Facial asymmetry correction using a surgery-only orthognathic approach with adjunctive facial contouring and revision genioplasty: a case report

Article information

Arch Craniofac Surg. 2026;27(2):100-107

Publication date (electronic) : 2026 April 20

doi : https://doi.org/10.7181/acfs.2025.0038

Atapol Yongvikul^1,2, Manop Khanijou², Natthamet Wongsirichat², Thongnard Kumchai^,2

¹Department of Oral and Maxillofacial Surgery, Masterpiece Hospital, Bangkok, Thailand

²Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bangkokthonbui University, Bangkok, Thailand

Correspondence: Thongnard Kumchai Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Bangkokthonburi University, 10 Thawi Watthana, Bangkok 10170, Thailand E-mail: thongnard@hotmail.com

Received 2025 July 24; Revised 2025 October 21; Accepted 2026 March 6.

Abstract

INTRODUCTION

Facial asymmetry is a frequent presentation in maxillofacial and facial plastic surgery, ranging from minor anatomical variations to severe skeletal disharmony affecting both aesthetics and function [1]. While mild asymmetry is often considered within normal limits, more pronounced deformities may involve combined discrepancies of skeletal structures, dentition, and overlying soft tissues, potentially leading to impaired mastication, temporomandibular joint dysfunction, and psychological distress [2].

Orthognathic surgery remains the standard treatment for severe skeletal facial asymmetry and is traditionally performed in conjunction with pre- and postoperative orthodontic treatment to optimize occlusal outcomes [2]. However, a surgery-only orthognathic approach has gained acceptance for use in carefully selected patients particularly adults with stable preoperative occlusion or those whose primary concern is facial aesthetics. By eliminating the orthodontic phase, this approach can significantly reduce overall treatment time while maintaining satisfactory functional and aesthetic results [3]. In addition, in some complex cases involving significant asymmetry of both hard and soft tissues from the suborbital to the submental level, additional procedures such as facial contouring surgery and genioplasty may be warranted to achieve optimal symmetry and proportion [4]. When performed simultaneously, these proce-dures demand meticulous planning but offer the advantage of comprehensive correction within a single operative and recovery period.

This report presents a case of severe maxillofacial asymmetry successfully managed using a surgery-only orthognathic approach combined with facial contouring and revision genioplasty. The case illustrates the clinical rationale, surgical strategy, and outcomes of this comprehensive approach, emphasizing its applicability in selected patients seeking efficient and aesthetically driven correction.

CASE REPORT

This report presents the case of a healthy 35-year-old Thai woman who aimed to achieve aesthetic maxillofacial contouring, focusing on the correction of facial asymmetry at the Department of Maxillofacial Surgery, Masterpiece Hospital. This case report was exempt from IRB review in accordance with institutional guidelines (IRB No. BTU-IRB-32/2568) and was prepared in compliance with HIPAA regulations. The patient provided informed consent to disclose certain identifying information, including her photograph and radiographic images. The patient was immunocompetent and reported no underlying medical conditions. The patient had no history of congenital syndromes commonly associated with facial asymmetry, such as hemifacial microsomia. She had undergone orthodontic treatment more than 10 years ago; however, the facial asymmetry— present since early childhood and not associated with any functional issues such as chewing difficulty or crossbite— persisted, suggesting a longstanding skeletal origin [5]. In terms of aesthetic history, she had received several interventions aimed at improving facial balance. These included a semi-open rhinoplasty performed 5 years ago, followed by an endoscopic brow lift combined with a midface lift 1 year ago (Fig. 1A). Additionally, she had undergone repeated liquid silicone injections in the chin region over a period of more than 10 years, in an attempt to camouflage the asymmetry. The patient presented with noticeable facial asymmetry, the right side being smaller than the left side. At rest and during facial animation, asymmetry was readily apparent, characterized by a general lack of projection and contour on the right hemiface. The malar eminence on the right was underdeveloped, contributing to midfacial flatness and a blunted transition from the orbit to the cheek, while the left malar eminence was projected and showed a masculine appearance. In the lower part of the face, the asymmetry became more pronounced. On palpation, the right gonial angle lacked definition, and the mandibular contour was less pronounced. The chin was deviated approximately 12 mm toward the right side, aligning with the shortened mandibular structure. From cone-beam computer tomography, the right mandibular ramus and body were visibly hypoplastic, with decreased vertical height and volume compared to the left, and the chin level was obviously different (Fig. 2A). Soft tissue over the right mandibular body and submental region was thicker, however. Intraoral examination revealed a reproducible occlusion, but the dental midline deviation was toward the affected side. The maxillary occlusal plane exhibited severe canting, with the right side positioned superiorly relative to the left approximately 6 mm. Dental occlusion parameters, including Angle’s classification, canine relationship, overjet, and overbite were within normal limits. The cone-beam computer tomography also showed occlusal plane canting down on the left side (Fig. 2A). During smile, the smile line was at the level of the cervical gingiva; however, the smile was also canted at the same level as the occlusal canting line. Mandibular movements were functional but asymmetric; during opening, the mandible deviated toward the right side with clicking, indicating joint imbalance likely associated with underdevelopment of the right condyle.

