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Figure. Frontal photograph demonstrating common facial developmental findings. A, Upper third of face with the left brow more superior in position. B and C, Standardization lines that are horizontal and equal in length within 2 mm. D, Left midface demonstrates inferiorly positioned malar eminence (ovals) on the wider side of the face. E, Vector of ala more superiorly positioned toward the wider side of the face. F, Left mandible wider in conjunction with midface findings.

Figure. Frontal photograph demonstrating common facial developmental findings. A, Upper third of face with the left brow more superior in position. B and C, Standardization lines that are horizontal and equal in length within 2 mm. D, Left midface demonstrates inferiorly positioned malar eminence (ovals) on the wider side of the face. E, Vector of ala more superiorly positioned toward the wider side of the face. F, Left mandible wider in conjunction with midface findings.

1.
Zaidel DW, Cohen JA. The face, beauty, and symmetry: perceiving asymmetry in beautiful faces.  Int J Neurosci. 2005;115(8):1165-1173PubMedArticle
2.
Hamilton WD, Axelrod R, Tanese R. Sexual reproduction as an adaptation to resist parasites (a review).  Proc Natl Acad Sci U S A. 1990;87(9):3566-3573PubMedArticle
3.
Moller AP, Millar AP. Sexual Selection and the Barn Swallow. New York, NY: Oxford University Press Inc; 1994
4.
Baudouin JY, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women.  Acta Psychol (Amst). 2004;117(3):313-332PubMedArticle
5.
Kowner R. Facial asymmetry and attractiveness judgment in developmental perspective.  J Exp Psychol Hum Percept Perform. 1996;22(3):662-675PubMedArticle
6.
Swaddle JP, Cuthill JC. Asymmetry and human facial attractiveness: symmetry may not always be beautiful.  Proc Biol Sci. 1995;261(1360):111-116PubMedArticle
7.
Light LL, Hollander S,, Kayra-Stuart F. Recognition memory for typical and unusual faces.  J Exp Psychol Hum Learn. 1979;5(3):212-228PubMedArticle
8.
Byrd HS, Salomon J, Flood J. Correction of the crooked nose.  Plast Reconstr Surg. 1998;102(6):2148-2157PubMedArticle
9.
Westreich RW, Lawson W. Perforating double lateral osteotomy.  Arch Facial Plast Surg. 2005;7(4):257-260PubMedArticle
10.
Yao F, Lawson W, Westreich RW. Effect of midfacial asymmetry on nasal axis deviation: indications for use of the subalar graft.  Arch Facial Plast Surg. 2009;11(3):157-164PubMedArticle
11.
Claman L, Patton D, Rashid R. Standardized portrait photography for dental patients.  Am J Orthod Dentofacial Orthop. 1990;98(3):197-205PubMedArticle
12.
Williams AR. Positioning and lighting for patient photography.  J Biol Photogr. 1985;53(4):131-143PubMed
13.
Larrabee WF Jr, Maupin G, Sutton D. Profile analysis in facial plastic surgery.  Arch Otolaryngol. 1985;111(10):682-687PubMedArticle
14.
Davidson TM. Photography in facial plastic and reconstructive surgery.  J Biol Photogr Assoc. 1979;47(2):59-67PubMed
15.
Hafezi F, Naghibzadeh B, Nouhi AH, Yavari P. Asymmetric facial growth and deviated nose: a new concept.  Ann Plast Surg. 2010;64(1):47-51PubMedArticle
16.
Kim YM, Rha KS, Weissman JD, Hwang PH, Most SP. Correlation of asymmetric facial growth with deviated nasal septum.  Laryngoscope. 2011;121(6):1144-1148PubMedArticle
17.
Delaire J, Precious D. Influence of the nasal septum on maxillonasal growth in patients with congenital labiomaxillary cleft.  Cleft Palate J. 1986;23(4):270-277PubMed
18.
Brain DJ, Rock WP. The influence of nasal trauma during childhood on growth of the facial skeleton.  J Laryngol Otol. 1983;97(10):917-923PubMedArticle
19.
El-Hakim H, Crysdale WS, Abdollel M, Farkas LG. A study of anthropometric measures before and after external septoplasty in children: a preliminary study.  Arch Otolaryngol Head Neck Surg. 2001;127(11):1362-1366PubMed
20.
Smith WM. Hemispheric and facial asymmetry: faces of academe.  J Cogn Neurosci. 1998;10(6):663-667PubMedArticle
21.
Ferrario VF, Sforza C, Poggio CE, Tartaglia G. Distance from symmetry: a three-dimensional evaluation of facial asymmetry.  J Oral Maxillofac Surg. 1994;52(11):1126-1132PubMedArticle
22.
Hwang HS, Hwang CH, Lee KH, Kang BC. Maxillofacial 3-dimensional image analysis for the diagnosis of facial asymmetry.  Am J Orthod Dentofacial Orthop. 2006;130(6):779-785PubMedArticle
23.
Farkas LG, Cheung G. Facial asymmetry in healthy North American Caucasians: an anthropometrical study.  Angle Orthod. 1981;51(1):70-77PubMed
Original Article
Mar/Apr 2013

