Management of Facial Asymmetry by Dr. S.M. Balaji

Facial asymmetry is one of those subjects every clinician encounters daily—particularly cosmetic physicians, maxillofacial surgeons, and plastic surgeons—yet it continues to challenge our judgment, our clinical eye, and, at times, our patience. Absolute symmetry remains a theoretical ideal, far more often discussed than truly achieved. As humorously stated, no one can be 100% prepared for an eternity in Hell, but years of listening to patients complain about minor asymmetries certainly builds a tolerance to torture.

Beneath the joke lies a serious reality: managing facial asymmetry means simultaneously managing biology, perception, and patient expectations. It is therefore with great pleasure that I strongly recommend reading the article by Professor S. M. Balaji, which addresses these challenges head-on and offers a thoughtful, pragmatic perspective on one of the most demanding aspects of facial surgery and medicine.

I am also delighted to announce that Professor Balaji will deliver a keynote lecture at the AIME Congress, introducing the session dedicated to facial asymmetry—a session that promises to set the intellectual and clinical tone for this essential topic.

Prof. Jean-Paul Meningaud

President, AIME 2025

The human face, shaped by nature and defined by its individuality, draws much of its character from subtle variations. Perhaps most striking among them is facial asymmetry, which is not a defect in itself but an inherent feature that makes each one of us different from one another.

There are no strict age restrictions for adults seeking correction of facial asymmetry. The key factors include proper diagnosis, detailed planning, and realistic expectations.

Management of facial asymmetry in adults is complicated by factors such as skeletal maturity, soft-tissue patterns, and long-standing functional adaptations, which make correction technically challenging. With advances in 3D imaging, virtual surgical planning (VSP), graft augmentation, and patient-specific implants, we can now achieve a level of precision previously considered unattainable.

"The challenge lies in asymmetry, while the achievement is found in harmony."

Challenges in managing facial asymmetry:

Diagnostic challenges:

The diagnostic challenges in facial asymmetry are multifactorial, including distinguishing between soft and hard tissues, assessing dynamic asymmetry, and examining occlusal cant.

Challenges in patient evaluation include photographic evaluation and clinical examination in frontal, vertical, and transverse planes. Study models to comprehend occlusal relationships, and imaging studies including 3D computed tomography (3D-CT), the temporomandibular joint (TMJ), and stereolithographic (STL) printing further aid in diagnosis.

Patient-related factors:

In addition to the challenges mentioned above, patients' psychological perceptions and expectations should also be considered. As a surgeon, my responsibility begins with monitoring the patient from the initial consultation through the final aesthetic and functional outcome, ensuring their satisfaction, comfort, and emotional reassurance throughout the correction.

Classification of facial symmetry:

Facial asymmetry can result from various causes. The following classification summarises common types and disorders, offering a framework for understanding and planning correction.

Surgical approach:

Management of facial asymmetry can be challenging. Based on the patient's specific facial asymmetry, developing and strategising a treatment plan should rely on a precise qualitative and quantitative assessment. It should be guided by aesthetic treatment goals based on the patient's primary concerns, the degree of occlusal deformity, and any associated sagittal or vertical jaw imbalances.

In recent years, the surgery-first approach (SFA) has gained significant popularity. This method is routinely used to effectively manage selected cases of asymmetric dentofacial deformities, addressing the drawbacks of time-consuming preoperative orthodontic treatment. SFA allows near-complete elimination of the presurgical orthodontic phase, providing the benefits of immediate correction of dentofacial deformities and soft-tissue imbalances, as well as reduced overall treatment time.

SFA for hard-tissue defects or skeletal correction includes:

• Lefort osteotomies

• Distraction osteogenesis

• Bilateral sagittal split osteotomy

• Genioplasty

If contour deficiency persists, grafts or patient-specific implants (PSI) provide additional support and provide accurate reconstruction of the mandible, chin, and midface.

Although skeletal correction improves the underlying asymmetry, soft tissue imbalances may persist.

They are managed using:

• Free fat graft transfer- Fat grafting, Anterolateral thigh graft [ALT], Dermal graft for larger soft tissue defect correction

• Alloplastic implants- Custom - made silicone or surgical-grade polyethylenes- for complex soft tissue asymmetry correction

• Myectomies and subcutaneous liposuction- performed using open or closed approaches to reduce soft-tissue bulk.

• Fat graft injections- Recommended for minor contour refinements.

Temporomandibular joint disorder and facial asymmetry- how are they related?

TMJ disorders can even affect the muscles and joints of the face, altering muscle tone and jaw alignment and possibly leading to facial asymmetry. TMJ disorders can cause chronic muscle tension, uneven tooth wear, and jaw misalignment-all contributing to making one side of the face look different from the other. Because the TMJ is an integral part of jaw movement related to speaking, chewing, and even yawning, disruption or dysfunction here may produce a ripple effect throughout the facial musculature and soft tissues. If this condition has persisted long enough, definite facial asymmetry may appear, unilateral or bilateral, depending on the underlying pathology.

Why This Matters for Practitioners

• Achieve facial harmony while respecting each patient's individuality.

• Address a wide range of asymmetries, from simple to complex.

• Utilising accurate surgical planning along with modern tools like 3D imaging, VSP, and patient-specific implants.

• Ensure patient satisfaction through careful, ethical, outcome-focused correction.

See It Live at AIME Conference 2026

• Join me for the session: "Management of Facial Asymmetry"

• Proudly endorsed by the International College of Maxillofacial Surgery (ICMFS)

Here's what you can look forward to:

• Strategies for surgical approaches to facial asymmetry

• Tips for planning and execution based on real cases

• Techniques for achieving both functional and aesthetic balance

Let's advance facial asymmetry correction with precision, ethics, and consistent results.

See you in Paris !

AIME CONGRESS 2025