with the short incision, the incision line in an “S” shape was designed in Asians from the temporal hairline to the preauricular area, around the earlobe to the retroauricular area. The skin was undermined to expose the underlying fat compartments and the superficial musculoaponeurotic system (SMAS) to the outer edge of the orbicularis oculi muscle, the zygomatic major, and 2 cm from the perioral area. A procedure that suspended the orbicularis oculi muscle and the malar fat pad as a unit was first performed in this study to reset the mid-malar support for Asian people (Fig. 1). The method of SMAS stacking or SMAS-ectomy was individually chosen, based on the preoperative assessment of facial asymmetry. Superficial musculoaponeurotic systemectomy was applied on wide lateral faces, while SMAS stacking was used on narrow lateral faces or lateral faces with depressions. SMAS stacking was performed by forming a 3-layered stacking structure, which was made by undermining limited proximal and distal SMAS and drawing the incised/undermined edges over the remaining SMAS base. Compared with the vertical vector in Caucasians, the vector of the SMAS and skin suspension in the operation was almost posterior-superior, largely shallowing the nasolabial fold and creating a smoother mandibular outline to meet the Asian aesthetic (Figs. 2 and 3) The procedure that suspended the outer edge of the orbicularis oculi muscle to the fascia temporalis profunda was firstly used in this study to improve ptosis of the lateral canthus with aging and to create an upward slant (Fig. 4). This method simultaneously tightened the orbicularis oculi muscle and orbit septum fascia, which made it very important for reshaping “youthful eye” in Asians. Hypertrophic scarring is more frequent in Asian people than in Caucasian people.7 A procedure that changed the preauricular linear incision to the tragus contour was performed to reduce scar formation (Figs. 1, 2, 3).
The Grid Method.
In this study, a novel method called the grid was applied to evaluate the improvement of facial symmetry. Frontal photographs of patients scanned with their heads in a natural position and in centric occlusion were used to produce the grid. Due to the middle and lower parts of the face being mostly suspended during this operation, the area was defined using 2 lines. The upper line was horizontally drawn through the left and the right exocanthions and the pupil-reconstructed point, while the lower line was drawn though the chin point parallel to the upper one. The grid was placed in the area where the upper and lower sides coincided with these lines. The midline of the grid was in line with the vertical line, which was drawn though the trichion, glabella, subnasale, and pogonion, to divide the face into 2 parts. A 4 × 6 grid, composed of 4 rows and 6 columns, was usually chosen in this study. Facial asymmetry could be analyzed by comparing the area of the bilateral faces in each corresponding cell (Fig. 5). In detail, relative to the midline, the facial area of each cell on the left side was compared with the area of the cell in the same place on the right side. The difference in facial area between both sides indicated facial asymmetry. Improvements in facial symmetry were revealed by comparing the respective scores of facial asymmetry before and after surgery. When the images were assessed using the naked eye, facial asymmetry was not always discernible. However, using the grid, facial asymmetry was easily observed. The improvement of facial symmetry was also visible (Fig. 6). Additionally, the density of the grid could be increased if more information about facial asymmetry was needed.
A retrospective analysis of 58 consecutive patients was performed between April 2009 and December 2016. All included patients were Asian women with adequate frontal photographs who had undergone individualized middle and lower facelifts by a single surgeon. Among them, 21 patients had lower eyelid blepharoplasty incorporated into the facelift, and no other plastic operations were included. Overall, the images were obtained over 6 months to 6 years of follow up, with an average of 17 months. The mean age of the patients was 49 years old (age range, 38–69 years). There was no discernible bias among the 5 observers’ assessments of facial asymmetry. In the group of images before surgery that were evaluated by the grid, the mean facial asymmetry score was 4.11, while in the postoperative group, the mean score was 1.07, which was significantly lower than the mean score before surgery (p < 0.001) (Fig. 7). The change in the mean scores of the before and after images illustrated that the individualized facelift technique was effective in improving facial symmetry in Asian people. None of the patients in this study experienced complications, such as seromas, wound dehiscence, hypertrophic scarring, nerve damage, and infection. Edema occurred in each patient and reached its peak usually on the third day, almost dissipating in the 3 weeks after the operation. Three patients had severe hematomas and healed without obvious sequelae with treatment by subcutaneous puncture. A total of 5 patients experienced local hematomas and recovered well without any treatment.
The differences between Asian and Caucasian people require the adaptation of current techniques for Asian patients. In Asian people, the structural and physiological characteristics of the skin, such as a thicker dermis, greater collagen, and darker pigment, reduce the appearance of wrinkles.6 Weaker skeletal support and a greater amount of malar fat lead to the need for greater tissue suspension in Asian populations.6 The atrophy of the fat pads and the descent of the fat compartments create multiple sagging problems.5 The deep fat system provides support in holding the smooth contour in the middle of the face.9 Compared with Caucasians, it is especially important in Asian people to suspend the orbicularis oculi muscle and the malar fat pad as a unit to reset mid-malar support.