Zonal Analysis of Facial Asymmetry and Its Clinical Significance in Facial Plastic Surgery

Author Affiliations

Author Affiliations: UCLA Harbor Department of Head and Neck Surgery (Dr Dhir) and UCLA Department of Head and Neck Surgery (Dr Binder), Beverly Hills, California; and Department of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, The Mount Sinai Medical Center, New York, New York (Dr Lawson).

JAMA Facial Plast Surg. 2013;15(2):110-112. doi:10.1001/2013.jamafacial.65
Abstract

Objectives To describe common patterns of facial asymmetry and to augment the facial analysis paradigm for improved preoperative counseling and surgical planning.

Methods We conducted a frontal photographic analysis of 50 patients who were seeking various types of facial cosmetic surgical procedures. The horizontal zonal thirds of the face were analyzed, and the bilateral data points were compared in regard to brow height, width of midface at maximum distance, malar eminence height, nasal alar height, and mandible width measured from the oral commissure to the gonial angle.

Results Forty-five patients demonstrated measurable asymmetry of the midface. The malar eminence was found to be more superiorly positioned and defined on the narrower side of the face in all cases. In contrast, the contralateral wider side of the face appeared flatter, with a more hypoplastic, inferiorly positioned malar eminence. Also, the wider side of the face more often demonstrated a wider mandibular dimension and a superiorly displaced ala. The upper third of the face, in regard to brow height, was the most variable and showed little correlation to the lower two-thirds of the face.

Conclusion This facial analysis exercise can assist the surgeon in (1) preoperative counseling, (2) managing expectations, (3) choosing appropriate-sized implants for improved symmetry, and (4) offering a more detailed assessment during the counseling of patients before face-lift surgery.

For centuries, facial symmetry has been linked to the perception of facial beauty, resistance to disease, and quality genetics for offspring survival. Although gross asymmetries may suggest disease, genetic mutation, or unattractiveness, the dividing line between natural and abnormal asymmetry has not yet been determined.13

Over the course of the last century, the relationship between facial symmetry and the perception of beauty has been studied intensely. Some authors concluded that symmetry has little influence or no impact at all on attractiveness.4,5 In fact, when photographs have been altered to reflect symmetrical mirror images of a left-left or right-right hemifacial duplication, the altered faces have been found to be less attractive than the original faces.6 Others disagree and suggest that facial symmetry, closeness to the average, and certain facial features, such as big eyes, a small nose, thin jaw, prominent cheek bones, a large mouth, and high eyebrows, play a role in what constitutes attractiveness.47

Nonetheless, attempts toward obtaining facial symmetry are commonplace in the field of facial cosmetic surgery, particularly in the field of rhinoplasty.810 In contrast, there is a paucity of literature that describes protocols on how to use facial augmentation and rejuvenation procedures for the purpose of correcting facial asymmetry. The aim of this study was to evaluate the prominent features of each horizontal third of the face for the purpose of delineating patterns of facial development. We used the standard horizontal division landmarks, including trichion to glabella, glabella to subnasale, and subnasale to pogonion. The malar eminence was found to be more superiorly positioned and defined on the narrower side of the face. In contrast, the contralateral wider side of the face demonstrated an inferiorly positioned and less defined malar eminence. This addition to the accepted facial analysis paradigm will assist in the preoperative planning and counseling for facial augmentation and lifting procedures.

