Jowls and Marionette Lines: Aging of the Lower Face

This is the full text of my column in the March 2025 issue of D&PS.

Many factors contribute to skin sagging, but fat compartments and ligaments are particularly important. The midface deserves close attention because it is a key indicator of how much a face has aged. We need to consider how to elevate this region and improve a descended malar fat pad. The forward vector matters just as much as the oblique vector when planning that correction.

The superficial fat compartments include the infraorbital, medial cheek, nasolabial, middle cheek, lateral cheek, superior jowl, and inferior jowl compartments. Of these, the medial cheek, nasolabial, middle cheek, superior jowl, and inferior jowl fat warrant particular attention. The deep midfacial compartments include medial suborbicularis oculi fat, or SOOF, deep medial cheek fat, and buccal fat. Buccal fat lies beneath the muscle layer and is sometimes called deep cheek fat. We once performed buccal fat removal through an incision inside the mouth, but no longer do so.

Figure 1. Superficial facial fat compartments and their relationship to the retaining ligaments. Source: Retaining Ligaments of the Face: Review of Anatomy and Clinical Applications, Mohammed S. Alghoul and M. Codner, Aesthetic Surgery Journal, 1 August 2013, DOI:10.1177/1090820X13495405.

Which anatomical changes cause jowls?

Jowls develop as the face's dense supporting tissues, chiefly the SMAS layer, become lax. Midfacial fat compartments descend, shifting volume downward. A jowl may result from inferior migration of the fat compartment itself or from loosening of the mandibular septum. When the fat compartment itself migrates downward, the submalar hollow becomes more pronounced.

Jowling involves shortening of the supraplatysmal plane; the tissues beneath the platysma show relatively little descent. Skin stretching contributes, but redundant subcutaneous tissue also develops. Previously, the mandibular ligament was thought to form a tight attachment from bone to skin, creating jowls and marionette lines, with the anterior border of the jowl corresponding to the marionette line.

Figure 2. The premasseter space, jowl, and labiomandibular fold. Anterior boundary of the premasseter space. Source: Surgical Anatomy of the Lower Face: The Premasseter Space, the Jowl, and the Labiomandibular Fold, Bryan C. Mendelson et al., April 2008, Aesthetic Plastic Surgery 32(2):185–195, DOI:10.1007/s00266-007-9060-3.

Figure 3. Descent of the superior and inferior jowl compartments. Laxity or dehiscence of the mandibular septum leading to jowl formation. Source: Getting Better Results in Facelifting, Rohrich RJ et al., Plastic and Reconstructive Surgery - Global Open, 27 June 2019, 7(6):e2270, https://doi.org/10.1097/gox.0000000000002270.

Why do marionette lines develop?

Marionette lines develop mainly because the skin and tissues on either side of the line differ. They age differently, producing a crease at the boundary. Several muscles intersect in this area, and tissue changes differ above and below the line and on its medial and lateral sides. Treatment requires a precise understanding of those differences.

The depressor anguli oris (DAO) and mentalis become progressively stronger with age. Most muscles along the lower-face outline originate inferiorly, so strong tone pulls the face downward. Increased mentalis and DAO tone gives marionette lines a downturned appearance and creates a recessed step on the medial side of the line.

As discussed, aging broadly involves loosening of the SMAS layer and the resulting shift of fat compartments. The retinacula cutis in the subcutaneous layer also play a very important role. A recent paper states, “The maximal jowl fullness corresponds with the area over the posterior end of the mandibular septum.” In other words, the greatest jowl descent occurs where the mandibular ligament ends. Histologically, this is also where the retinacular fibers are longest. The paper found that subplatysmal structures do not contribute to jowl volume. Micro-CT examination of tissues around the buccal fat showed that, although muscle attaches to bone, the connection from muscle to skin consists of dense and loose retinacula cutis rather than a firm ligamentous structure. The authors propose that this arrangement lets the skin glide when the mouth opens. The deep third of the mandibular ligament interconnects with the platysma, depressor labii inferioris (DLI), and DAO and attaches close to bone. Toward the skin, however, it is a dense retinacular structure rather than a true osteocutaneous ligament extending from bone to skin.

Figure 4. Reassessment of surgical anatomy, showing how different areas across the mandible respond when the mouth opens. At the premasseter space (blue), the platysma glides over the masseter without additional skin gliding. At the mandibular ligament (yellow), the skin must glide over the mandible–muscle complex at the common mandibular attachment of the platysma, DLI, and DAO. At the perioral adhesion zone (red), the mandible, lower-lip muscles, and skin move together, maintaining their relative positions. Source: The Surgical Anatomy of the Jowl and the Mandibular Ligament Reassessed, Minelli L et al., Aesthetic Plastic Surgery, 1 September 2022, 47(1):170–180, https://doi.org/10.1007/s00266-022-02996-3.

(To be continued in the next issue)

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