Why do some facelifts appear "Joker-like" and show large salivary glands sticking out on the side of the neck?

Why are some patient's faces pulled back so tightly during a facelift that their mouths tend to stay open or have a "joker-like" expression? Is the surgeon simply inexperienced or is the surgeon compensating for more sagging that will occur naturally with age? I have see photos that look painful due to the "tight" appearance of the skin; do some clients request this look or is is most likely due to inexperience on the surgeon's part in calculating the facelift? How is the lift calculated?

Doctor Answers 15

Unnatural Facelift Results

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This is a great question.  I always urge patients to start their search for a surgeon by viewing many many before and after photos. Photos alone do not provide enough information to select a surgeon, so continue to carefully research the background, training and safety record of your surgeon.

In some cases, results you describe may be due to inexperience. But, patients and surgeons also have their own aesthetic ideal. I personally prefer a natural looking result. In fact, I won't perform surgery on people who have a different goal in mind. Some people feel like they paid for surgery and they want to look like they have had surgery. For some this means a pulled, tight face.  In some cases, plastic surgeons are giving their patients exactly what they are asking for. 

The same is true not just for faces. Some women want extra large breast implants that look and feel nothing like something natural. There is no shortage pf plastic surgeons willing to provide the "I just had plastic surgery" look. It's not what most people want.  By looking at the work a surgeon does by sharing before and after photos, you can see whether or not you share an aesthetic ideal with the surgeon you are considering. 

Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

Face Lift

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Thank you for posting your question. During a face lift, the skin layer and SMAS layer are pulled carefully to achieve the desired result. While different physicians may use different combinations of techniques, the various degrees these two layers are pulled and sutured ultimately decide how natural the result looks. With that said, some people do prefer the tighter appearance and specifically ask their physicians for such result. Therefore, it is always important to choose an experienced physician and meet for in-person consultation to address your specific goals before any procedure. Best of luck. 

Why do some facelifts appear "Joker-like" and show large salivary glands sticking out on the side of the neck?

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There are actually three issues that you have described: "joker-like" expression, "tight appearance", and large salivary glands.  

A so-called "joker-like" look is often termed Joker lines or a cross-cheek depression by experienced surgeons.   This is a situation, that should be noticed before surgery,  where the patient has an indentation from the sides of the mouth that extends to the ear.  A  facelift, without simultaneous volume augmentation (e.g., fat transfer, filler), can exacerbate the joker lines and make the person look "done" or "pulled".

A "tight" look can arise by a number of ways but is typically the result of a surgeon not re-positioning and tightening the muscle layer (SMAS layer) well or artistically enough, and he/she will then over-tighten the skin to compensate, creating a "tight", un-natural and pulled look.

Large submandibular glands can become more visible after a neck lift.  It is not uncommon to have these glands reduced in size to minimize their visibility.

The attached link provides more information.

I hope this helps.


Timothy R. Miller, MD
Orange County Facial Plastic Surgeon
5.0 out of 5 stars 70 reviews

Joker lines

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Some face lift techniques are more prone to these and some patients faces are more prone to this.  Good luck.

Over pulled lift

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The short answer is that it is likely a combination of the surgeon's aesthetic and the patient's demand. While most surgeons will pride themselves on achieving a natural looking result and most patients request this there is most definitely a group of patients who demand "super tightness" and want people to notice their lift. They will find surgeons who offer this type of result.

Michael L. Schwartz, MD
West Palm Beach Facial Plastic Surgeon
4.8 out of 5 stars 12 reviews

Poor technique

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If wide subcutaneous undermining and heavy pull is performed the joker look is obtained. Most surgeons now do less undermining and more deeper SMAS modification to retain a natural look. I hope this helps. Good Luck!


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Hello and thank you for your question. The simple answer to your question to carefully evaluate before and after pictures of the surgeon you are choosing and make sure you like what you see.  If good technique is used, a facelift can be done with minimal scarring and can result in a natural look, not over-done look, with rejuvenation of your face.  The most important aspect is to find a surgeon you are comfortable with. I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Joker faces

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There might be many reasons for the overpulled look.  These patient might be repetitively unhappy, and end up seeking multiple procedures and multiple revisions to their faces, or their doctors are doing a very tight skin closure or are doing more horizontal instead of vertical pull. You can't really comment on pain based on the look of tightness and it may not be painful. Lifts are marked pre op to determine proper pulls to deal with problem areas. True salivary submandibular glands can become more evident in thin liposuctioned necks  but I'm not sure that's what you're looking at.

Joker facelift

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Facelift techniques that produce pulling  of  tissue more back than up can create this look.    The most natural facelift creates mosly upward lift,  which also creates natural neck improvement at the same time. I prefer the deep plane technique to achieve this.     

Over pulled look

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Thanks for sharing your question. I can appreciate your concern.

The redundant salivary glands are secondary to the plication technique on patients that have excess tissue. In those patients excision is better for the final outcome. 

Personally I do not think that over pull is a good technique because it is difficult to predict when to much is too much. Adequate pull or minimmaly overcorrected should be a better approach. At the end the bottom line is do you like the outcomes your plastic surgeon is giving you on patients followed for a year. If that is the answer then pick that surgeon.

Finally, make sure that you have a consultation with a board certified plastic surgeon.

Wishing you the best in your journey

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.