What surgical options are available for addressing asymetrical lips and one-sided droop? (Photos)

Question

I'm 37F with mild hemimandibular hyperplasia on the right — the right side of my mandible is larger and my chin deviates about 5mm to the left. My nose is structurally straight but leans left, which is linked to the jaw asymmetry. I also had Bell's palsy on the same side in my twenties. It resolved with no residual weakness, but the skin on that side droops more, and the skeletal asymmetry underneath makes it more obvious. What bothers me most is the right corner of my mouth: it sits lower, pulls down, and has a much more pronounced marionette line than the left. A plastic surgeon has recommended an open rhinoplasty to straighten the nose plus a deep plane facelift to lift the lower face, camouflaging the jaw asymmetry and lifting the right corner. He's happy to do both in one operation, but mentioned he's only asked to combine them about once every ten years. That, plus the extended time under general anaesthetic, is making me hesitate. I know orthognathic surgery is the corrective route rather than camouflage. I'm weighing that separately.. for now I'm asking about soft-tissue options. Botox (including to the depressor anguli oris) and filler at the commissure made no noticeable difference. My question: alongside the rhinoplasty, are there other surgical options for the mouth corner short of a full deep plane facelift? Is a corner lip lift worth considering? Or would I not be suitable for this?

Anna Chacon, MD, FAAD · Answer

You’ve described the anatomy and history exceptionally clearly, and I think the most important point is that you are dealing with three overlapping contributors:

Mild hemimandibular hyperplasia with chin deviation
Nasal asymmetry that appears secondarily related to the skeletal asymmetry
Residual soft-tissue asymmetry after Bell’s palsy, even if formal motor strength has recovered

That combination is very different from a typical “aging lower face,” which is why treatments such as DAO Botox and filler often produce disappointing results. If the mouth corner sits lower because of underlying soft-tissue descent, tethering, or asymmetrical skeletal support, weakening the depressor muscle may not be enough to create a visible lift.

The key question: do you need a deep plane facelift?

A deep plane facelift can certainly improve the marionette line and elevate the right oral commissure indirectly, but based on your description I would not assume it is the only surgical option.

The fact that your surgeon has only combined open rhinoplasty and deep plane facelift about once every ten years is not necessarily a red flag, but it does suggest that this is an uncommon combination rather than a routine pairing. At 37, I would pause and ask whether the amount of lower-face laxity truly justifies a full deep plane dissection, especially if your primary complaint is the right mouth corner.

A corner lip lift is probably not the first procedure I would choose

This is the part I feel most strongly about.

A corner lip lift (commissuroplasty) is designed for patients whose oral commissures are symmetrically downturned because of lip shape or age-related descent. In your case, the asymmetry appears to be:

Unilateral
Associated with facial skeletal asymmetry
Potentially influenced by post-Bell’s-palsy soft-tissue behavior

A corner lip lift removes a small wedge of skin above the mouth corner. It can create a slight upward turn, but it does not correct the deeper marionette fold, lower-face volume imbalance, or asymmetrical support from the jaw and chin. In patients with unilateral facial asymmetry, it can sometimes make the difference between the two sides more noticeable if the underlying support is not addressed.

So I would be cautious about a corner lip lift unless a surgeon specifically demonstrates that the asymmetry is primarily cutaneous and localized to the vermilion–commissure junction.

Surgical options short of a full deep plane facelift
1. Limited lower-face / mini-lift focused on the right side

This is probably the option I would explore first.

A short-scar SMAS lift or limited lower-face lift can:

elevate the right oral commissure region,
soften the marionette line,
improve jawline asymmetry caused by soft-tissue descent,
and involve less dissection and shorter operative time than a full deep plane facelift.

Because your problem is predominantly one-sided, a targeted lower-face lift is often more logical than a bilateral aggressive facelift.

2. Sub-SMAS or deep-plane marionette suspension

Some facial plastic surgeons perform a focused perioral suspension through a preauricular incision, elevating the tissues that contribute to the marionette fold and mouth-corner descent without performing a full neck and midface deep plane lift.

This can be particularly useful when:

the midface is relatively youthful,
neck laxity is minimal,
and the concern is concentrated around the commissure and jowl.
3. Autologous fat grafting to the right perioral region

Even though filler did not help, fat grafting behaves differently from HA filler.

In patients with post-paralytic asymmetry, there is often a subtle volume deficiency and tissue quality difference on the affected side. Small-volume fat grafting to the:

modiolus,
pre-jowl sulcus,
marionette region, and
lateral lower lip support area

can sometimes improve both the fold and the apparent droop more effectively than filler, especially when repeated micro-fat grafting is used.

4. Static commissure suspension

This is a reconstructive technique more commonly used for facial paralysis, but it can be adapted for mild persistent unilateral oral commissure ptosis.

A small fascial or tendon graft is used to provide static upward support to the mouth corner. It is much less common in patients with only subtle asymmetry, but given your Bell’s palsy history, it is worth knowing that there are reconstructive options between “Botox/filler” and “full facelift.”

Combining rhinoplasty with lower-face surgery

If you decide to address the nose surgically, I would think carefully about whether the lower-face procedure truly needs to be done simultaneously.

The advantages of staging them are:

Shorter anesthesia time
Easier recovery
Ability to judge how much the nasal straightening changes your perception of facial asymmetry
Less swelling overlap between the nose and lower face

Many patients are surprised that improving one asymmetrical feature (such as the nose) makes the mouth asymmetry feel less prominent.

My honest impression from your description

Because:

you are 37 rather than 57,
the asymmetry is predominantly unilateral,
Botox and filler were ineffective,
and the underlying issue includes skeletal asymmetry plus post-paralytic soft-tissue differences,

I would be less enthusiastic about a corner lip lift and less convinced that a full deep plane facelift is the only reasonable option.

If this were my patient, I would be most interested in discussing:

Open rhinoplasty (if the nasal asymmetry is bothersome),
A limited right-sided lower-face/SMAS lift or focused commissure suspension, and
Selective fat grafting to the right marionette and modiolus region.

That combination is more targeted to the specific problem you described — a lower, more descended right mouth corner with a deeper marionette fold — while avoiding the additional morbidity of a full deep plane facelift unless there is more generalized lower-face and neck laxity than is apparent from your description.

The fact that you’re already recognizing the difference between camouflage and true orthognathic correction is important. Since you are still weighing orthognathic surgery separately, I would favor the least aggressive soft-tissue procedure that specifically addresses the right commissure, rather than committing to a full deep plane facelift whose benefits may extend well beyond the area that actually bothers you most.

What surgical options are available for addressing asymetrical lips and one-sided droop? (Photos)

Answers (1)

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