Fig. 1.

A 35-year-old woman with facial asymmetry due to hypoplasia of the right mandibular ramus–condyle unit and a history of orthodontic treatment in early adolescence. (A) Preoperative photographs showing mandibular retrusion and facial asymmetry. Surgical intervention was performed to correct skeletal asymmetry without altering the occlusion. (B) Photographs obtained 1 year postoperatively demonstrating improvement in facial profile, symmetry, and a smoother, more balanced smile line.

Fig. 2.

Three-dimensional computed tomography images before and after surgery. (A) The preoperative image reveals pronounced maxillofacial asymmetry, extending from the malar bones through occlusal plane canting, which slopes downward on the left side, culminating in a severe rightward deviation of the chin point. (B) The immediate postoperative image demonstrates comprehensive surgical correction, including reduction malarplasty, Le Fort I osteotomy, right sagittal split osteotomy, left intraoral vertical ramus osteotomy, and T-shaped genioplasty. (C) At the 7-month postoperative stage, the images confirm adequate bony healing, with no observable signs of relapse.

The patient’s clinical history and examination findings were consistent with the right-sided unilateral condylar hypoplasia, characterized by underdevelopment of the mandibular ramus and body [5]. The facial asymmetry extended from the sub-orbital region through the midface and mandibular angle to the submental area, reflecting both skeletal deficiencies. Additionally, the presence of long-standing liquid silicone injections in the chin further complicated the lower facial contour. These combined factors necessitated a comprehensive, multi-modality surgical approach to correct the underlying skeletal asymmetry, refine soft tissue irregularities, and restore facial balance. Accordingly, the patient was scheduled to undergo a surgery-only bimaxillary orthognathic procedure including Le Fort I osteotomy, right mandibular sagittal split osteotomy and left vertical ramus osteotomy, to correct the asymmetry of the dentofacial matrix. This was combined with adjunctive facial contouring surgery to both correct and conceal the remaining asymmetry caused by the surrounding maxillofacial bones, including reduction malarplasty, bilateral reduction mandibular anguloplasty, and buccal fat pad removal. In addition, a revision genioplasty was planned to address residual severe chin asymmetry and prior permanent non-resorbable filler complications, involving surgical removal of liquid silicone, capsulectomy, and realignment of the chin musculatures. The summary of the surgical procedures is shown in Table 1.

Table 1.

Summary of surgical procedures

A standard Le Fort I osteotomy with preservation of the descending palatine arteries was performed to correct transverse canting by impacting the left maxilla by 3 mm and lowering the right side by the same amount, thereby maintaining the vertical level of the incisal edge and preserving the patient’s preoperative smile line. The occlusal plane remained unchanged, as the position and angulation of the maxillary central incisors were deemed satisfactory and within normal limits. The correction of the maxillary canting was planned based on the clinical assessment of the upper jaw position, with particular attention to the tip of the maxillary canine, without the use of computer-assisted analysis. The midline was determined using the position of the nasal dorsum corresponding to the intercanthal point as a reference. While mandibular osteotomy was conducted using two distinct techniques: a sagittal split osteotomy on the right side secured with a straight 2.0 mm four-hole plate and 5 mm miniscrews (Le Forte System, Jeil Medical), and the vertical ramus osteotomy without fixation on the contralateral side. Sagittal split osteotomy was performed on the non-deviated side as the most recent mandibular osteotomy technique, while vertical ramus osteotomy was selected on the deviated side to minimize the risk of condylar torque [6]. The combination of these techniques allowed more symmetry of the body of the mandible [7]. The double-jaw surgery was guided by the soft tissue paradigm, re-evaluated following completion of the mandibular osteotomy, and performed without the use of an occlusal splint. To correct the remaining asymmetry at the angle of the mandible, subsequent contouring of the mandibular angle was performed using a reciprocating saw. At the patient’s request for a slimmer facial appearance with more facial feminization, angle reduction was performed to achieve the most natural and refined result. The osteotomy line, without a surgical guide, according to the soft tissue paradigm, extended from a point 0.5 cm below the earlobe to approximately 2 cm anterior to the mandibular angle.

