Lateral midface fractures occasionally require open reduction and internal fixation to restore function and facial symmetry. However, some patients retain facial asymmetry despite undergoing surgery due to hard tissue displacement or soft tissue sagging. This study aimed to determine the influence of soft tissue sagging on the postoperative facial symmetry.

We examined the medical records of 590 patients who underwent planned plate removal after lateral midface or zygomatic bone fractures. After applying the inclusion and exclusion criteria, we analyzed 106 cases of lateral midface fractures for hard tissue displacement and soft tissue sagging using pre- and postoperative radiological imaging and postoperative face scanning.

We observed significantly larger soft tissue sagging (p < 0.001) and hard tissue displacement (p = 0.006) on the fractured side than on the non-fractured side. There was no correlation between differences in the soft tissue sagging and those in the hard tissue displacement (|rho|=0). Linear regression analysis showed no statistical influence of sex or age group on the soft tissue sagging and hard tissue displacement.

Therefore, we recommend treating soft tissue sagging as a discrete aspect of midfacial fracture treatment to achieve optimal postoperative facial symmetry. From a clinical perspective, we recommend better soft tissue management during open fracture treatment than focusing mainly on the reduction of bony hard tissues.