I'm 66 and a happy person. But I look sad because of the lines going down from the corners of my mouth to each side of my chin. I also have little pockets of fat on each side along my jaw line. Guess this is all normal, but I'm tired of hiding behind my long hair. I'm afraid of a face lift, and have read that a lower face lift does not take care of the Marionette lines anyway. What to do? Thank you
Is a Facelift the Only Answer for Marionette Lines and Jowls?
Doctor Answers 84
Solution for Marionette (Puppet or Drool) lines and Jowls
A successful solution and treatment are always based on proper diagnosis. For this reason, a picture would have made answering your question much easier and applicable to your situation.
Young people do NOT have nose to mouth (Nasolabial) lines or corner of mouth to jaw (Marionette, Puppet or Drool) lines, these come on with age.
As we age, our facial bones become smaller resulting in the scenario of the same table cloth (IE skin) covering an ever shrinking table - as a result, less of the teeth are showing and the skin sags. But the sagging is not uniform. Instead, it is seen most where there is active sagging of the skin AROUND the points of fixation of the skin to the skull which happen to be just central to these lines. The result of this tectonic plate like skin movement is that the saggin stops at these points with heaping of the skin over them causing the folds.
1. FILL the valleys (Fat,Restylane, Perlane, Juverderm etc)
2. Fill the face with fat to make up for the bone resorption to "take up the slack"
3. EXCISE the valleys (leaving permanent scars where the valleys were (rarely done)
4. Correct the sagging by lifting and replacing the skin where it belongs (Facelift with vector pulling of the areas just in front of the folds
Which is THE treatment for you? It would depend on YOUR presentation and your willingness to accept a less than perfect result but with a lot lower risks and vice versa.
Jowls - Look at many facelift before and after images
The surgical procedure that has traditionally been referred to as a' facelift' involves mobilizing the skin and soft tissues of the lower face and jawline (and in most cases, the neck), and advancing them upward and laterally to eliminate sagging (jowls) and provide the appearance of improved skin tone. The excess skin is removed.
What is currently referred to as a facelift usually means some combination of surgical lower face rejuvenation with procedures that are designed to improve other facial aesthetic areas: the brow and eyelids, the midface, and the neck. The combination of procedures I perform on any patient are customized for that individual's specific needs and desires, and thus no two 'facelifts' are exactly alike.
The facelift procedure involves incisions that skirt the contour of the ears, using the anatomy of the ear to help conceal them. For a full facelift, the incision starts in the sideburn area, follows the contours of the junction of the ear with the face, curves behind the earlobe into the recess between the posterior ear and the neck/scalp, and then extends into the hairline posteriorly at the top of the ear. When I make these incisions, I design them so that, once fully healed, they may be difficult for even a hairdresser to detect. That goal can often be achieved, and it requires meticulous attention to every centimeter of the closure.
So what about this "Weekend Facelift"?
A standard facelift involves incisions as described in the paragraph above. That pattern of incisions is generally required for patients with prominent jowls and very loose neck skin, who require significant skin advancement and removal. A shorter incision which does not extend into the scalp at either end, but is made only in front of the ear and immediately behind the earlobe, can be used to improve jowls and to tighten the neck somewhat in selected patients with lesser degrees of lower face and neck aging changes.
This latter facelift procedure involves shorter incisions, less dissection, and quicker recovery than a conventional facelift, and has been dubbed by some as "the weekend facelift". This, in my mind, is a marketing strategy designed to make the procedure attractive to those who might shy away from a 'full' facelift. I have seen marketing materials which actually suggest that a patient might "go shopping" immediately after this surgery, or drive themselves home!
I think that "weekend facelift" is a misleading term, as it suggests dramatic surgical improvements are possible with minimal surgery. As with most things which sound too good to be true, so it is with the "weekend facelift". As you might expect, the degree of improvement one obtains from surgery is, in general, directly proportional to the surgeon's effort. An hour of surgery through a shorter incision can not be expected to produce a result approaching that of a conventional facelift.
Patients with relatively small 'jowls' and minimal neck skin laxity, however, can obtain a very nice improvement using the technique described above. A better term, however, might be "Mini-facelift", as no surgeon can guarantee a two-day recovery, and patients' expectations may be inappropriately heightened by the promise of a big improvement by a minimal surgery.
Aesthetic improvement of the neck
The majority of patients having a facelift surgery also have aging changes in the neck, which can be corrected and improved through a variety of surgical procedures. To improve the neck contours, the facelift can be extended over the jawline and onto the anterior and lateral aspect of the neck. In other patients without major aging changes at or above the jawline, neck rejuvenation alone may be performed.
