One of the signs of the aging face that people object to is
jowling. The jowls are areas of fullness along the jawline that tend to increase with age. The straight, strong jawline of youth is gradually replaced by the soft, irregular jawline of the aging face. It is thought that jowls result from the combination of muscle, skin and fat that all begin to sag with age. An area known as the
pre-jowl region is located directly in front of the jowl. It is thought that a ligament (the
mandibular ligament) attaches the skin to the bone in this region, creating a depression in front of the jowl. Because the ligament doesn't stretch with age, as the howl increases in size with age, the pre-jowl depression becomes deeper and deeper, making the jowl look even bigger.
There are several ways to treat the jowls, both surgical and non-surgical. Surgical options include mainly
facelifting and
liposuction. During a facelift, the facial soft tissues are pulled upward and backward, thereby raising the jowls upward above the jawline so that they don't hang over the jawline. Adding a mid-face lift may improve things even further, since the mid-face lift pulls the facial soft tissues vertically, raising the jowls even higher above the jawline to hide them even more than with just a facelift alone. These procedures don't remove any jowl tissue, they simply reposition the jowls.
Another surgical option is a facial implant. These
pre-jowl implants are similar to chin implants, but the part of the implant over the chin itself is paper thin. The implant then flares out to thicken in the pre-jowl area. The implant minimizes the jowl by filling out the depression that forms in front of the jowl, in the area of the mandibular ligament. With this implant, the jowl is not repositioned or removed, it is simply camouflaged.
Recently, another surgical option has been developed, although the jury is still out on this one. Various
suture suspension techniques have been developed over the last few years in an attempt to minimize downtime. Names such as
Featherlift and
Threadlift have been bandied about in the media for the past few years. There is very little long-term data on these procedures at this time. At a recent plastic surgery conference in Palm Springs CA, the consensus among the surgeons in attendance was that it was too early to tell what role these suture suspension techniques would play. However, it was apparent that the techniques may be appropriate for younger individuals who want a minimal procedure that may last less that a year.
Liposuction, which actually removes some of the jowls, can be performed in conjunction with a facelift or it can be performed as a stand-alone procedure. Many surgeons feel that repositioning alone will not completely eliminate the jowls. These surgeons feel that the jowls need to be reduced in size somewhat in addition to being repositioned. However, liposuction needs to be performed carefully in this region with a very small cannula (1.5 to 1.8 mm diameter) because it is easy to cause irregularities and ridges if this area is liposuctioned too aggressively. Some surgeons use scissors to directly remove the jowls during a facelift, in an attempt to avoid irregularities from liposuction.
Non-surgical options include
fillers,
Thermage and
mesotherapy. Of these, fillers have the longest track record. Any number of fillers can be used, including
collagen, Cosmoplast, Restylane, Radiesse and
fat. While none of these fillers is permanent, Radiesse and fat potentially last the longest. With the recent FDA approval of Radiesse, this is becoming more and more popular to treat jowling. With any of these fillers, the principle is the same: the filler is placed in the pre-jowl area in order to camouflage the jowl, similar to the pre-jowl implant.
Like the suture suspension techniques, the jury is still out on techniques such as Thermage and mesotherapy. Thermage uses a radiofrequency device to melt the fat and mesotherapy uses a "cocktail" of various ingredients injected into the jowl to melt the fat. The body then absorbs the fat and the skin then shrinks and tightens, theoretically.
Many surgeons, including myself, use a combination of techniques. During surgery, I will often perform a combination of a facelift, midface lift and jowl liposuction. After that, I will inject Radiesee into the pre-jowl area to fill the depression. In the months and years after surgery, I will inject Radiesse every year or so to maintain volume in the pre-jowl area. There may be a role for such things as mesotherapy or Thermage for maintenance, but I am waiting for more solid data before I proceed with these modalities.