The procedure that suspended the outer edge of the orbicularis oculi muscle to the fascia temporalis profunda is necessary for Asians to obtain a more youthful eye in face lift. In Caucasian people, neck lift combined with a facial lift is necessary to increase the longevity of facial rejuvenation.10 Unlike Caucasians, Asian women place more emphasis on the correction of orbital aging problems, not aggressive neck correction. Myriad techniques of lower blepharoplasty have been reported for resetting the youthful eye, characterized by an upsweep of lateral canthus.11 In Springer et al.’s12 study, a 9° upward tilt from the medial canthus to the lateral canthus was regarded as the most attractive. A youthful eye was regained in Asian patients typically by suspending the outer edge of the orbicularis oculi muscle. Orbital aging problems were simultaneously improved due to tightening of the orbicularis oculi muscle and orbit septum fascia. In combined surgery with blepharoplasty, more skin in the lower eyelid area could be removed. Ectropion as a complication is common in single lower blepharoplasty.13 Aesthetic sequela could also be avoided through the incorporation of the facelift technique.
In this study, individualized oblique SMAS suspension and a classic incision were performed to meet Asian aesthetic standards and surgical expectations. Although myriad facelift techniques have been reported, the SMAS is still the core treatment for aging faces due to its characteristics of wide distribution and high resistance.5 In this study, SMAS stacking or SMAS-ectomy was individually chosen, not only balancing the width of the face on both sides but also improving facial depression. Asymmetry of the bilateral face could be greatly improved after individual surgery (Figs. 6 and 8). Compared with Caucasian people, the appearance of oval facial shape and a smooth mandibular outline are more popular in Asian people, instead of a sharp and more angular mandibular contour.7 The posterior-superior vector suspending the skin and SMAS were more beneficial for improving the aging changes of the mandibular contour and gaunt over the buccal recess. In the published literature, the vertical vector is more common. However, aesthetic sequelae, such as misdirected facial rhytides and lateral sweep, could be produced.14 The prominent advantage of encouraging patients to choose the vertical vector is the small scar size without a postauricular incision. Compared with a preauricular scar, the postauricular incision is not visible and causes little trouble for most patients. Moreover, temporal hairline incisions are sometimes needed in many short-scar techniques to avoid problems related to temporal hairline elevation and a dog-ear appearance. Short-scar techniques tend to be popular due to increasing demand for faster healing times and less invasive operations.16 In Antell’s15 investigation, there was no obvious difference in short-term efficacy between short-scar and classic incision techniques, but the short-scar techniques yielded less longevity, especially regarding the correction of cervical contours.14 In this study, a classic incision was applied, and all patients healed well with no severe complications. Overall images were obtained over 6 months to 6 years of follow up, which indicated the reliability and longevity of the individual facelift in Asian patients (Fig. 9).
Impactful tools for assessing facial asymmetry in plastic surgery are currently lacking. Rohrich et al.8 analyzed facial asymmetry using 3 basic facial parameters—midface width, facial length, and facial fullness, while Dhir et al.17 evaluated the differences in the bilateral face based on brow height, malar eminence height, width of the midface, nasal alar height, and mandible width. However, these methods are not intuitive and not useful for reflecting the facial asymmetry of multiple planes, especially with facial contouring. Since 3-dimensional facial images were validated by Verhoeven et al.,18 3-dimensional CT has become increasingly popular. In Kaipainen et al.’s19 study, a mirror model of the face was created though the identification of 22 soft tissue landmarks and the construction of 15 planes using 3-dimensional images. Facial asymmetry could be measured accurately, and the system error was very small, at less than 0.5 mm.19 However, the complexity involved with this method increases time consumption and adds additional costs. Most patients cannot tolerate these issues. Additionally, the 3-dimensional method emphasizes the hard tissues but does not demonstrate the soft tissue components involved in facial asymmetry.20
In this study, application of the grid provided a method that was simple and more detailed to evaluate the improvement of facial symmetry. Using the grid to cut the face into many cells offered more information about facial asymmetry, which provided the basis for combined operations, such as mandibular liposuction, fat filling, and forehead rhytidectomy. It is always a great challenge for plastic surgeons to obtain ideal, comparable preoperative, and postoperative images that are similar in facial size and position. The procedure that used the grid to evaluate facial asymmetry greatly reduced the demand for photographs. The difference between the facial size and position on the preoperative and postoperative images did not influence the analytic outcomes for asymmetry. At the same time, application of the grid is not limited to the middle and lower parts of the face. The grid is able to cover the whole face, and it provides guidance for plastic surgeons when performed forehead rhytidectomy or other types of combined surgeries. However, there are still problems with this method. Using the grid to evaluate facial asymmetry cannot provide objective and accurate measurements and, provides only visual improvement. Whether this method could be widely used in the clinical evaluation of facial symmetry still requires further controlled studies.
In this study, the individual facelift technique was applied to adapt it to the characteristics of Asians. A more youthful eye was reset by the special method of suspension. The statistically significant decrease in facial asymmetry scores after surgery indicated that the individual facelift technique was effective in improving facial symmetry in Asian women.
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