52, female - Surgical options for facial aging and asymmetry? (Photos)

Question

Hello, I’m a 52-year-old female. In the past decade, I’ve developed increasingly noticeable facial asymmetry. In addition to facial volume loss and skin laxity, the muscles on the right side of my face are stronger than the left side. When smiling, my mouth pulls toward the right side & I have eyelid ptosis on the left side. I do grind my teeth, but I wear custom night guard. Is this correctable with a deep plane face & neck lift, upper and lower eyelid surgery and fat transfer? Can a DPFL correct the muscle asymmetry too? Photos attached. I appreciate your feedback. Thank you.

Gianfranco Frojo, MD · Answer

I would recommend a deep plane face/necklift, lower eyelid blepharoplasty, facial fat grafting, upper eyelid ptosis correction (levator advancement). This will be the best combination of procedures to address the facial asymmetry and aging as seen in the photos. This is a complex combination of procedures that requires a highly experienced surgeon. I would ensure that your future surgeon has
1) certification by the American Board of Plastic Surgery (ideally also a member of The Aesthetic Society or completed an accredited The Aesthetic Society fellowship)
2) performs these procedures frequently and has extensive experience
3) performs the procedures at an accredited facility with proper hospital admission priviliges
4) has good photos and reviews available in person or online

Mehmet Ozdemir, MD · Answer

It is completely natural for facial asymmetry to become more apparent in our 50s as skin loses its "snap" and underlying volume shifts, but I can see why it's becoming frustrating for you. A Deep Plane Facelift (DPFL) along with a neck lift and fat transfer would be a fantastic foundation; while the DPFL primarily addresses sagging by repositioning the deeper tissue layers (the SMAS), it doesn't actually change how your muscles fire when you smile. However, by surgically "resetting" the soft tissue and using fat grafting to add more volume to the weaker side, we can create a much more balanced, symmetric appearance at rest. For the eyelid ptosis, a specific ptosis repair (not just a standard blepharoplasty) can definitely realign your lids. To address that "stronger" side pulling when you smile, we often use a little bit of Botox post-surgery to relax those overactive muscles. It’s a multi-layered approach, but combining these procedures is exactly how we create that harmonious, refreshed look you're after!

Dallas Buchanan, MD · Answer

Thank you for your pictures and questions. You are looking great for 52, but there are some standard early signs of facial aging that you mentioned concerned you. Some amount of facial asymmetry is considered normal and natural, so that part does not worry me as a surgeon much. There is some skin laxity and loss of facial volume. As well as some changes to the peri-ocular area. One other thing I noticed that you did not mention was some changes to the peri-oral area as well. 
I think that the best option for treatment would be a deep-plane facelift, deep-plane necklift with facial fat transfer. Some additional optional procedures you could consider for a more complete rejuvenation would be upper/lower blepharoplasty (eyelid lift), deep laser resurfacing (Contour TRL), and a subnasal lip lift. 
Hope this helps!
Dallas Buchanan, MD
VIVIFY plastic surgery
Tampa, FL

Earl Stephenson, Jr., MD, DDS, MBA · Answer

Dear sabe1,

Thank you for the thoughtful question and for sharing your photos. At 52, I do think you appear to have a combination of normal facial aging changes, including volume loss and skin laxity, along with a genuine asymmetry in animation that becomes more apparent when you smile. From your description, that dynamic asymmetry is an important part of the problem, and that is the part a facelift alone typically does NOT correct. Deep-plane or other advanced facelift techniques are designed to reposition descended facial soft tissues and improve the jawline, midface, and neck. Fat grafting and blepharoplasty are also commonly combined with facial rejuvenation surgery when volume loss and eyelid aging are present.

In my opinion, a deep plane face and neck lift could potentially improve the STATIC imbalance in your lower face and neck, and fat transfer could help with deflation and soften some side-to-side differences. Upper and lower eyelid surgery may also be worthwhile, but the left upper lid issue needs to be defined carefully first. True eyelid ptosis, brow descent, and excess upper lid skin can look similar in photos, but they are treated differently.