Following mandibuloplasty, revision genioplasty was performed. The patient had previously received liquid silicone injections, which were planned for removal as thoroughly as possible. The intraoral approach provided exposure from the region of the lower second premolars, with both mental nerves clearly identified and protected throughout the procedure. The key technique was a layer-by-layer dissection method, which enabled precise capsulectomy and en bloc excision of the silicone deposits along with the surrounding fibrous capsule (Fig. 3). All genial muscles were carefully identified and re-draped to their anatomical positions. To further address residual facial asymmetry, asymmetric malar reduction was performed in combination with buccal fat pad removal. The surgical technique for reduction malarplasty was an inverted L-shape osteotomy and fixation with 1.6 mm microplates and screws (Le Forte System). The extent of bone resection was determined intraoperatively to achieve maximum symmetry at the malar prominence and camouflage any remaining asymmetry. Wound closure was completed with resorbable material following placement of an alar base cinch suture with non-resorbable material. Although the patient underwent multiple bone procedures, intraoperative bleeding was limited to 300 mL; therefore, no surgical drain was placed.

Fig. 3.

(A) The non-resorbable filler, liquid silicone, appeared as dispersed gel-like material within the chin’s muscle fibers, partially encapsulated or interwoven with fibrotic tissue. (B) During surgery, the encapsulated silicone was meticulously removed as much as possible to minimize residual foreign material.

Postoperative recovery was uneventful, and the patient tolerated the procedure well (Fig. 2B). The patient was admitted for a night. As vertical ramus osteotomy was performed on the left side of the mandible without plate and screw fixation, maxillomandibular fixation was applied for 2 weeks using four intermaxillary fixation screws placed during surgery. Dental occlusion remained stable and reproducible following the removal of maxillomandibular fixation. At the 1-month dental check-up, occlusion was confirmed to be consistent, with no evidence of open bite. Maximum mouth opening, including lateral and anterior translation of the temporomandibular joints, was restored. The surgical sites healed without any signs of infection or dehiscence. At the 3-month follow-up, improvements in facial symmetry were visibly apparent, particularly in the mandibular contour, chin alignment, and midface volume. Evaluation of dental occlusion parameters, including Angle’s classification, canine relationship, dental midline alignment, overjet, and overbite revealed no significant deviation from the preoperative status. The mandibular function, including mouth opening and lateral excursions, was within normal limits. The patient reported high satisfaction with the overall aesthetic outcome. The revision genioplasty achieved improved projection and midline positioning of the chin, with no evidence of recurrent asymmetry or significant fibrosis. The patient was more satisfied with her smile following the smiling rehabilitation. A minor complication included transient lower lip paresthesia, likely related to manipulation near the mental nerve during silicone removal and chin realignment. Sensory function showed gradual improvement and was nearly fully restored by the 6-month followup.

At 12 months postoperatively, results remained stable with no relapse of asymmetry or functional impairment. Serial photographic and radiographic assessments confirmed skeletal and soft tissue symmetry (Figs. 1B, 2C). The patient expressed continued satisfaction with both aesthetic and functional outcomes and did not require further interventions.

DISCUSSION

Facial asymmetry represents one of the most complex challenges in orthognathic and facial plastic surgery due to its multifactorial etiology and the need to address both skeletal and soft tissue discrepancies [3]. The present case demonstrates that a surgery-only orthognathic approach, when combined with targeted facial contouring and genioplasty, can effectively correct pronounced facial asymmetry in a carefully selected adult patient. The key clinical contribution of this case lies in showing that stable functional and aesthetic outcomes can be achieved without orthodontic treatment when preoperative occlusion is acceptable, and the primary treatment goal is aesthetic improvement. The integrated surgical strategy—including Le Fort I osteotomy, a combination of sagittal split and intraoral vertical ramus mandibular osteotomies, and adjunctive contouring procedures—highlights the importance of comprehensive, individualized surgical planning. In this patient, the decision to forgo orthodontic treatment was supported by stable preoperative occlusion and the patient’s desire for timely aesthetic enhancement. This aligns with prior reports emphasizing that, in well-selected cases, surgery-first or surgery-only orthognathic protocols can shorten overall treatment time while maintaining high levels of patient satisfaction [3,4]. The favorable outcome in this case further supports the notion that complex facial asymmetry can be managed efficiently through a facial-plastic–oriented orthognathic approach.

