Jowls certainly are one of the main facial aging issues that leads people to seek a facelift, and jowls absolutely can recur after a face and necklift – especially if the ‘facelift’ is limited to surgery on the facial skin only. Not only may jowls recur, but they also may be incompletely corrected by a face and necklift, if the procedure performed is not appropriate for the nature of the ‘jowl’ problem. So carefully evaluate your surgeon’s ‘before and after’ photos for jowl area improvement.
Like all aspects of a facial rejuvenation procedure, jowls require careful evaluation as to their nature and their specific treatment. Jowlfullness over the mid-jawline frequently is lower cheek fat that has descended due to increased skin and subcutaneous tissue laxity as part of the normal aging process, and that has increased in volume, which is also part of the normal aging process. Fat tends to atrophy (i.e. melt away) where you’d like it to stay – like high in the cheeks - and to increase in volume where you don’t want it, like in the jowl area, in the neck and above the nasolabial folds.
Skin-only facelifts have an inherently limited ability to improve jowls. Jowl fat is intimately associated with a deeper plane of facial soft tissue called the SMAS, so pulling on the skin does little to improve jowls. And skin is elastic, so as the skin stretches out, jowls recur. Jowlfat can be surgically removed during a skin-only facelift, but that form of treatment tends to skeletonize the jawline, which does not lend itself to a youthful appearance.
The most powerful means of correcting jowls is by advancing jowl-area fat back up over the jawline into the cheek. This can be accomplished by the High-SMAS face and necklift, which involves elevation and advancement of a tougher connective tissue layer below the skin called the SMAS. SMAS elevation (high in the cheek, hence the term ‘High-SMAS’ face and necklift) has positive effects on the peri-oral area (softening nasolabial folds, elevating the corner of the mouth, correcting marionette lines), pulls jowl fat back up into the cheek, and also tightens the area under the jawline – as it is continuous with the platysma muscle in the neck. And because the SMAS is made primarily of collagen, it had tensile strength and does not relax like skin does. The skin is carried passively with the SMAS, and all of the tension that holds the facelift is placed on the SMAS rather than the skin. So High-SMAS facelifts are closed without any tension on the skin, and the results are more natural-appearing and more long-lasting.
A ‘lower face and necklift’ implies skin elevation (and facial tightening with tension on the skin) to treat the jawline and neck, and I reserve this procedure for patients with relatively early facial aging changes. If patients have notable midface aging, peri-oral aging changes (nasolabial folds, downturn at the corner of the mouth, marionette lines etc), jowls, or significant neck skin laxity, they are best served by a High-SMAS face and necklift. When a skin-tension facelift is used to attempt to correct the peri-oral aging changes listed above, the result is a wind-swept, unnatural, surgical appearance that unfortunately is a permanent change.
I see many patients who think that they have ‘jowls’ but who actually have fat atrophy at the anterior jawline and posterior jawline – in other words loss of soft tissue volume in front of and behind the ‘jowls’, which makes the mid-jawline area appear fuller. Not only fat but also mandibular bone (the jawbone) atrophies in the areas where fat atrophies, which contributes to the hollowness that bookends what appears to be jowls. These patients have what might be termed ‘pseudo-jowls’, and this can often be very nicely corrected by means of structural fat grafting of the anterior and posterior jawline recesses. Some individuals have both atrophy at the anterior and posterior jawline and mild fullness of the jowl area, and for these patients conservative fat aspiration can be combined with fat grafting on either side of the jowls to restore a youthful profile. Many patients with this form of early facial aging can have a full, smooth and youthful jawline restored by fat grafting and fat aspiration only, putting off a more invasive procedure like a High-SMAS facelift until it is really needed for more advanced facial aging issues.
