Keywords skilled practitioners - multi-axes facial rotation - facial asymmetry - filler injection
Facial asymmetry is an inherent trait present from birth, which becomes more pronounced
with age due to changes in the facial skeleton, such as bone resorption, loss of soft
tissue volume, and shifts in facial structures. These changes can accentuate preexisting
asymmetries, making it crucial for aesthetic practitioners to thoroughly assess each
patient's unique needs before recommending treatment. The skull, as any 3D object,
allows for rotation around three axes, namely the x -, y -, and z -axes ([Fig. 1 ]). New scientific evidence involving a diverse population of 340 individuals has
revealed previously unreported common anatomical patterns of “multi-axes facial rotation,”
underscoring the need for traditional facial assessment and treatment standards to
evolve (“deciphering multi-axis facial rotation: the key to understanding facial asymmetry”—accepted
for publication in Plastic and Aesthetic Nursing, Volume 46, Issue 2). Modern aesthetic
practices, armed with the knowledge of multi-axes facial rotation patterns, can adapt
this latest research to provide state-of-the-art, personalized treatments.
Fig. 1 Rotation of the faces can be found on the x , y , and z -axis. This makes it difficult to make generalized injection techniques.
The aim of this communication is to address the limitations of conventional, effective
2D dermal filler guidelines, such as MD Codes™ and BeautiPHIcation™, by not only addressing
the complexities of 3D asymmetry but more specifically, particular facial rotation
patterns. The conventional methods primarily focus on enhancing individual features
rather than achieving overall facial balancing, potentially neglecting broader aesthetic
needs.
MD Codes™, developed by Dr. Mauricio de Maio, is a structured approach to dermal filler
injections that divides the face into specific zones with precise, symmetrical injection
points to achieve targeted aesthetic goals such as lifting, volumizing, and contouring.
While MD Codes™ enhance safety and predictability by providing clear guidelines and
a standardized, “cooky-cutter” method, they can sometimes overly focus on individual
features rather than overall facial balancing. This simplistic approach overlooks
broader aesthetic needs, especially in cases of significant multi-axes facial asymmetry
patterns or skeletal changes with age. Despite these limitations, MD Codes™ remain
a valuable tool to achieve standardized results in facial aesthetics, in particular
for novices.[1 ]
BeautiPHIcation™, developed by Dr. Arthur Swift, is a concept that applies the mathematical
principles of the “golden ratio” (phi) to facial aesthetics. The golden ratio is a
proportion historically associated with beauty, and Dr. Swift's method uses this ratio
to guide the enhancement of facial features by pursuing 2D symmetry with dermal fillers.
While BeautiPHIcation™ represents a significant advancement in achieving proportionality
within individual features, it can also emphasize specific (asymmetrical) proportions
at the expense of overall facial balance. By focusing on achieving the golden ratio
in isolated facial features, this approach might neglect the broader concept of facial
balancing, which would require enhanced individual rotational facial features to be
treated to improve overall symmetry and harmony across the entire face.[2 ]
These methods, while structured and scientifically grounded, may not fully address
the challenges posed by facial asymmetry and the anatomical changes that occur with
aging. As individuals age, the lower face undergoes retrograde movement along the
x -axis, resulting in volume loss and leading to contractures in the lip depressor muscles
and stiffening of the orbicularis oris muscles, causing lip inversion. Notable changes
in facial anatomy with age include bone resorption in specific areas of the facial
skeleton, such as the pyriform aperture and the maxilla, which deepens the nasolabial
crease and causes the nose tip to droop. Additionally, aging affects the mandible,
altering its angle and reducing the definition of the lower face, significantly impacting
the overall perception of aging. Where asymmetry is present at birth, the asymmetry
between the two sides of the face increases steadily with aging (Linden #3857[3 ]).