Consistent with existing literature, this case reinforces the growing evidence supporting surgery-only orthognathic treatment in patients with acceptable occlusion and significant aesthetic concerns [4,8,9]. Careful preoperative assessment of basic orthodontic parameters—such as canine and molar relationships, overjet, overbite, and dental midline alignment—was essential to ensure postoperative occlusal stability [10,11]. Although occlusal splints are commonly used to verify final occlusion, they were not required in this case because maximal intercuspation was considered sufficiently stable [12]. If the final occlusion differs from the preoperative alignment after unfavorable Le Fort I segment positioning or temporomandibular joint changes, such as condylar sagging, have been ruled out [13], minor orthodontic treatment may be considered. In the present case, any minor occlusal discrepancies were smaller than 0.5 mm and were therefore considered clinically insignificant, not warranting orthodontic intervention. This approach is further supported by the dynamic nature of occlusion, which varies throughout the day under the influence of masticatory muscle activity [14].

For mandibular correction, a combination of sagittal split and intraoral vertical ramus osteotomies was selected. Vertical ramus osteotomy on the deviated side is particularly effective in reducing condylar torque when significant mandibular rotation is required to realign the chin and mandibular border with the facial midline [6,7]. In this case, the patient also experienced improvement in temporomandibular disorder symptoms postoperatively. However, a recognized limitation of this technique is the need for temporary maxillomandibular fixation during healing when internal fixation is not used [15]. Residual asymmetry in the gonial region was addressed with mandibular angle reduction, consistent with reports that combined osteotomy techniques and adjunctive contouring can further refine mandibular symmetry [7].

Contemporary management of facial asymmetry increasingly emphasizes the soft tissue paradigm, recognizing that skeletal symmetry alone does not guarantee optimal facial balance [16]. Although some authors advocate combining orthognathic surgery with facelift procedures to address soft tissue discrepancies [17] the present case focused on hard tissue correction while planning dissection and contouring with soft tissue behavior in mind. Adjunctive procedures, including reduction malarplasty and buccal fat pad removal, were performed to enhance overall facial harmony, consistent with facial plastic surgery literature supporting combined interventions for complex asymmetry [3,4].

An additional challenge in this case was revision genioplasty following previous liquid silicone injection. Although silicone fillers have been widely used due to low cost and ease of application, their use is associated with well-documented complications, including infection, fibrosis, migration, and disfigurement [18]. While revision genioplasty following the removal of foreign material is less frequently reported, existing literature aligns with reconstructive approaches used to manage filler-induced complications [19]. The revision strategy involved meticulous removal of silicone and surrounding fibrous tissue while preserving the superficial subdermal layer to prevent skin irregularities. A key technical challenge in this procedure was the meticulous re-draping of the perioral and para-mental musculature, including the mentalis, depressor labii inferioris, depressor anguli oris, and orbicularis oris. These muscles were carefully repositioned as close as possible to their original anatomical locations to restore both functional integrity and aesthetic balance. From our experience, precise muscle re-draping represents the most critical step in revision genioplasty following foreign material removal, as inadequate repositioning can lead to contour irregularities, impaired animation, and longterm asymmetry. To further minimize complications, postoperative smiling exercises were emphasized to promote neuromuscular coordination, reduce fibrosis, and facilitate adaptive soft tissue remodeling, thereby optimizing long-term facial symmetry and dynamic expression.

This case report is limited by its single-patient design, which restricts generalizability. Long-term stability beyond the 12-month follow-up remains unknown, and objective outcome measures, such as validated quality-of-life assessments, were not included. These limitations underscore the need for larger cohort studies to better define patient selection criteria and to evaluate the reproducibility and long-term outcomes of this comprehensive surgical strategy.

In conclusion, this case illustrates that a surgery-only orthognathic protocol, when combined with adjunctive facial contouring and revision genioplasty, can effectively correct complex facial asymmetry in carefully selected adult patients with stable occlusion and primarily aesthetic concerns. Importantly, this integrated approach allowed correction of skeletal and soft tissue imbalance while maintaining a favorable temporomandibular joint condition [20]. These findings add to the literature by demonstrating that a strategically planned hybrid orthognathic and facial contouring approach can deliver stable, harmonious aesthetic outcomes together with functional stability and temporomandibular joint–friendly results in well-selected adult patients.

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