Jowls and facelift procedures
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Facelift only answer for marionette lines and jowls
A well performed facelift is the best procedure to treat sagging and puffy jowls as well as the associated sagging skin and soft tissues of the neck. At your age,
most people have, to a greater or lesser degree, the findings of laxity of the skin
and soft tissues of the face and neck.
These findings are amenable to a facelift that will provide redraping with significantly improved contours. Unfortunately, surgery to treat the marionette lines is often far from successful. In some cases, there may be some degree of improvement but I would not recommend having a facelift specifically to treat these marionette lines. The best treatment for these depressions is the use of appropriate fillers.
Marionette line solutions
The simplest answer is for injections of filler, either hyaluronic acid products like restylane or juvederm, or calcium based products like radiesse. these are temporary though, so some patients then consider fat transfer as a more permanent solution. But in many cases that just leaves patients with a full, jowly chipmunk appearance. So that is why a facelift of some type is a better solution.
Facelifts have lots of names, and mean different things in different offices. So whether its a minifacelift, lower facelift, neck lift, or facelift is hard to distinguish. The main thing to keep in mind is that more release means more improvement and longevity to the surgical result. With that in mind, you would need to talk to your surgeon about what is the best facelift in his or her hands to improve your situation.
And I would also agree with some of the other surgeons that the best solution may also include some form of volume in the fold as well. Chin implant, prejowl chin implant, fat, portions of tissue normally discarded from the facelift (fat, SMAS) , or post op fillers all have merit.
Marionette Lines and Jowls Options?
There are a number of surgical and non-surgical options that can improve one's cosmetic appearance: fillers, skin-tightening procedures, lasers, fat contouring, and face lifts. Each
has benefits and drawbacks. Mini procedures do not produce the long lasting maximum improvement that is achieved with a natural appearing artistically performed lift performed by an expert experienced plastic surgeon. That is achieved by a combination of elevating the sagging tissues, removing the excess skin, contouring the fat, and adding micro-fat grafts or fillers where there is a deficiency.
Keep in mind, that following the exact advice from a surgeon on this or any other website who proposes to tell you what to do without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of the proposed operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.
Robert Singer, MD FACS
La Jolla, California
Treating jowls and marionette lines
Marionette lines are the grooves that appear with time running from the corners of the mouth to the jawline by the chin. Jowls are loose skin, fat and muscle that accumulate just outside the marionette lines as the skin thins, the fat and muscle atrophies and the ligaments holding them relax with age.
Treatment should be based on the severity of the problem and the anticipated result on the part of the patient. A traditional facelift will most likely always be the best bet as it addresses the skin laxity by removing excess skin and the soft tissue laxity by tightening the underlying muscles. For people with minimal skin laxity, the Silhouette Lift with special sutures may be an option but if there is any significant skin laxity I would not recommend this. One can fill the groove between the jowl and lip/chin with fillers to give the illusion of a face lift but this is likely to widen the anterior jawline and may look even more unnatural than a traditional facelift.
In the end, the best bet is probably to find a physician you are comfortable with and seek their advice.
Alternative to a facelift
There is no real alternative to a Facelift, particularly for marionette lines and jowls. However, one can do a relatively good job of mimicking the effects of a facelift with fillers. I prefer Radiesse for this area. It is quite long lasting and allows the body to build some of its own collagen, the support substance of the skin.
The problem is that to disguise the jowl, you are forced to make the chin look wider. In spite of this, this really is an excellent alternative until you build up enough courage to have a facelift. I would not, however, be afraid of a facelift. The modern facelift is quite safe, produces excellent results and has a relatively fast (5-10 days) recovery.
Combination treatment is best
The very best solution is usually a combination of a surgical lift and some type of filler. Lift alone or filler alone will give improvement, but not the maximum possible. At age 66 a complete "erasure" of all lines is unrealistic and would look unnatural. I prefer to use the term "soften" and this can be obtained by the above methods.
Treating the marionette lines
Isn't it great the way we plastic surgeons can make such wonderful names for all the signs of aging! The marionette lines or Charlie McCarthy lines are a result a fixed point in the face and the face aging around it. If they are severe then only a facelift will give you adequate result often combined with adding your own fat or tissue. If they are mild you can use fillers like restylane, juvaderm or radiesse to give you temporary relief. If you are willing to accept some improvement you might want to try the fillers first and then proceed.