Asymmetry of nasolabial folds is a sign of a number of neurological diseases, occurs in some dental pathologies, may be a consequence of aesthetic operations, cosmetic manipulations. The difference in the depth and angles of the folds varies from insignificant to pronounced. Pathology is often observed simultaneously with other types of facial asymmetry. The cause of the violation of the symmetry of the nasolabial folds is determined according to the survey, neurological examination, imaging and electrophysiological techniques. Treatment before diagnosis is not indicated.
Why does the asymmetry of nasolabial folds appear
The faces of most people are asymmetrical, which is explained by small differences in the structure of the right and left halves, the formation of facial wrinkles. The asymmetry of the nasolabial folds is especially noticeable with the habit of smiling at one corner of the mouth, twisting the mouth, expressing dissatisfaction, sleeping on one side or chewing gum on one side of the mouth. Symmetry disorders progress with age, but in the absence of other causes do not reach the degree of a noticeable cosmetic defect.
Neuritis of the facial nerve
The most common neurological cause of nasolabial fold asymmetry is considered to be facial neuritis (Bell’s palsy), accompanied by unilateral weakness of facial muscles. Pathology occurs primarily due to a cold or complicates the course of the following conditions:
- Otitis media. Symptoms develop against the background of shooting pains in the ear.
- Epidemic mumps. The appearance of asymmetry is preceded by an increase in the salivary gland, a change in the contours of the face, signs of general intoxication.
- Herpes infection. The manifestation of neuritis is caused by a special form of shingles – Hunt syndrome, in which there are ear pains, skin rashes, hearing impairment, dizziness.
- Facial nerve injuries. The nasolabial fold is smoothed due to a violation of the integrity of the nerve trunk or its compression by scar tissue.
- Melkersson-Rosenthal syndrome. It proceeds with periodic relapses. It is complicated by neuritis in 2% of patients. Other manifestations include dense swelling of the face, a folded tongue.
- Alternating syndromes. Facial paresis in Millard-Gubler syndrome is complemented by the opposite hemiparesis, in Gasperini syndrome – strabismus, hearing loss, sensitivity disorders. Brissot-Sicard syndrome is characterized not by paresis, but by a spasm of the facial muscles with a deepening of the nasolabial fold.
Neuritis is diagnosed with tumors of the brain and the zone of passage of the facial nerve, for example, neurinoma of the internal auditory canal. In addition, Bell’s palsy occurs against the background of neuroinfections, which include:
- Encephalitis. A group of diseases of fungal, bacterial and viral nature with intoxication syndrome, cerebral and focal symptoms.
- Polio. The lesion is caused by the polio virus, observed in the stem form of the disease.
- Brain abscess. Limited accumulation of pus in brain tissues, accompanied by focal symptoms, severe intoxication.
- Neurosyphilis. In the early stages, focal, cerebral, and general infectious manifestations are detected. Subsequently, mental disorders, progressive dementia, stroke-like symptoms are detected.
- Neurospeed. Paresis is combined with aphasia, ataxia, mnestic disorders, psychopathological manifestations.
- Botulism. Develops acutely after eating canned food. Paresis and paralysis are typical, respiratory and cardiac disorders are possible.
In the initial stages of neuritis, asymmetry appears due to smoothing of the nasolabial fold from the affected side. In the absence of treatment or inadequate treatment, patients develop contracture of facial muscles. In this case, the nasolabial fold on the sick side, on the contrary, becomes more pronounced.
Disorders of cerebral circulation
The asymmetry of the nasolabial folds is of great practical importance in the development of acute disorders of cerebral circulation. This symptom is clearly visible, it is detected at an early stage. Along with other signs (slurred speech, weakness of limbs, deviation of the tongue to the side), it allows you to quickly determine the nature of the problem, deliver the patient to a medical institution in a timely manner. It is detected with the following variants of CVA:
- transient disturbance of cerebral circulation;
- ischemic and hemorrhagic strokes;
- migraine stroke;
- subarachnoid hemorrhage.
The frequency of occurrence of changes in the configuration of nasolabial folds varies with different types of CVA. The symptom is quite typical, but not pathognomonic for this pathology, it occurs due to damage to the departments responsible for the work of the facial nerve. The absence of a sign is not a reason for the exclusion of CVA.
Traumatic brain injuries
As in the previous case, the asymmetry of the nasolabial folds develops as a result of disruption of the brain centers that regulate the activity of the facial nerve. It can be observed with the following traumatic brain injuries:
- brain injury (mainly moderate and severe);
- acute compression of the brain;
- diffuse axonal injury;
- intracerebral, subdural, epidural hematomas.
The severity of the asymmetry is significantly different. Pathology is most noticeable in acute compression, combined with “sailing cheek” and lagophthalmos.
Disorders of innervation in children
The symptom often accompanies various forms of dysarthria in children. Gross changes in most cases are noted in cerebral palsy. Slight asymmetry of the nasolabial folds is found in children with erased dysarthria associated with defective innervation of the tongue, lips, and soft palate. Several cranial nerves suffer, asymmetry is complemented by limited movements of the lower jaw and tongue, hypersalivation, impoverishment of facial expressions.
Asymmetry of nasolabial folds can be congenital or acquired. Caused by the following reasons:
- Lack of teeth. With the prolonged absence of molars and premolars on one side, the contours of the face gradually change, the nasolabial fold deepens. The bilateral absence of teeth causes deepening of the folds on both sides, the severity of the asymmetry is determined by the location of the preserved dental units.
- Cross bite. There is a crossing of the dentition when the jaws are closed. The chin shifts, the lip sinks, which entails a violation of the symmetry of the lower parts of the face.
