Case Study: Correcting Facial Asymmetry

Facial symmetry is a fundamental goal of many facial aesthetic treatments, and yet some asymmetry is inherent in any face and a natural part of the ageing process.¹ Paresis of the facial nerve after a stroke causes functional and aesthetic defects, manifested by facial asymmetry, which is exacerbated by the passing of time as collagen levels deplete and disproportionate deflation occurs.

Patients experiencing pronounced asymmetry to the face typically present to aesthetic clinics with a number of concerns, which usually include the brows, eyelids, jawline and cheek areas.

Case study

Patient presentation

A 59-year-old Caucasian woman presented to me with pronounced asymmetry and a tired, gaunt appearance, sagging jowls, thin skin and subcutaneous tissue. The patient had experienced a brain tumour 13 years previously, which had been debulked, however during surgery she had suffered a stroke which had resulted in left-sided paralysis. Whilst she had recovered movement she ended up with pronounced asymmetry to the left side of her face and a particular complaint regarding the ptosis of her left eyelid.

Consultation

The degree of asymmetry was carefully assessed during an initial 40-minute consultation, with careful note taken of past treatments. The patient’s thin skin was prudently noted and presented additional challenges to be considered. The elasticity of the skin was evaluated by pinching the skin, and it was apparent that there was a moderate degree of volume loss and tissue sag, leading to a tired appearance. The tiredness was permeating from the temple area and through to the side of the face, resulting in a sagging jawline which the patient explained was one of her main concerns.

The asymmetry of her face, specifically the disparities in the size of each eye, was a particular challenge. It was important to ensure significant consideration of the patient’s underlying medical considerations, which has resulted in a number of limitations to facial movement. The patient exhibited a degree of asymmetry from soft tissue loss as part of the natural ageing process, however the patient’s facial muscle movement exhibited inconsistencies on each side of the face, resulting in a greater degree of unevenness to the face than would typically be expected. It is always of the upmost importance to consider the functional element to any treated area and, as such, careful planning was required to address both the static and dynamic presentation of the asymmetry.

A collagen-stimulating filler was the most effective course of treatment, addressing both soft tissue laxity and volume loss

At all consultations, I believe it is imperative to photograph the patient’s face from a multitude of angles. This not only ensures the patient can view their concern from a number of angles, but also enables strong, clear, measured discussion about treatment options and results that can be expected. Photographic imagery also ensures that a patient will have clarity around both what a treatment can and, often more importantly, cannot achieve, so reasonable expectations are set. Time was taken to photograph the patient’s front, three quarter and side profiles, ensuring the background was free of objects.

During the consultation, it was apparent that a non-surgical, minimally-invasive treatment was the patient’s preference. A number of treatment options were discussed including thread lifts, plasma technology treatment and also surgery. The patient advised that they had experienced a serious inflammatory response following plasma treatment in recent years, and therefore ruled this option out. She also did not want to undergo surgery at this time, as she works full time in an industry where appearance is important and did not have the luxury of downtime to recover from a treatment. It was therefore recommended that the use of a collagen-stimulating filler would be the most effective course of treatment, addressing both soft tissue laxity and volume loss, while improving the quality of the thinning skin in the ensuing months post-treatment.

Following the consultation, a letter detailing the patient’s main concerns and agreed treatment plan was handed to the patient. I then allowed for a cooling-off period of two weeks to ensure that the patient had ample opportunity to ask follow-up questions.

The patient was instructed not to consume alcohol or take blood-thinning medication for three days prior to treatment.

Treatment

Makeup was removed before the procedure and the area was carefully disinfected with Clinisept+ Prep and Procedure. The patient was offered topical anaesthetic cream, and both sides of the face were evaluated carefully once more.

Over the course of an hour, 8ml of the product, Ellansé S, was judiciously administered. Typically, treatment to address concerns pertaining to menopausal skin takes around 30 minutes, but due to the complexities of the case, it was necessary to take extra time and precautions throughout.

Treatment commenced in the dips of the temple region, moving downward to the mid and lower face, and finally the jawline; a particular area of focus due to the patient’s concerns relating to the degree of sagging she was exhibiting. A needle was used to treat the deeper fat pads, while a 25 gauge 38mm TSK cannula was used extensively to treat the subcutaneous and more superficial fat pads with a fanning technique. A cannula was chosen for this part of the treatment as I believe that it is safer and also causes less bruising for the patient, because it only requires one entry point from which product can be distributed evenly.

At regular stages during the treatment, it was important to assess the changing symmetry to the face and ensure natural and full muscle movement. As a result of this careful monitoring, no additional challenges became apparent during the treatment period.

Immediately post-treatment, photographs were taken ensuring the same front, three quarter and side profile angles were captured. The patient experienced an immediate change in her symmetry and was thrilled with her results. Increased volume occurs immediately post-injection, however volumisation continues to develop for up to four months, as the ingredients within the filler encourages the body to produce Type 1 collagen in response.

Post procedure and follow up

At the 12-week review, the patient was delighted with the final results and reported no side effects from treatment. There was significant improvement to the overall balance and harmony of the face, even when at rest. Of particular significance, she felt less conscious about the asymmetry which had reduced significantly. An additional round of photographs, carefully constructed to mirror both the pre- and immediately post-treatment images, were taken to capture the degree of change that was able to be achieved.

The patient was advised to attend a routine follow-up appointment to assess her progress a year after treatment, and to repeat the treatment after 16-18 months to maintain her results.

Conclusion

My experience over two decades as an aesthetic ophthalmic plastic and reconstructive surgeon has taught me to appreciate that patients have to ‘wear our work.’ When mature patients with volume loss and tissue sag insist on achieving a lifting effect with hyaluronic acid fillers alone, they are at risk of developing ‘facial overfilled syndrome.’ This is where I find administration of collagen-stimulating dermal fillers a more effective option, by providing natural volume restoration and structural skin support. In this case specifically, where the patient’s asymmetry required a firmer level of structural support on one side, I was able to tailor her treatment more readily using the tuneable collagen stimulator, delivering a result the patient was delighted with.

As clinicians, it is critical that we invest sufficient time to discuss the patient’s aesthetic priorities, social needs and tailor our approach. I have found that when patients are better educated on the ageing process and the results that treatments are able to achieve, it helps minimise complications and achieve natural results by ensuring realistic patient expectations.