Facial asymmetry often presents along the x -axis, where the left side of the face appears more prominent or wider than the right
([Figs. 1 ]
[2 ]
[3 ]). This phenomenon is associated with the “zygion,” the most lateral point of the
zygomatic arch, a critical landmark in assessing facial width. Historically, studies
have shown that the left side of the face tends to be wider, leading to the term “left
face dominance.” (Ercan, 2008 #3859; Hafezi, 2017 #3860). Correcting this asymmetry
by widening the right face, as advocated by conventional guidelines is likely to result
in poor outcomes and should be planned with great care. Observing the patient from
a top–down, or “birds-eye” view helps identify y -axis rotational changes (left-to-right, or right-to-left), which can impact facial
projection, appearance, and function. With left-to-right rotation, the nose can often
be seen deviating to the right. This can be corrected by placing dermal filler in
the right piriform fossa and pushing the nose back to the midline. If the injector
follows conventional treatment guidelines they may also feel obliged to place dermal
filler on the left side, thus maintaining the nasal rotation. Frontal observation
of the face allows for the identification of either clockwise or counter-clockwise
rotation and associates asymmetries around the z -axis. A lower left cheekbone could be separately treated along the superior rim to
correct the asymmetry. Such observations are crucial for diagnosing and strategizing
suitable interventions for facial asymmetries. The changes in the X, Y, and Z axes
with aging and their implications for filler techniques are summarized in [Table 1 ].
Fig. 2 A photograph of an Asian patient with a visibly asymmetrical face. Red arrows indicate
the direction of asymmetry, with the left side of the face appearing wider and oriented
downward. Green arrows highlight the relative direction of the right side of the face,
which appears more lifted and oriented upward compared with the left side.
Fig. 3 A photograph of a Caucasian patient with a visibly asymmetrical face. Red arrows
indicate the direction of asymmetry, with the left side of the face appearing wider
and oriented downward. Green arrows highlight the relative direction of the right
side of the face, which appears more lifted and oriented upward compared with the
left side.
Table 1
The effects of aging along the 3D axes of the face
Axis
Aging
Implications for filler
x -Axis (horizontal)
Retrograde movement of the lower face; jawline recedes, and chin becomes less prominent.
Muscle contractures lead to lip inversion
Focus on restoring volume along the jawline and chin using structural fillers to counteract
retrograde changes and muscle contractures
y -Axis (vertical)
Vertical shortening of the face; nasal tip droops, and midface volume decreases, affecting
overall projection
Enhance midface volume and lift nasal tip with filler placement to improve vertical
projection and balance
z -Axis (depth/projection)
Asymmetry in facial width and depth; left face dominance becomes more apparent, with
one side appearing wider or more prominent
Address asymmetries by carefully adding volume to the narrower or less prominent side
to restore overall harmony
To achieve effective treatment outcomes, the manuscript emphasizes the importance
of face-to-face consultations and comprehensive assessments by experienced practitioners.
Integrating the latest anatomical findings into aesthetic practice is crucial for
providing state-of-the-art treatments. By improving individual patient facial assessments
and enhancing patient education, practitioners can build trust and credibility, offering
clearer and more effective treatment plans that lead to better outcomes and higher
patient satisfaction.
The authors advocate for evolving facial assessments, patient education, treatments,
and treatment guidelines to reflect the latest discoveries in facial anatomy. This
comprehensive approach ensures enhanced patient satisfaction and better aesthetic
outcomes, addressing the limitations of contemporary techniques that focus on individual
features rather than overall facial harmony (Ercan, 2008 #3862).
In conclusion, while advancements in aesthetic treatments such as MD Codes™ and BeautiPHIcation™
are commendable, it is imperative to incorporate the latest anatomical discoveries
for optimal patient outcomes. Current guidelines do not need to be discarded but need
to evolve by introducing facial rotation patterns around the xyz -axes in their model. The manuscript calls for a more complete, holistic approach
that combines the strengths of existing techniques with new insights into facial asymmetry,
ultimately leading to more balanced, harmonious, and satisfactory results for patients.[3 ]
[4 ]
