Surgery and symmetry

A drawing of a woman's shoulders, neck and head.

Every once in a while I get an unhappy patient complaining that that her results are “uneven.” Unless the patient has been counseled beforehand that perfect symmetry is virtually impossible to achieve, she will be very upset, as most patients expect surgery to make things perfectly “even.” Most patients know not to expect perfection, but I have heard people say, “I knew it wasn’t going to be perfect, but this is UNEVEN.” Indeed, the surgeon himself expects and wants symmetry, but rarely gets it. Why is this?

To begin with, everybody is asymmetric, meaning, the left side is different than right side. Look in the mirror at any part of your body you like, let’s say the face. Most people arch one eyebrow higher than the other. Some people have one outside corner of the eye slightly higher than the other. If you look carefully at each half (left versus right) you may notice how the lip border arches differently on side. All of these differences are subtle on most people and most likely you didn’t notice until I made you look closely.

After plastic surgery, people tend to examine themselves relentlessly, first as they heal, later as they scrutinize what they spent so much money for. If they were not made aware of asymmetries before, they will be acutely aware of them after surgery. Unless they were warned that they were going to be somewhat uneven, they are going to be upset.

Starting from an uneven situation, the surgeon tries to restore symmetry. This is why most plastic surgeons spend time before surgery marking the body part that will be operated on. They are trying to get everything exactly right by measuring and defining landmarks before the patient gets on the operating table. Once the patient is laying down everything changes. Some surgeons bring preoperative photos into the operating room as further guidance.

Once the operation starts, tissues retract and relax in different directions and swelling is more prominent in some areas than others. The surgeon puts everything together according to his preoperative markings, making adjustments where he thinks it will help. This is part of the artistry of surgery.

After surgery, the body has to heal. The body will heal differently in each area depending on the local conditions. Scarring may differ from one area to another. Skin tension may be slightly higher on one side affecting both scar direction and thickness.

Given all these factors, it is a wonder that most of the time we usually end up with at least as good symmetry as before surgery. We still get some cases where symmetry is worse after surgery, but those are the exception.

Most plastic surgeons are neat freaks, and they are, like the patient, trying their best to get symmetry. A lot of time in surgery is spent just stepping back and looking to ensure that things look “right.” Sometimes I will even undo a surgery and redo it until I get the perfect look. I know it won’t be perfect by the time the body heals, but it’s my best, professional effort at an excellent result.

The two most important things for a plastic surgery patient to remember are that: A) The human body is asymmetric to begin with, and that, B) Plastic surgeons aim to IMPROVE asymmetry, not eliminate it. Somehow, if the patient goes into surgery conscious of asymmetry issues, she will happily accept her result after surgery, even when she notices things don’t “match up” perfectly. Don’t let disappointment over an “uneven” result prevent you from enjoying an excellent outcome!

By Dr. Ricardo L. Rodriguez MD Board Certified Plastic Surgeon Cosmeticsurg Baltimore, Maryland Ricardo L. Rodriguez on American Society of Plastic Surgeons.

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