How to avoid the joker mouth? Is it random or can it be prevented?

I am scheduling my face lift in a few weeks and my big concern is avoiding the joker smirk. I see celebrities that have it as well as regular people. Four of my friends have had face lifts by the same board certified plastic surgeon and three look amazing while one has a disturbing joker grin. Is there a type of face that is more prone to ending up with this result? Is there away this can be avoided?

Doctor Answers 18

Preventing the Joker's Face

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The Joker's Face deformity can be seen with two complications; an exaggerated traction pull on the corner of the mouth during the facelift or an injury to the Depressor Anguli Oris (DAO) the muscle which holds and stabilizes the corner of the mouth during dissection of the neck. When this happens the muscles responsible for lifting the corner of the mouth are unopposed and result the a grotesque Joker Smile. 

I encoorage you to discuss it with your Plastic surgeon and hear what he has to say. 

Dr. Peter A. Aldea
Memphis, TN

Memphis Plastic Surgeon

Joker smile

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This should be avoidable by limiting the tightness of the suturing to achieve the lift and the preventing an overly upward vector of lift for any suturing which affects the corner of the mouth. With the deep plane lift there is excellent control of these variables and thes are some of the reasons I feel the deep plane lift achieves the best results. 

Best wishes, 
Dr. Donath

Alexander Donath, MD, FACS
Cincinnati Facial Plastic Surgeon
4.7 out of 5 stars 45 reviews

For a Natural-Looking Smile, No Pulling

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I'm familiar with the "joker face" result you describe. You can rest assured that modern approaches to facelift surgery are rather effective at avoiding this. In most cases, this look results from excessive pulling on the skin or the underlying muscles of the face. This causes the sides of the mouth to stretch to the point of looking unnatural or forced. The best way to avoid this is to choose a board-certified plastic surgeon with ample before-and-after photos to get a good sense of your potential results. Be sure to share your specific concerns with your surgeon for a better sense of how your particular procedure will avoid it. 

James N. Romanelli, MD, FACS
Long Island Plastic Surgeon
4.4 out of 5 stars 25 reviews

Avoiding Joker Mouth

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Dear springrolll,

Most often this comes about when the deep layer (SMAS) is pulled too vigorously along the corner of the mouth. Although a goal of the facelift is to smooth the nasolabial folds (folds that run from the lateral nostril to the corner of the mouth) this is done with more traction on the skin rather than the deep layers. Most of the pull on the SMAS should be redirected so that it is primarily restoring the contour of the lower jawline.

I hope this has been helpful.

Robert D. Wilcox, MD

Robert D. Wilcox, MD
Dallas Plastic Surgeon
4.1 out of 5 stars 22 reviews

How to avoid the joker mouth? Is it random or can it be prevented?

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 Hi, I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts. Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces. Heart shaped faces have cheeks that are full and round in the front. Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.

A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin. Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face. I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.

If you have "jowls” these are sagging facial tissues and an indication for some form of a SMAS facelift. The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last). The excess skin is then removed and the facelift incisions closed.

My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:

  • very small incisions
  • minimal tissue dissection = less bruising and swelling = rapid recovery
  • can be performed in 90 minutes or less, with or without general anesthesia
  • no incisions within the hair = no hair loss
  • excess fat can be removed
  • excess skin removed
  • cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
  • most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure. When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face. The "joker" look results from over pulling the facial tissues or with a subperiosteal facelift that lifts all the tissues of the face upward in a manner that can cause the corners of the mouth and eyebrows to be overly raised.

Hope this helps.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 28 reviews

Joker mouth

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Thank you for your question. There are multiple ways to perform a facelift.  It is important to discuss with your surgeon the exact procedure that will be performed and the results that you should expect to receive. Best wishes.

Michael Sullivan, MD
Columbus Facial Plastic Surgeon
4.9 out of 5 stars 112 reviews

Joker Mouth Prevention

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Prevent over-pulling the underlying SMAS, avoid too much tension on the skin layer, delicate handling of facial soft tissue, respect for facial planes and nerves within the surgical plane, awareness of the vectors of pull on each side, use of surgical landmarks/markings on the face to ensure symmetry; these are some basic core knowledge of a competent facelift surgeon.

Johnny Mao, MD, FACS
Orange Facial Plastic Surgeon
4.9 out of 5 stars 59 reviews

Facelifting #woundhealing #cosmeticsurgery #beauty

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Dear Springroll

Thank you for your question!  The JOKER look is caused by pulling- whether its the skin or the SMAS or both.

The key is that the surgeon shape your face.
With Warm Regards

Trevor M Born MD

Trevor M. Born, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 126 reviews

How to avoid the joker mouth? Is it random or can it be prevented?

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Hello Springrolll,

The "Joker look" after a facelift is caused by too much pulling at the corner of the mouth.  This can be avoided both by the vector or direction the sutures are placed for the lift and where they are placed.  I'd recommend you consult with a facial plastic surgeon to go over your options and expected outcomes.

I hope this helps and good luck.  

William Marshall Guy, MD
The Woodlands Facial Plastic Surgeon
5.0 out of 5 stars 31 reviews

Facelift with a Natural, Younger Look

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Thank you for your question about facelift.

The most important determining factor in avoiding the "joker mouth" after a facelift is the angle or vector which the plastic surgeon pulls or suspends the face.  Straight back can give the wind-swept look and straight up can give the suspended like a curtain look.  Pulling on the corners of the mouth gives the joker mouth.  

It is important that the plastic surgeon be atune to the subtle details in order to give you a natural look.

To be sure, see two or more experienced, board-certified Plastic Surgeons in your area for a complete evaluation to make sure you are a good candidate and that it is safe for you to have surgery.

I hope this helps.

J. Jason Wendel, MD, FACS
Nashville Plastic Surgeon
5.0 out of 5 stars 221 reviews

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.