For Life interviewed Dr Matthew Yeo from the Picasso Plastic Surgery Clinic about ideal facial proportion, and how standards of measurement dictate facial symmetry.
Q: Do many patients ask for facial asymmetry correction? Can you describe one or two memorable examples?
Facial asymmetry may occur as a result of injury (for e.g., following facial fractures, facial tumour excision, facial burn injuries, etc.), or occur as a natural phenomenon. Every individual has some inherent asymmetry, although it is often minor and may go unnoticed by the individual, and sometimes, the treating doctor. Prior to performing any treatment, it is important for the doctor to perform a detailed assessment of the face, and identify any pre-procedural or any anticipated post- procedural asymmetries and discuss this with the patient.
I recall being consulted by a 40-year-old female who requested for filler injections to the face to rejuvenate it. She shared that her right cheek was smaller and flatter than the left and wished to restore some symmetry. An assessment of the patient showed that she had an abnormal cross-bite, and her chin was subtly pointing towards the right side. I diagnosed her with a condition known as hemifacial microsomia, a congenital condition in which one side of the face is smaller than the other. She was referred to an orthodontist, who subsequently installed braces which resulted in a good bite, and thereafter I performed filler injections to her cheeks and restored cheek symmetry. She is an example where careful assessment permitted identification of underlying functional issues and optimal restoration of both facial form and function.
I recall another case: a 20-year-old male who previously underwent excision of a congenital facial tumour, leaving a depression in a visible location just beneath the eyelid. He was bothered by his appearance and was concerned about its effect on his employability as well as his social life. I restored his facial symmetry with filler injections, a simple in-clinic procedure. He is currently happily employed, and is engaged to be married.
Q: Do many patients request for overall facial proportion correction? Can you describe one or two memorable examples?
A majority of patients who are considering undergoing aesthetic treatments consciously or subconsciously seek alteration of the facial proportion. In East Asia, many patients have flat cheekbones and request for improvement to the anterior cheek projection. Many patients have a wide lower jaw, and they often request for a V-shaped jawline. Other popular requests include augmentation of the nasal bridge, and alteration of the chin which requires lengthening or increasing the anterior projection. Minor changes in the facial proportions may be achieved using botulinum toxin, fillers, and/or fat transfers from the abdomen to the face, or a combination of these techniques. Alteration of the facial skeleton often requires minor surgery. Pre-procedural assessment by an experienced professional will allow patients to receive treatments appropriate to their expectations.
I was consulted by a 65-year-old female senior executive who wanted to improve her “tired look”, as she frequently received comments that she looked tired from her family and co-workers. This caused her to lose confidence when leading meetings at her workplace, and caused her to be socially withdrawn. I performed botulinum toxin and filler injections in a simple clinic procedure. The filler injections increased her cheek projection, lifted up the cheek tissue and effaced her laugh lines, creating a balanced, refreshed and rejuvenated look which restored her confidence. She was pleased with the outcome and shared that she experienced significant improvements in her professional and social life. She has since undergone a surgical facelift and regular botulinum toxin injections, and remains a satisfied patient.
Q: How can hyaluronic acid (HA) fillers correct facial asymmetry and improve the overall proportion of the face?
There is a variety of HA fillers with different properties which achieve different objectives. Highly-cross linked HA fillers have a higher G prime (i.e., are more stiff) and have a supporting function and may be used to replace areas in which there is bone loss which occurs naturally with ageing, or to lift areas in which the soft tissue has loosened. Fillers which have HA cross links but to a lesser extent are softer and simulate subcutaneous fat, and are optimal for filling in areas where fat atrophy has occurred due to ageing or injury. An example of a HA filler brand is Restylane where they have a wide range of fillers with varying G prime and particle size for different injection sites and depths.
A particular advantage of HA fillers is that they are reversible or correctible with the use of hyaluronidase, a naturally-occurring enzyme. Injection of an inappropriate amount of HA filler, or at inappropriate locations or depths, may sometimes result in a suboptimal appearance and/or irregularities. In such cases, hyaluronidase injections may be performed in the clinic; they are simple and effective for partially or totally erasing the preceding HA filler treatment.
HA fillers are different from permanent fillers. In the 1990s, the use of permanent fillers was popular due to its promise of long-lasting improvements with a single treatment. As long-term results generally show irreversible complications, such fillers have largely fallen out of favour. There are also other fillers that are resorbable, but do not have similar reversal agents like hyaluronidase, where complications will only resolve after the filler is absorbed by the facial tissues.
Q: Is it important to follow standards of measurements when correcting facial asymmetry?
In cases where the facial pathology or deformity exists only on one side (unilateral), the normal side is taken as the reference point for the assessment and planning of subsequent treatment(s). More frequently, the deformity may occur on both sides and this most frequently occurs in ageing patients and/or patients who have been undergoing aesthetic treatments. Where the deformity is bilateral, or involves structures in the midline, such as the nose, lips and chin, well-established facial canons such as the Golden Ratio, Rickett’s line, and the Holdaway H line help the patient and the doctor plan to achieve a balanced and harmonious facial proportion, and aids in directing treatment goals and outcomes.
The aesthetic facial appearance does not comprise solely of its individual parts, but is the sum of these parts and how their appearance blend with each other. It is like the aesthetic appreciation of a painting or a sculpture, where the proportions of the individual parts contribute very much to the overall aesthetic appearance of the object.
Q: Should standards of measurement apply when treating facial asymmetry?
Achieving facial harmony should be the overall and most important aim, instead of strict adherence to measurements and angles. The ideal facial proportions and angles are subject to ethnic variations and individual preferences, and these should be taken into consideration instead of applying a single textbook ideal to the patient. Achieving the best appearance in the individual patient requires tailoring of the treatment plan in accordance with the pathology and the patient’s concerns, with due consideration of facial canons and measurements, and is best delivered by experienced practitioners. Similarly, we know the best-fitting clothes are not obtained off-the-rack from a department store, but rather, from our favourite tailors who cut and stitch the cloth according to our individual characteristics and measurements. The best restaurants are also those that individualize their cooking to bring out the flavours and textures of fresh ingredients that are purchased daily and not fast-food restaurants that cook using a standard guide. Aesthetic treatments are no different.
About Dr Yeo: Dr Matthew Yeo is a Ministry of Health (MOH) and SMC-certified consultant plastic surgeon. He completed his residency in 2012 and was awarded the Gold Medal for performance at the national plastic surgery board examinations by the College of Surgeons, Singapore. In 2013, he received the Health Manpower Development Program scholarship from MOH and completed a one-year fellowship in Advanced Reconstructive Microsurgery in Taiwan, Republic of China, under the mentorship of the world-renowned Professor Hung-Chi Chen. He has also completed multiple aesthetic surgery visiting fellowships in the USA, Europe, South Korea, Taiwan, and Thailand. Dr Yeo is also the first local plastic surgeon to be awarded Fellow of the European Board of Plastic, Reconstructive and Aesthetic Surgeons following successful completion of the board examinations in year 2015.