What's the best way to get rid of jowls that are beginning to appear from the corners of my mouth down to my chin? It's especially noticeable in my profile view. About a year ago, I had Restalyne treatments in the areas just below the corners of my mouth with only limited success. Is there any longer-lasting, more effective treatment specifically for "lifting" jowls? I'm 51 years old and have really good skin otherwise. I'm including two side by side pix after I was snorkeling in Aruba last spring, so I look really bad, but it pretty clearly shows the jowls issue.
Effective and Long-lasting Procedure for Lifting Jowls?
Doctor Answers 102
How to Effectively Treat Jowls
Jowls certainly are one of the main facial aging issues that leads people to seek a facelift, and jowls absolutely can recur after a face and necklift – especially if the ‘facelift’ is limited to surgery on the facial skin only. Not only may jowls recur, but they also may be incompletely corrected by a face and necklift, if the procedure performed is not appropriate for the nature of the ‘jowl’ problem. So carefully evaluate your surgeon’s ‘before and after’ photos for jowl area improvement.
Like all aspects of a facial rejuvenation procedure, jowls require careful evaluation as to their nature and their specific treatment. Jowlfullness over the mid-jawline frequently is lower cheek fat that has descended due to increased skin and subcutaneous tissue laxity as part of the normal aging process, and that has increased in volume, which is also part of the normal aging process. Fat tends to atrophy (i.e. melt away) where you’d like it to stay – like high in the cheeks - and to increase in volume where you don’t want it, like in the jowl area, in the neck and above the nasolabial folds.
Skin-only facelifts have an inherently limited ability to improve jowls. Jowl fat is intimately associated with a deeper plane of facial soft tissue called the SMAS, so pulling on the skin does little to improve jowls. And skin is elastic, so as the skin stretches out, jowls recur. Jowlfat can be surgically removed during a skin-only facelift, but that form of treatment tends to skeletonize the jawline, which does not lend itself to a youthful appearance.
The most powerful means of correcting jowls is by advancing jowl-area fat back up over the jawline into the cheek. This can be accomplished by the High-SMAS face and necklift, which involves elevation and advancement of a tougher connective tissue layer below the skin called the SMAS. SMAS elevation (high in the cheek, hence the term ‘High-SMAS’ face and necklift) has positive effects on the peri-oral area (softening nasolabial folds, elevating the corner of the mouth, correcting marionette lines), pulls jowl fat back up into the cheek, and also tightens the area under the jawline – as it is continuous with the platysma muscle in the neck. And because the SMAS is made primarily of collagen, it had tensile strength and does not relax like skin does. The skin is carried passively with the SMAS, and all of the tension that holds the facelift is placed on the SMAS rather than the skin. So High-SMAS facelifts are closed without any tension on the skin, and the results are more natural-appearing and more long-lasting.
A ‘lower face and necklift’ implies skin elevation (and facial tightening with tension on the skin) to treat the jawline and neck, and I reserve this procedure for patients with relatively early facial aging changes. If patients have notable midface aging, peri-oral aging changes (nasolabial folds, downturn at the corner of the mouth, marionette lines etc), jowls, or significant neck skin laxity, they are best served by a High-SMAS face and necklift. When a skin-tension facelift is used to attempt to correct the peri-oral aging changes listed above, the result is a wind-swept, unnatural, surgical appearance that unfortunately is a permanent change.
I see many patients who think that they have ‘jowls’ but who actually have fat atrophy at the anterior jawline and posterior jawline – in other words loss of soft tissue volume in front of and behind the ‘jowls’, which makes the mid-jawline area appear fuller. Not only fat but also mandibular bone (the jawbone) atrophies in the areas where fat atrophies, which contributes to the hollowness that bookends what appears to be jowls. These patients have what might be termed ‘pseudo-jowls’, and this can often be very nicely corrected by means of structural fat grafting of the anterior and posterior jawline recesses. Some individuals have both atrophy at the anterior and posterior jawline and mild fullness of the jowl area, and for these patients conservative fat aspiration can be combined with fat grafting on either side of the jowls to restore a youthful profile. Many patients with this form of early facial aging can have a full, smooth and youthful jawline restored by fat grafting and fat aspiration only, putting off a more invasive procedure like a High-SMAS facelift until it is really needed for more advanced facial aging issues.
Vertical facelift is the best option to improve jowls
The best option for correcting the jowl is a Facelift and the best Facelift technique for the jowl is the vertical Facelift. This procedure requires an extended skin elevation to the corner of the mouth so that the full extent of the jowl can be seen. Then the excess fat can be directly excised and the sagging tissue can be lifted upward instead of backward ( like seen with the more typical SMAS lift or deep plane face lifts).
Face lift to Improve Jowls
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Long Lasting Facelifts
Effective restoration of the face which is done with a “Lift & Fill” facelift where the central facial and malar deep fat compartments are filled with your fat and then the deep layer SMAS is used as an anchor to lift the deep layers of the face, This facelift has longevity and allows for a natural, youthful result.
