The ABC's of plastic and cosmetic surgery:
"J" Is for Jowls: What You Can Do About A Droopy Jawline

From Spring 2002 Issue

Most of us are quite familiar with the term “jowl” and most of us would prefer not to have it used to describe any part of our appearance. The origin of the word is varied but it’s often used to describe the cheek and jaw area of our animal relatives. More specifically, it’s used to refer to the lower jaw area or the flesh under the lower jaw. And when this feature becomes apparent in the mirror, most men and women do not welcome this change.

In order to talk about treatment options, let me tell you how I discuss this with my patients when they point frustratingly to the loose skin and fat drooping below their previously smooth jaw line. Often, a deepening crease extends from near the corner of the mouth downward to the lower jaw border, creating an aged, tired and sorrowful appearance. Extending the neck, pushing the jowl upwards or lying on one’s back greatly reduces this unflattering feature.

The soft and mobile tissues of the face are suspended from the bones and cartilage by connective tissue fibres of collagen, elastin and fibrous tissue. These are generally loose attachments, but in specific areas the tissues coalesce to form ligaments. Common locations for these firmer-tissue anchors are at the front of the jowl along the jaw border; along the smile lines (nasolabial folds), extending from the corners of the mouth towards the sides of the nose; and under the marionette lines (melomental folds), extending from the corners of the mouth to the jaw. These points of attachment form pivot points around which our more mobile cheek tissues move downward under the effects of gravity and repeated animation. As our tissues stretch and lose their natural tone, the entire cheek slides downward with the lowermost extension forming the jowl. These ligaments create the effect of a “snow-fence” for the gravity-driven drift of our tissues. If we are overweight, these tissues are heavier and usually the jowl is larger. However, in the vast majority of clients, the jowl represents a normal amount of tissue that has fallen from the cheek area to the jaw border or below.

Now that we know what jowls are, what can we do about them?

Facial Exercises:
Wouldn’t it be great if we could exercise our faces to eliminate the signs of aging caused by gravity? Although there is a lot of promotion about facial toning, facial fitness programs and gizmos to stimulate muscle contractions, this strategy is more likely to reduce your wallet than your jowls. To be fair, some facial muscles will increase in size and improve facial contours if excessively exercised. This can achieve some improvement along the jaw angle and central cheek. In most of us, the muscles are just fine but the ligaments and connective tissue have stretched out. Therefore, exercising specific facial muscles will not help.

Posture, makeup and fillers:
Although many will laugh at the suggestion, some simple strategies can reduce the appearance of jowls. Lifting your chin and standing up straight tightens the neck tissue. Using makeup to maximize the beauty of the lips and cheeks de-emphasizes the jowl area. And finally, you can have the folds in front of the jowls filled with any of the many soft-tissue enhancing products available from cosmetic-oriented dermatologists and plastic surgeons (see Injectables and Fillers, Canadian Healthstyle Magazine, Summer 2004).

Laser and radiofrequency treatments:
Two strategies have been tried over the past decade. The first is to improve the jaw line contour with lasers. Erbium and CO2 lasers burn away the outer skin surface in very thin layers, resulting in a smoother and firmer skin surface. The skin’s shrinkage can create a temporary lifting effect on the deeper tissue but only to a minimal degree. The second strategy is to use a laser light that penetrates deeper without burning the skin’s surface. The Nd-Yag laser is the most common for this, but again, the effect is very minimal at best—the skin may improve but the contours remain the same. Note, however, that the energy and type of light required to penetrate the skin sufficiently to achieve good results is only available with medical grade laser systems. So forget about the gentle lasers you can buy at the drugstore or on TV for improving your jowls.

“Jowls do not need to be part of your future if you don’t want them to be.”

The most exciting non-surgical technology available to treat the jowl area is the ThermaCool™ device. This device pulses heat deep into the skin while a spray cools the top layer to prevent burning. The thermal damage to the deeper tissue causes a tightening of the connective tissue and induces a healing response that may increase the collagen and elastin in the area. The result may be some tightening that’s less effective than a facelift but more dramatic than other non-invasive techniques now available. And, unlike laser or chemical treatments that can take weeks to heal, there's no down time. Many plastic surgeons have not yet embraced this technology, as the results can still be a little unpredictable. When performed competently, about two-thirds of patients will experience visible improvements while the remainder will see little change. Currently the treatment can be very uncomfortable unless proper pain management and sedation is used. Aside from the discomfort, the only other concern is the occasional permanent dent or depression caused by the thermal injury to the deeper tissues. Recent treatment protocol changes will hopefully result in more effective, predictable, less expensive and less painful results. Costs $900-$2000 per treatment.

Featherlift or Threadlift:
This interesting cosmetic procedure lifts the face with tiny monofilament threads. It’s widely popular in Europe and South America, and rapidly gaining attention in North America. There are no incisions but it does involve placing multiple small threads, each with numerous small barbs, under the skin so only a specialist physician familiar with facial surgical anatomy should perform it. During the procedure, the tissues are gathered along the thread and the barbs hold the tissue upward or back, depending on the thread placement. Scar tissue in the skin collects around the newly placed threads and the effects of this treatment can last several months. Potential results are much less than those expected with a facelift, but it’s usually performed only under local anesthesia and most patients are able to recover from the one-hour procedure quickly. Bruising lasts less than a week. The downside: the threads frequently lose their hold and can extrude through the skin and need removal. Costs $1500-$4000 per session.

Facial liposuction
Removing fat from localized areas of the face can be very helpful or very harmful. In most persons of normal weight, it is unusual for there to be an excess of fat in the face. The exception can be in the area under the chin where hereditary fat storage can create unwanted fullness. Careful liposuction can improve the jowl—but beware of this as a long-term solution. Procedures lifting the jowl restore the position of the soft tissues upward, while liposuction permanently removes them. If your skin and tissues require a lift in the future, the hollow created below the jawline may look awful when lifted above. A thorough discussion about liposuction and the potential consequences will help you decide if this is a good strategy. This treatment usually requires about a one-week recovery while swelling and bruising subsides.

Limited facelift procedures
Many surgeons promote these smaller procedures designed to lift and, in most cases, pull the skin of the face up and back. Small skin lifts can create nice contour improvements along the jaw line but the results are often unsatisfactory after a few months. The S-Lift, Delta Lift, QuickLift and others involve an excision of skin from in front of the ear with some kind of permanent suspension suture into the deeper layer of the cheek. Tightening this suture gathers the superficial muscle and fat layer (known as the SMAS) which lifts the jowl independent of the skin tightening. In skilled hands, these procedures can produce nice results in patients needing less correction along the jaw line. Careful selection of patients is important. Patients can expect to return to normal activities in five to seven days.

Traditional facelift
This procedure also comes in many forms and a skilled plastic surgeon should be able to discuss which variation would work best for you. Modern techniques allow for the jowl tissues to be lifted into a natural position while restoring youthful contours to the cheek, jaw line and neck. Ligaments can be released to allow tissue to be re-draped in a manner not possible with other approaches. With careful planning and execution, all of the stereotypical results of looking pulled or unnatural can be avoided. Although this is the most effective treatment for sagging along the jaw line, it requires the most skill to perform. Clients can return to normal activities usually within 10 to 14 days.

So if you find yourself staring at your jowls, you can do something about it. Start by thinking about what you would be willing to accept in terms of the degree of improvement, cost and amount of downtime. Then make an appointment with a Royal College-certified physician who can discuss all of your alternatives. Each treatment has limitations and risks and must be considered in the context of your goals and boundaries. Jowls do not need to be part of your future if you don’t want them to be.

© CHS Inc. 2003/2004 All Rights Reserved.