Thank you for your question. I understand you’re 51-years-old and concerned about the appearance of your jowls. You want to know what happens to jowl fat after a face and neck lift—whether it is removed, repositioned, or customized for the patient.Face and neck lifting are a big part of my practice and I can share my approach, and how my style has evolved over the years. I’m a Board-certified cosmetic surgeon, certified by the American Board of Cosmetic Surgery, and a Fellowship-trained oculofacial plastic and reconstructive surgeon, practicing in Manhattan and Long Island for over 20 years.To understand jowls, it’s also important to understand anatomy. A misunderstanding of this aspect often leads to sub-optimal results, regardless of whether it’s with a facelift, an injectable, or a thermal heating device.The term “jowl” basically refers to the absence of a clearly defined jawline. Several factors contribute to that—one is the fat right below the level of the skin, which can shift downwards and hang over the jaw. In some cases, this fat will seem kind of separate, and in situations like that, the fat can be excised. Excision can be done by doing liposculpture first, followed by a lift. In other cases, a direct excision can be done. Another factor that contributes to this is buccal fat. Buccal fat is fat that’s located in a very distinct compartment and gives the face a certain amount of fullness: one is a more diffused, localized fullness; the other is a type of fullness that protrudes more and creates a small, roundish bulge on the face. Another factor that contributes to the appearance of jowls is the bone located in front of the jowl, called the mandibular notch. This area is indented, so even if you lift the skin, that natural indentation may look like there’s still a bit of jowl left.To answer your question, there is no one standard approach when addressing jowls, and each procedure has to be customized for every patient, in the same way that a procedure will not work the same way for two different people. When you meet with doctors, you will get varied opinions on how to deal with this, so you will have to determine which options you are most comfortable with.In my practice, surgery is a dynamic process. There are certainly standard practices such as making observations and determinations before surgery. When actually performing surgery, as I’m lifting and moving the layer of muscle called the SMAS (Superficial Muscular Aponeurotic System),I’m making decisions. I look at the contour and I look to see if the buccal fat is prolapsing outwards.There was a time in my practice when it was practically a given to perform liposuction on any patient with a bit of jowl and chin fat at the beginning of the surgery. However, my approach has evolved since then—I’m more conservative with the application liposuction, and do more of liposculpturing with direct excision so that the tissues are not traumatized as much. All my facelifts are performed under local anaesthesia with LITE® sedation, which allows me to properly position the face without the patient having a tube in the throat that can obstruct my assessment of the angle. Doing it this way gives me more information and more ability to judge, and it also feels better for the patient because they don’t go under general anaesthesia, and they feel generally good after their surgery.When it comes to addressing the mandibular notch, sometimes we’ll either place some type of facial implant, such as a pre-jowl implant, or we can address the issue non-surgically by means of a Y Lift™, which is an injection procedure that makes use of cosmetic fillers, such as Juvederm or Voluma, to achieve a facelifting effect, as well as restore volume and definition to the face. Such a procedure can help create more continuity in the jawline area, takes only 30 minutes to perform, and yields great results.I’ve heard patients who say they prefer a certain type of facelift over others, and it’s important to keep in mind that competent and experienced cosmetic surgeons know all about the different types of methods of facelifting. It’s really more about the style and aesthetic of the doctor—and there is variety of styles and aesthetics among doctors. For example, what is considered a great result for a surgeon who prefers a more natural result may not be aggressive enough for someone who wants a more exaggerated result. There is variability, which you can get a sense of by looking at a doctor’s before and after case photos and from your rapport in conversation during consultation.Ultimately, I think it’s important to customize each approach for every patient. Tt’s very important to understand the nature of facial aging, as well as the different options there are to address it, so that you can address the situation in the best way and at the best time. I hope that was helpful and I wish you the best of luck!This personalized video answer to your question is posted on RealSelf and on YouTube. 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