METHODS

We conducted a frontal photographic analysis of 50 patients (23 men and 27 women) who were seeking various types of facial cosmetic surgical procedures. The exclusion criteria included patients younger than 18 years as well as a history of facial cosmetic surgery, trauma, cleft lip, or congenital microsomia.

To standardize the frontal photographs and to minimize variability in the patient population, accepted ideal frontal photographic principles were used.1114 A digital camera body (Nikon D90) with a 100-mm lens was attached to a tripod. The photographic frame encompassed the crown of the head to the clavicles, with the lateral canthus horizontal to the superior attachment of the ear. The midlens was raised to a height parallel to the patients' pupils. The patients were instructed to bite down on the back molars, without clenching, and to not smile with the lips closed. Using photoediting software (Adobe Photoshop CS5; Adobe Inc), the frontal photographs were included if the horizontal distances from the lateral canthus to the superior attachment of the ear were within 2 mm of each other and the interpupillary line was horizontal to the floor.

Once included, the horizontal zonal thirds were analyzed, and the bilateral data points were compared in regard to brow height, width of midface at maximum distance, malar eminence height, alar height, and mandible width measured from the oral commissure to the gonial angle. We used the standard horizontal division landmarks, including trichion to glabella, glabella to subnasale, and subnasale to pogonion

RESULTS

A total of 50 individuals were included in the study. The mean age was 37 years (age range, 19-65 years), with a female to male ratio of 1.17:1. Twenty-nine patients were white, 9 were Hispanic, 7 were Middle Eastern, 3 were Asian, and 2 were African American.

Forty-five patients demonstrated measurable asymmetry of the midface. The malar eminence was found to be more superiorly positioned and defined on the narrower side of the face in all 45 patients. In contrast, the contralateral wider side of the face was found to have a hypoplastic, inferiorly positioned malar eminence.

Moreover, the wider side of the face demonstrated a wider mandibular dimension in 30 of the 45 patients (67%) and a superiorly displaced ala in 32 of them (71%). Interestingly, the upper one-third of the face, in regard to brow height, showed no correlation to the lower two-thirds of the face, with only 26 of the 45 patients (57%) demonstrating a higher brow on the wider side of the face (Figure).

COMMENT

A review of the literature yields few studies correlating the effects of facial asymmetry between nasal, midface, mandibular, and orbital development. One recent study that examined patients with gross nasal deviation observed that the deviated side of the nasal septum (concave side) correlated with specific growth patterns, such as a lower cornea, brow, acanthi, and ala.15 However, the causality of septal growth affecting the facial development or vice versa was not discussed. Studies that suggest that the nasal septum plays a direct role in the growth of the surrounding structures of the face often extrapolate information from developmental findings observed on patients with cleft palates.16 Also, animal studies have been used to strengthen this argument. Young rabbits that underwent surgical procedures involving the septum demonstrated marked retardation of growth in the nose and upper jaw.17,18 However, this theory was questioned in humans in 1 publication that studied 26 children who underwent septal surgery for significant nasal obstruction or cosmetic disfigurement. Postoperative measurements demonstrated no deleterious effects on the development of the nose and midface at a mean follow-up of 3.1 years.19

Other studies have attempted to link facial asymmetry and growth patterns to facial musculature function. This hypothesis stems from the recent work on lateralization of brain hemispheres. One such study suggested that facial asymmetry in regard to greater width, or as the authors term facedness, depended on the dominant cerebral hemisphere.20 For example, individuals whose cognitive styles and activities are primarily verbal (left hemisphere) will, on the average, be right-faced. Individuals whose cognitive styles and activities involve visuospatial and nonverbal symbolic manipulation, (right hemisphere) on the average, are left-faced. The authors studied the faces of academe and argued that professors of humanity (left hemisphere dominant) demonstrated larger right faces. Conversely, the professors of mathematics and physics (right hemisphere dominant) demonstrated larger left faces. They did not include the upper face in the study owing to the cross-innervation of facial mimetic musculature. In agreement, our patients demonstrated the lower two-thirds of the face to be wider in tandem. The brow height did not correlate with the lower two-thirds of the face, possibly strengthening the argument of brain lateralization as the driving force in facial development.20