- Tumors of the salivary glands. The misalignment of nasolabial folds can be determined with adenomas, lipomas, angiomas, neurinomas, sarcomas, carcinomas, formed a second time against the background of compression or germination of the facial nerve passing near the salivary gland.
- TMJ diseases. Restriction of movements in the temporomandibular joint with arthrosis, ankylosis, contractures causes lateral displacement of the lower jaw, facial distortion.
- Tumors of the jaws. Asymmetry becomes one of the first symptoms of a neoplasm of the upper jaw when it is located in the projection of the nasolabial fold.
- Defects of the jaws. Malformations, post-traumatic deformities, defects after tuberculosis, osteomyelitis, removed tumors of the upper jaw lead to sinking of the cheek, smoothing of the nasolabial fold. In patients with mandibular defects, asymmetry is formed due to the displacement of the jaw when opening the mouth.
- Injuries. With fresh fractures of the jaws, asymmetry is provoked by edema and displacement of fragments. In the long-term period, the change in the contours of the nasolabial folds is caused by improper fusion of bone fragments, excessive formation of bone callus.
Consequences of aesthetic procedures and operations
The lesion is more often potentiated by the introduction of fillers based on calcium hydroxylapatite, polycaprolactone, L-lactic acid polymer. These agents cause increased formation of fibrin fibers, growth of connective tissue. Some time after the procedure, uneven fibrosis or the formation of coarse fibrous strands may occur, causing asymmetry.
Collagen-based fillers quickly dissolve, which necessitates the introduction of an excessive amount of the drug and possible hypercorrection of nasolabial folds. Sometimes, after the application of such fillers, granulomas and compaction zones appear. The formation of granulomas is also noted after the introduction of the patient’s own adipose tissue.
In some patients, asymmetry occurs after ligature lifting of nasolabial folds, the use of various methods of surgical facelift. The reason for the changes are insufficiently careful planning or violation of the technique of intervention, non-compliance with medical recommendations by the patient, complications in the postoperative period.
The reason for the change in the configuration and depth of the nasolabial folds is determined by a neurologist. According to the indications, patients are referred to dentists, maxillofacial, aesthetic surgeons. The examination program provides for the following diagnostic procedures:
- Survey, inspection. The doctor finds out when and under what circumstances the symptom appeared, how it changed throughout the disease. Evaluates the speech, memory, and psycho-emotional state of the patient. Through conversation and physical examination reveals other manifestations of the disease.
- Neurological examination. The specialist pays attention to the violation of symmetry of different parts of the face, the size of the pupils and eye slits. Examines eye movements, asks to inflate cheeks, show teeth, furrow eyebrows, show tongue. Determines reflexes, sensitivity, muscle tone of various areas of the face and body.
- Radiography. In case of TBI, skull radiography is performed, in case of traumatic injuries and diseases of the facial skeleton, jaw images and TMJ radiographs are taken.
- Echoencephalography. Performed at the initial stage of the examination. It allows you to quickly detect volumetric processes (tumors, abscesses, hematomas) that cause displacement of the median structures of the brain.
- CT and MRI of the brain. They are used at the stage of clarifying the diagnosis, make it possible to clarify the nature, volume and localization of hemorrhages, neoplasms, inflammatory processes.
- Electrophysiological studies. Electromyography, electroneurography, evoked potentials are prescribed to determine the localization of the pathological process, the severity of damage to the nerve trunk in facial neuritis.
Assistance at the pre-hospital stage
The sudden appearance of asymmetry in the nasolabial folds in combination with speech disorders, weakness of the limbs may indicate a stroke, are a reason for an immediate ambulance call. Patients with TBI also need emergency hospitalization.
Before the arrival of the medical team, patients with TBI and suspected CVA should be laid in a comfortable position with their heads raised. Victims in an unconscious state should lie on their side, this facilitates breathing, prevents saliva and vomit from entering the respiratory tract. A temporary soft bandage is applied to patients with jaw fractures.
Therapeutic tactics are determined by the nature of pathology:
- Defeat of the facial nerve. Glucocorticoids, B vitamins, decongestants and vasodilators, UHF, paraffin applications, ultrasound, electrical stimulation, massage, physical therapy are used. The treatment of the underlying disease is carried out. With severe pain, blockades are performed.
- CVA. According to the indications, resuscitation measures are carried out, symptomatic agents are prescribed. Antiplatelet agents, anticoagulants, and vasoactive drugs are used in the treatment of ischemic stroke. At the recovery stage, massage, electrical stimulation, physical therapy, correction of speech disorders are shown.
- TBI. If necessary, measures are taken to maintain vital activity, mannitol is administered to prevent intracranial hypertension, antibiotics to prevent infection.
- Violations of innervation. Vitamins, nootropics, physical therapy, massage, physiotherapy, exercises for the development of coordination of movements are recommended for children’s patients.
- Dental problems. Dental treatment and prosthetics, installation of orthodontic devices may be required.
Taking into account the peculiarities of pathology , the following surgical interventions are performed:
- Facial neuritis: neurolysis, nerve suture, static or dynamic hanging of the corner of the mouth.
- CVA: thrombolysis, stereotactic or open hematoma removal.
- TBI: transcranial, endoscopic or stereotactic removal of intracerebral, subdural and epidural hematomas.
- Dental pathologies: splinting of teeth, osteosynthesis of the upper or lower jaw, resection of the jaw with a tumor, arthroscopy, arthrocentesis and endoprosthesis of the TMJ, dental implantation, removal of neoplasia of the salivary glands.
- Aesthetic problems: facelift, reconstructive surgery.