The correction of the aging perioral area is more complicated. If there are deep folds around the lips (commissures) then the facelift will help with deep nasolabial folds. If there are deep creases as well as fine perioral wrinkles, then a facelift with fat compartment lifting, and filling, as well as laser resurfacing are in order.
• If there are jowls with extra skin and deep nasolabial folds, then restoration using the “Lift & Fill”
SMAS facelift is essential.
• If there are deep creases in the corners of the mouth and deep perioral wrinkles, then deep fat augmentation of the commissures, Juvederm injections to the lips, and perioral Erbium-type laserbrasion works well.
There is more than one way to skinny up a jowl
I do not think that facelift surgery is the only option for the correction of jowls. It is just one of the techniques that can be used. It is important to remember that jowls can be caused by multiple conditions such as gravity pulling the jowl tissue down, selective fat atrophy or loss of fat in the face which produces an indentation in front of the jowl making the appearance of the jowl worse as well.
The techniques of filler injections around the jowls do not really fix the jowels themselves but try to camoflougue the pre-jowl sulcus. If the patients skin tone is adequate and they are not a candidate or do not desire facelift surgery an improvement in the jowl shape can be achieved by a small amount of liposuction, laser liposuction, or of injection of lipo dissolve.
I realize that the idea of using lipo dissolve is not very popular today, however it is absolutely remarkable how effective one or two injections can be in the small areas of fat collection. Sometimes to improve the appearance of the jowl and some what mimic an effect of a facelift in that area the release of the mandibular ligaments can be performed under local anesthesia.
For patients that have skin laxity in that area especially in front of the jowl, facelift surgery even with SMAS can be effective, however good results can also be achieved with an aggressive peel in the perioral area.
I think that there are a variety of techniques available for jowl improvement. Minimally invasive to very invasive. The key is to make sure that during the process of improvement for the jowls you discuss with your surgeon more then jnust the jowls and create a comprehensive plan in improving your facial appearance. This way you have a plan of action so to speak that would usually include a skin care regimen, lasers, peels, facial surgery and maybe even hormonal modifications.
Camouflage vs corrective interventions
There are many options and there is no one right answer. It may depend on your "appetite" for correction.
As you have had restylane, you are now familar with what we would call a camouflage procedure. These are interventions that compensate or mask the signs of aging without necessarily correcting the problem.
The jowls are a difficult area that are effected by the size and shape of the mandible (jaw bone), fatty deposits of the skin and buccal fat pad, skin and muscle laxity.
Other fillers are available such as Radiesse, Juvederm, Perlane, Sculptra, etc.
Skin tightening modalites such as Thermage, Titan, Accent, etc tend to use energy (radiofrequency) to contract the skin. This has met with mixed success and while some patients have demonstrated benefits it is difficult to achieve predicable consistent results.
Laser assisted lipolysis such as Smart-lipo, Cool touch, etc use a very fine laser cannula to destroy the fat and supposedly contract the skin but this is not a widely held belief among plastic surgeons.
Fat removal (open surgical excision of the neck or buccal fat extraction) or via liposuction is may provide you with some benefit especially in reducing the localized fullness in the neck/chin area.
Face lifts may provide you with the maximal benefit but tends to involve greater risk.
Adjunctive procedures such as a prejowl implant can also provide some enhancements in this area of your face and would achieve what the restylane accomplished on a more long term basis. Alternatively, you could consider lipoinjection in the prejowl area.
You recieved a great number of answers to your question and quite extensive procedure recommendations. You say that you have good skin and I agree. Consequently, based on careful examination of you pictures, I would recommend liposuction of your neck and jowls, and platysmorrhaphy ( removal of fat from under the platsma muscles and tightening of the muscles ). That procure will improve your appearance dramaticaly. If you want to improve also on your Marionettes ( the folds under the corners of the mouth ) , a neck skin tightening will do it. Be sure to select a board certified plastic surgeon who has experience in facial cosmetic surgery.
Best of luck,
I would recommend neck and jawline liposuction, buccal fat pad excision, and a short scar facelift with MACS lift technique or Lateral SMASectomy. This procedure results in a 7-10 day downtime, requires use of a neck/chin strap garment x 2 weeks. It can offer substantial correction to your concerning jowls, yet provide a natural elegant result.
Proper way to correct jowls
As with any procedure, the first thing a surgeon needs to do is make a correct diagnosis. The jowls usually are caused by normal aging of the face, but in some individuals there is an additional component that causes jowls, and that is buccal fat. If that is not addressed than the results of a face lift will be sub-optimal, of course removing buccal fat in a wrong patient will also cause sub-optimal result. As for the type of face lift, the surgeon needs to address deeper structures during the face lift to correct jowls. Once again, individualized approach is paramount to obtain great result. An experienced and talented surgeon will explain to the patient the ideal approach to correct jowls.
The answer depends on the commitment you want to make. As you have seen, lesser procedures such as fillers. skin resurfacing, mini-lifts, and imlants will minimally improve the appearance. There is nothing wrong with this approach, but the ultimate result would be achieved with a facelift including liposuction and a pre-jowl implant. It would be benificial to loose weight prior to any procedure. I strongly suggest you do this and then re-evaluate your alternatives.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.