The part of your concern involving stronger muscles on the right side and the mouth pulling to that side with smiling is more of a  "dynamic muscular asymmetry" issue. That is usually not something a DPFL corrects. In clients with facial asymmetry of movement, treatment often involves a separate plan tailored to the cause, which may include asymmetric neuromodulator use (i.e. BOTOX®), selective volume balancing, brow work, ptosis repair, or in more significant cases, static or dynamic facial balancing procedures. The key is identifying whether this is simply long-standing asymmetry, dental or bite-related influence, brow and lid imbalance, or a true facial nerve-related issue.

I would also be a bit cautious anytime someone describes progressively increasing asymmetry over a decade, especially when eyelid position and smile mechanics are both involved. That does not necessarily mean something serious is present, but it does mean I would want a careful in-person facial exam before committing to a large rejuvenation surgery. That evaluation should include brow position, levator function, lower lid tone, smile vectors, facial nerve function, and often dental occlusion and masseter activity as well.

So, yes, you may be a candidate for a combination approach, but I would frame it this way: a facelift and neck lift can improve aging changes; fat grafting can improve volume loss; eyelid surgery may help, depending on whether this is skin excess, brow descent, or true ptosis; and the smile asymmetry will likely need an additional, more targeted strategy rather than expecting the facelift to solve it completely. In many clients, the best result comes from treating the aging and the asymmetry as related but separate problems.

Given the complexity here, it would be worthwhile to consult in person with a board-certified plastic surgeon who is very comfortable with facial rejuvenation and periorbital surgery, and possibly with a facial nerve-focused specialist if your exam suggests that component is significant. My background is in facial aesthetics and complex facial analysis, which is exactly why I would encourage a detailed, hands-on evaluation before deciding on the right operative plan.

All the best,

Dr. Stephenson

Williams Bukret, MD · Answer

Thank you for the detail in your question — it reflects a sophisticated understanding of what you are experiencing, and it deserves a careful answer.
What you are describing involves multiple distinct structural problems, and they do not all respond to the same intervention. Separating them clearly is the first step toward an honest surgical plan.
On the facial asymmetry and muscle dominance:
A deep plane facelift repositions soft tissue and addresses descent, volume redistribution, and structural support. It does not correct functional muscle asymmetry. If the right-sided musculature is dominant, that pattern will persist after structural surgery. What surgery can do is improve soft tissue symmetry and reduce the visual impact of the asymmetry by optimizing position, support, and volume distribution on both sides. Surgical correction of soft tissue descent is different from neuromuscular correction — and managing that distinction clearly matters before any decision is made.
On the eyelid ptosis:
Left upper eyelid ptosis should be evaluated independently. The cause — whether aponeurotic, myogenic, or related to the asymmetric muscle activity you describe — determines the correct approach. Upper eyelid surgery in the context of existing ptosis and asymmetric orbicularis function requires precise preoperative analysis. This is not a standard blepharoplasty decision.
On the deep plane facelift, neck lift, and fat transfer:
Based on what you describe — a decade of progressive change, skin laxity, volume loss, and combined facial and cervical involvement — you have multi-regional structural aging with involvement across the upper face, midface, and neck. That pattern does benefit from a combined multiplanar approach. Fat transfer in the context of volume loss with structural repositioning can be appropriate, but the sequence and extent depend on tissue quality, degree of descent, and how volume has redistributed over time.
The most important consideration before any decision:
The combination of asymmetric muscle function, eyelid ptosis, and bruxism means your preoperative evaluation needs to be more thorough than a standard facelift consultation. The ptosis needs to be characterized before any upper face surgery is planned. The muscle asymmetry needs to be documented in terms of its origin and behavior. And the surgical plan needs to address each region with proportional intent — matching the operative burden to the dominant structural problem in each area.
The plan should follow the anatomy. In a case like yours, that analysis is the most valuable thing a consultation can offer.

52, female - Surgical options for facial aging and asymmetry? (Photos)

Answers (5)

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