Is Lifting Alone Enough for Jowls? An Anatomical Assessment of Facial Aging III
The full text of my column published in the September 2025 issue of D&PS.
The lower face is often the first area patients become unhappy with as aging begins. Loss of jawline definition makes the contour look heavy; mouth corners descend, marionette lines deepen, and the expression can appear sad. Yet this region is difficult to improve with a single procedure. The problem involves more than sagging skin: skeletal changes, shifting fat pads, weaker ligaments, muscle imbalance, and declining extracellular-matrix quality occur together.
The key is to understand how aging affects each layer and choose a corresponding target. Combining energy-based devices with other procedures on an anatomical basis lets us plan treatment that restores a more youthful structure.
Why do jowls and other lower-face aging changes develop?
Common changes include descent of jowl and buccal fat, loss of jawline definition, and more prominent jowls. As the mouth corners descend, marionette lines deepen and create shadows continuous with the nasolabial folds. The jawline becomes blunter and its straight contour less distinct. Skin around the mouth becomes more hollow and develops fine lines through the combined effects of skin atrophy, fat redistribution, and increased muscle tension.
These changes involve several anatomical structures at once. Remodeling and retrusion of the mandible, chin, and region around the mental foramen weaken the skeletal foundation. Fat pads become fragmented and descend, particularly the jowl compartment. Increased tension in the depressor anguli oris (DAO), mentalis, and platysma accelerates changes in expression and lower-face descent. Support from the mandibular and labiomandibular ligaments also declines. In the skin and extracellular matrix, collagen density, elasticity, and microcirculation diminish. Lower-face aging therefore presents as an overlapping set of changes.
In the jowl and mandibular region, the DAO, platysma, mentalis, and risorius are described as contributing to downward pull. Loss of resting tone with age allows the mouth corners to descend and destabilizes the modiolus. Because this is the convergence of several muscles, reduced tone here contributes to marionette lines and jowls. Weakening of the mandibular ligament, platysma-auricular ligament, and retinacula cutis allows fat and skin to descend. Inefficient collagen reorganization and reduced elastic-fiber density further loosen lower-face skin. Clinically, the jowls become more prominent, the jawline less distinct, marionette folds deeper, and redundant perioral skin and a double chin may develop.
Correcting lower-face aging requires more than pulling tissues upward or adding volume. It involves repositioning displaced structures layer by layer. As aging tissues move out of place and lose function, restoring their anatomical relationships requires a treatment strategy for each layer.
Which procedures and energy-based devices are used for jowls?
Restoring mandibular contour and mouth-corner support begins with reinforcement at the periosteal plane. High-elasticity hyaluronic acid filler or calcium hydroxylapatite placed immediately above the periosteum at the pogonion, jaw angle, and mandibular notch can restore support lost through mandibular retrusion and help resist sagging.
Devices can be combined with this approach. HIFU can selectively heat the SMAS level, while deep RF using a 4–6 mm tip can stimulate the periosteal extracellular matrix and encourage a biological response in the supporting foundation.
Descent of jowl and buccal fat, a characteristic visible sign of lower-face aging, arises in the subcutaneous layer. These pads shift as the retinacula cutis and fibrous septa loosen, obscuring the jawline. Microneedle RF can contract the retinacular structures to help reposition fat pads. Where fat volume is excessive, a 1060 nm diode laser, 2.45 GHz microwaves, or MPT high-intensity ultrasound can be used to induce localized lipolysis.
Subcutaneous fat, however, is prone to strong inflammatory and fibrotic responses, so excessive heating increases the risk of nodules. Appropriate temperature, exposure time, and region-specific intensity are essential. Marionette lines require attention to medial structures; jowls depend on the lateral vector; and the jawline requires maintenance of horizontal tension.
Figure 1. Facial muscle layers: a botulinum toxin injection depth guide. Source: Consideration of Muscle Depth for Botulinum Toxin Injections: A Three-Dimensional Approach, Julie Bass Kaplan, Plast Surg Nurs. 2017 Jan/Mar;37(1):32–38. doi:10.1097/PSN.0000000000000172.
Muscle imbalance has the most direct influence on downturned mouth corners and deepening marionette lines. Increased tension in downward-pulling muscles such as the DAO, mentalis, and platysma can make the entire face look heavy and sagging. Botulinum toxin can be used to reduce this pull. Combining it with HIFES (High-Intensity Facial Electrical Stimulation) to restore the function and tone of the upward-pulling zygomaticus major and minor may improve both facial balance and lift.
Prominent jowls and loss of jawline definition are largely associated with weakened retaining ligaments. Laxity of the mandibular and labiomandibular ligaments reduces support for adjacent fat and accelerates structural collapse. Thread lifting is one way to restore this support, but the thread path must be planned precisely. Extending a thread into the medial marionette-line area can cause dimpling during smiling, so the insertion should stop at the midline, with tension adjusted to the surrounding anatomy. Fractional bipolar RF can be combined with the procedure to remodel the matrix around the ligaments and restore elasticity.