With the improvement of 2- and 3-dimensional imaging modalities and the use of computer-assisted measurements on standardized landmarks, many publications have tried to quantify common findings of asymmetry, with little agreement on the degree, side, and spatial localization of asymmetry. Although the quantification of facial asymmetry with these modalities is novel, it is difficult to use them in the clinical setting. Therefore, other studies, including this one, have relied on examining 2-dimensional images to determine common developmental findings when analyzing the face in order to recommend, assist, or modify surgical procedures to correct the facial asymmetry.21,22

The nose is the most prominent midface feature and deserves separate discussion. The predictable nature of growth is conventionally extrapolated from cleft lip nasal deformities.10 True maxillary hypoplasia results in posterior, inferior, and lateral deflection of the ala's attachment to the face. However, midface asymmetry and its effect on nasal axis deviation do not often follow this tenet in patients without a cleft lip.10 In our study, we concluded that the alar position was higher toward the wider side of the face. We hypothesize that the increased midface width retracts the ala in a posterosuperior direction. The implication in patients who are undergoing rhinoplasty is 2-fold. First, understanding alar retraction in the asymmetrical face helps guide the physician in managing expectations during the preoperative consultation. Second, it may suggest the need for surgical maneuvers such as the subalar graft or implant.

There are differing viewpoints regarding the degree of the most asymmetrical zone of the face. Farkas and Cheung23 carried out a study of 308 white children and provided data to support the theory that the upper third of the face was the most asymmetrical. Similarly, in our study, the brow position was found to be independent of midface width, with only 57% of patients demonstrating a higher brow on the ipsilateral wider side of the face. Others authors have published varying viewpoints suggesting that the lower area of the face and the midface are the most asymmetrical. We concluded that the midface and mandibular dimensions were 67% more likely to be asymmetrical in tandem from the opposite side of the face. Causation for this finding may include masticatory function, dentition, or a combination of both.

In the preoperative planning for facial augmentation, it can be advantageous to be mindful of common developmental patterns in the general population. In our patients, the wider side of the face consistently demonstrated a less pronounced malar eminence and a deficient anteroposterior projection as compared with the narrower side of the face, which demonstrated more projection in conjunction with a higher, more-defined malar eminence. This facial analysis exercise can assist the surgeon in preoperative counseling, managing expectations, choosing appropriate-sized implants for improved symmetry, and offering a more detailed assessment during the counseling of patients before face-lift surgery.

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Article Information

Correspondence: Karan Dhir, MD, UCLA Harbor Department of Head and Neck Surgery, 120 S Spalding Dr, Ste 340, Beverly Hills, CA 90212 (drdhir@drdhir.com).

Accepted for Publication: April 10, 2012.

Published Online: December 10, 2012. doi:10.1001/2013.jamafacial.65

Author Contributions:Study concept and design: Dhir, Lawson, and Binder. Acquisition of data: Dhir, Lawson, and Binder. Analysis and interpretation of data: Dhir, Lawson, and Binder. Drafting of the manuscript: Dhir and Binder. Critical revision of the manuscript for important intellectual content: Dhir, Lawson, and Binder. Statistical analysis: Binder. Administrative, technical, and material support: Dhir and Lawson Study supervision: Dhir, Lawson, and Binder.

Conflict of Interest Disclosures: None reported.

