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Arch Aesthetic Plast Surg > Volume 29(3); 2023 > Article
Hwang: Impossible symmetry
“Mankind imposing order on the chaos, impossible symmetry.”
- Agatha Christie
When I encounter a patient with a fractured nose, I tell them that the goal of closed reduction is not to obtain a straight nose, but to return to the state before injury. I show deviation of the nasal septum on the axial view of computed tomography and show that it cannot be straightened at this time. In the preoperative design of upper blepharoplasty in elderly patients, the extent of excision is not the same in both eyelids. Usually, laxity is more severer on one side than on the other side.
Patients planning to undergo aesthetic procedures often want to make their faces symmetrical. A symmetrical face has often been regarded as a feature of true beauty, and many movie stars are hailed for their mirror-image looks. However, a perfectly symmetrical face is quite rare. Facial symmetry is observed in only 2% of the world’s population. For example, Amber Laura Heard (1986- ) (Fig. 1), an American actress who plays leading roles in horror films, is regarded as having a perfectly symmetrical face. Some degree of congenital or acquired asymmetry is normal and universal. Significant facial asymmetry, however, causes both aesthetic and functional problems [1]. Factors such as aging, trauma, and lifestyle choices, such as smoking or sun exposure, may contribute to asymmetry. Sometimes an asymmetrical face is the result of an individual’s genetics. There is a link between increasing age and facial asymmetry. Smoking exposes the face to toxins and can cause vascular problems. Excessive exposure to ultraviolet rays can also cause an asymmetrical face. Trauma, such as a broken nose, a deep cut, or being involved in a vehicle collision, can damage the face. Furthermore, using dentures or getting dental veneers may change the contours of the face. If a person has always had asymmetrical features, there is no cause for concern. However, new and noticeable facial asymmetry may be a sign of a serious underlying condition, such as stroke or Bell’s palsy. Facial drooping may be a sign of a stroke. Bell’s palsy is a condition involving paralysis of the facial nerves, usually causing one side of the face to droop [2].
When patients complain of facial asymmetry, the underlying cause should be investigated. Its causes are congenital disorders, acquired diseases, and traumatic and developmental deformities. Many cases of developmental facial asymmetry have indistinct causes. An appropriate assessment includes the patient’s history, a physical examination, and medical imaging [3]. When my patients want perfect symmetry, I usually quote a sentence from Murder on the Orient Express, written by Agatha Christie (1890–1976). Hercule Poirot says, “I was looking forward to seeing La Sainte Sophie. I love cathedrals. Mankind imposing order on the chaos, impossible symmetry. The most beautiful woman I ever saw had two different colored eyes, one blue one green” (heterochromia iridis).


No potential conflict of interest relevant to this article was reported.

Fig. 1.
Amber Laura Heard (1986- ) at the Metropolitan Museum of Art Costume Institute Gala (Met Gala) in 2016. Note her symmetric face. Photo source:


1. Kobus K, Kobus-Zalesna K. The treatment of facial asymmetry: review. Adv Clin Exp Med 2017;26:1301-11.
crossref pmid
2. White C. What to know about having an asymmetrical face [Internet]. Medical News Today; c2020 [cited 2023 Feb 10]. Available from:

3. Cheong YW, Lo LJ. Facial asymmetry: etiology, evaluation, and management. Chang Gung Med J 2011;34:341-51.
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