More advanced lower-face aging also involves reduced dermal elasticity, epidermal atrophy, and pigmentation. Repeated movement around the mouth makes wrinkles and rough texture particularly apparent. For these superficial changes, dermal injections of skin boosters such as non-cross-linked hyaluronic acid, PN, or PDRN can restore matrix hydration and elasticity. They may also be combined with picosecond laser treatment, LDM, or microneedle RF.
Figure 2. Classification of ligament morphology. From deep to superficial, the main planes are deep fascia/pericranium, sub-SMAS, SMAS/galea, subcutaneous tissue, and skin. Three forms of ligamentous attachment cross the sub-SMAS plane into superficial tissues: true ligaments, septa, and adhesions. Source: Surgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions, Christopher J. Moss, Bryan C. Mendelson et al., May 2000, Plastic & Reconstructive Surgery 105(4):1475–1490; discussion 1491–1498. DOI:10.1097/00006534-200004040-00035.
Why does repositioning matter more than pulling alone?
Treating lower-face aging ultimately requires repositioning, not just restoration. This is where aging is often most visible and where patients notice the greatest change in their appearance. A blurred jawline, downturned mouth corners, bulging jowl fat, and marionette-line shadows immediately convey an older appearance. Trying to resolve every change through lifting or volume replacement alone risks overcorrection, unnatural results, and short-lived improvement.
Figure 3. Anatomy of the face and jowl. Left: important neurovascular structures marking the posterior jowl-fat border. The facial artery is red, the facial vein blue, and the marginal mandibular nerve (MMN) yellow, crossing perpendicular to the vessels. Middle: a male cadaver with digital markings defining the jowl treatment area. A, lateral canthus; B, antegonial notch; C, oral commissure; D, prejowl sulcus; E, midline labiomental sulcus; F, ear lobule. The white hatched area marks the MMN innervation zone at the lower mandibular border. Right: the inferior jowl fat pad is shaded green. Source: Novel Surface Anatomic Landmarks of the Jowl to Guide Treatment with ATX-101, Sachin M. Shridharani, Plastic and Reconstructive Surgery. DOI:10.1097/GOX.0000000000002459.
Lower-face aging has no single cause. It is a structural change across multiple layers, combining skeletal remodeling, fat-pad displacement, altered muscle tension, ligament separation, and reduced extracellular-matrix quality. Restoring this system requires more than simply returning it to an earlier appearance. It calls for restructuring the points of anatomical failure and repositioning tissues to recover function.
The most important skill is the ability to assess the layers separately. Anatomical knowledge must translate into a practical understanding of structure when planning treatment. Pulling only the subcutaneous fat when periosteal support is weak provides insufficient anchoring, making the lift unstable and short-lived. Raising a mouth corner with filler when the cause is downward muscle pull can create asymmetry or an unnatural smile. Placing threads only superficially when the ligaments are lax limits durability. If the actual problem layer is missed, treatment merely conceals the signs instead of addressing their cause.
Energy-based devices have an increasing role in lower-face treatment. Earlier approaches centered on physical traction with threads or volume replacement with filler. Treatments targeting subcutaneous organization, SMAS contraction, extracellular-matrix remodeling, and heat-induced fibrosis have since strengthened the role of these devices.
Devices cannot, however, address every structure alone. Likewise, PDO threads, botulinum toxin, fillers, and biostimulators work more effectively when energy-based treatment has prepared the foundation. These approaches function as successive layers of treatment: the device improves the matrix and the support between periosteum and skin, and the procedure builds the desired structure on that foundation.
Figure 4. The traditional description of facial spaces and retaining ligaments, with most spaces defined by ligamentous boundaries. Published with permission. Source: Anatomy of the Facial Glideplanes, Deep Plane Spaces, and Ligaments: Implications for Surgical and Nonsurgical Lifting Procedures, Lennert Minelli et al., Plast Reconstr Surg. 2023 Sep 25;154(1):95–110. doi:10.1097/PRS.0000000000011078.
Figure 5. 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), skin glides over the mandible–muscle complex at the common 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, Lennert Minelli et al., Aesth Plast Surg. (2023) 47:170–180, https://doi.org/10.1007/s00266-022-02996-3.
Although we analyze the lower face in layers, those layers are closely connected. SMAS laxity, for example, allows a fat pad to descend, which disrupts the retinacula cutis and creates dermal creasing. A visible surface wrinkle may originate two or three layers deeper. Understanding these connections is essential to choosing the timing, intensity, and sequence of treatment.
Many patients say they want a lift. The clinical task is to realign the structures beneath it. Lower-face tissues have not simply moved downward: their position, volume, and tension have changed. Effective correction restores those relationships. Along with lifting the skin, it requires redirecting fat, balancing muscle tension, restoring ligament elasticity, and rebuilding periosteal support.
(To be continued in the next issue)
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