REFERENCES
1.
Zaidel DW, Cohen JA. The face, beauty, and symmetry: perceiving asymmetry in beautiful faces.  Int J Neurosci. 2005;115(8):1165-1173PubMedArticle
2.
Hamilton WD, Axelrod R, Tanese R. Sexual reproduction as an adaptation to resist parasites (a review).  Proc Natl Acad Sci U S A. 1990;87(9):3566-3573PubMedArticle
3.
Moller AP, Millar AP. Sexual Selection and the Barn Swallow. New York, NY: Oxford University Press Inc; 1994
4.
Baudouin JY, Tiberghien G. Symmetry, averageness, and feature size in the facial attractiveness of women.  Acta Psychol (Amst). 2004;117(3):313-332PubMedArticle
5.
Kowner R. Facial asymmetry and attractiveness judgment in developmental perspective.  J Exp Psychol Hum Percept Perform. 1996;22(3):662-675PubMedArticle
6.
Swaddle JP, Cuthill JC. Asymmetry and human facial attractiveness: symmetry may not always be beautiful.  Proc Biol Sci. 1995;261(1360):111-116PubMedArticle
7.
Light LL, Hollander S,, Kayra-Stuart F. Recognition memory for typical and unusual faces.  J Exp Psychol Hum Learn. 1979;5(3):212-228PubMedArticle
8.
Byrd HS, Salomon J, Flood J. Correction of the crooked nose.  Plast Reconstr Surg. 1998;102(6):2148-2157PubMedArticle
9.
Westreich RW, Lawson W. Perforating double lateral osteotomy.  Arch Facial Plast Surg. 2005;7(4):257-260PubMedArticle
10.
Yao F, Lawson W, Westreich RW. Effect of midfacial asymmetry on nasal axis deviation: indications for use of the subalar graft.  Arch Facial Plast Surg. 2009;11(3):157-164PubMedArticle
11.
Claman L, Patton D, Rashid R. Standardized portrait photography for dental patients.  Am J Orthod Dentofacial Orthop. 1990;98(3):197-205PubMedArticle
12.
Williams AR. Positioning and lighting for patient photography.  J Biol Photogr. 1985;53(4):131-143PubMed
13.
Larrabee WF Jr, Maupin G, Sutton D. Profile analysis in facial plastic surgery.  Arch Otolaryngol. 1985;111(10):682-687PubMedArticle
14.
Davidson TM. Photography in facial plastic and reconstructive surgery.  J Biol Photogr Assoc. 1979;47(2):59-67PubMed
15.
Hafezi F, Naghibzadeh B, Nouhi AH, Yavari P. Asymmetric facial growth and deviated nose: a new concept.  Ann Plast Surg. 2010;64(1):47-51PubMedArticle
16.
Kim YM, Rha KS, Weissman JD, Hwang PH, Most SP. Correlation of asymmetric facial growth with deviated nasal septum.  Laryngoscope. 2011;121(6):1144-1148PubMedArticle
17.
Delaire J, Precious D. Influence of the nasal septum on maxillonasal growth in patients with congenital labiomaxillary cleft.  Cleft Palate J. 1986;23(4):270-277PubMed
18.
Brain DJ, Rock WP. The influence of nasal trauma during childhood on growth of the facial skeleton.  J Laryngol Otol. 1983;97(10):917-923PubMedArticle
19.
El-Hakim H, Crysdale WS, Abdollel M, Farkas LG. A study of anthropometric measures before and after external septoplasty in children: a preliminary study.  Arch Otolaryngol Head Neck Surg. 2001;127(11):1362-1366PubMed
20.
Smith WM. Hemispheric and facial asymmetry: faces of academe.  J Cogn Neurosci. 1998;10(6):663-667PubMedArticle
21.
Ferrario VF, Sforza C, Poggio CE, Tartaglia G. Distance from symmetry: a three-dimensional evaluation of facial asymmetry.  J Oral Maxillofac Surg. 1994;52(11):1126-1132PubMedArticle
22.
Hwang HS, Hwang CH, Lee KH, Kang BC. Maxillofacial 3-dimensional image analysis for the diagnosis of facial asymmetry.  Am J Orthod Dentofacial Orthop. 2006;130(6):779-785PubMedArticle
23.
Farkas LG, Cheung G. Facial asymmetry in healthy North American Caucasians: an anthropometrical study.  Angle Orthod. 1981;51(1):70-77PubMed
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