Can toxin or filler injections treat jowls?
One of the most common problem areas on the face that develops with age is the jowl area in the lower part of the face. Patients frequently feel like this area makes them look older or even more chubby than years past. Many patients ask if in office injections can help treat this area.
Why do I develop jowls?
Studies suggest jowls develop as a result of the long-term effects of gravity on the facial fat pads, and soft tissues.1 Jowls are part of the normal aging process. There are a number of incredible videos of fighter pilots g-force training which show the effect of gravity on the face. The pilots appear to age multiple decades in a matter of seconds when the forces of gravity are amplified. As the G forces increase, the pilots develop wrinkles, sunken eyelid bags, sagging of the cheeks, deep creases in the nasolabial folds, downturned corners of the mouth, and jowls.
There is a genetic component to aging and also an exposure component. Patients who don’t smoke, exercise daily, have a good diet, and routinely take care of their skin with medical grade treatments will be slower to see the effects of jowling, because their skin will be stronger and tighter and thicker. However, there is some genetic component to jowls which cannot be controlled.
I’m starting to see some fullness in my jowls. I don’t want surgery, but what options do I have?
It’s always best to start by considering the least invasive options available. There are two muscles at the corner of the mouth (called the depressor anguli oris, DAO) that can be targeted with toxins such as Botox, Dysport, Daxxify or Xeomin. In some patients, these muscles create lines at the jowl area that make them look older. The key to injecting this area with tox is to use a very low-dose (it’s a small muscle) and treat the muscle low along the jawline to avoid affecting other muscles that move the corner of the mouth. Some patients are very happy with tox in this area, but for most people the impact is fairly minimal since toxin does not treat the jowl itself and only works by relaxing the DAO muscle nearby that can improve shadowing in the area.
Fillers injections are another option and are an easy in-office procedure. Hyaluronic acid fillers such as Juvederm and Restylane are popular choices to camouflage bulges and shadows in the jowl area. Fillers are not without risks, however, and they do not cause any actual lifting of the soft tissue. Remember, jowls are a result of gravity causing a sagging of facial tissues. Filler or other injections, such as fat grafting, do not lift tissue. Improvements from these injection techniques are due to camouflage or changing shadows. I always warn my patients that more is not better when it comes to fillers in the lower face and jowl area. A little filler in this area can look nice and natural, but overdoing it can be disastrous, particularly in females. The youthful female face has a heart shape with a narrowed lower border at the chin. Too much filler in the jowl area can make a woman look masculine or have a square jaw. This is a common complaint when patients visit us after filler injections elsewhere that did not live up to their expectations.
Another non-surgical option to treat jowls are skin tightening procedures, such as radiofrequency microneedling, lasers, and chemical peels. For patients with early aging these may be a great option because they work by stimulating the skin to turnover and can result in a smooth and tightening effect. However, lasers, radio frequency, microneedling, and peels work on the skin, and not on the underlying fat and soft tissue. Therefore, they are less impactful when used by themselves in patients with more advanced aging. These skin treatments are a great combination when added to injections or lifting procedures.
Moving on from injections and lasers to the next option for jowls which are procedures that lift. Because jaws are caused by the effects of gravity on the facial soft tissue pads, procedures that lift are truly the most effective option for treatment. Lifting procedures include Thread lifts, mini lifts, jowl lifts, and facelifts. The only “non-surgical” option of these is a thread lift. Thread lift procedures involve barbed sutures like fishing line which are injected under the skin and then pulled to create a lifting effect. Historically, thread lifts used a permanent material. But because there were so many problems with infection and exposed threads, permanent threads were largely taken off the market.2 Modern thread lift techniques use dissolvable threads. However, the risk of a pulled appearance, infection, and exposure of the threads still exist, which can cause long-term problems even after threads dissolve. Overall, the upside of thread lifts is that they can be performed in the clinic in a relatively simple procedure, but they are costly and the lifting effects are temporary, and there are significant risks. A recent study of 160 patients found that the lifting effect from a thread lift was present at 1 month, but had significantly diminished by 6 months and disappeared completely by 12 months.3 It is important that patients realize the short-lived nature of this treatment if they choose to undergo a thread lift procedure.
The last option for treating jowls are surgical procedures, such as a mini lift (SMAS lift) or deep plane facelift. Surgical lifting procedures are the only option which treat the cause of jowling by releasing tissue and repositioning back where it was years ago. Because they treat the actual cause of jowls, they are the most effective treatments, but come with longer downtime and a higher upfront cost. Mini lift and some SMAS lift procedures are a great choice for patients with early aging and can often be performed in the clinic under local anesthesia. For patients who are looking for a meaningful lasting result in the cheeks and middle part of the face, and neck a true extended deep plane facelift is often the best choice. Make sure to consult with a facial plastic surgeon who is well versed in these techniques to determine which is the best choice for you.
Disclaimer: This blog does not constitute medical advice and no doctor-patient relationship is formed by reading it. Prior results do not guarantee a similar outcome. Additional facts or future developments may affect subjects contained within this blog post. Before acting or relying upon any information within this newsletter, seek the advice of a medical doctor.
Sources
1. Ramesh S, Johnson P, Sarcu D, Wulc AE. Gravity in Midfacial Aging: A 3-Dimensional Study. Aesthet Surg J. 2021 Jan 25;41(2):143-151.
3. Bertossi D, Botti G, Gualdi A, Fundarò P, Nocini R, Pirayesh A, van der Lei B. Effectiveness, Longevity, and Complications of Facelift by Barbed Suture Insertion. Aesthet Surg J. 2019 Feb 15;39(3):241-247. doi: 10.1093/asj/sjy042. PMID: 29474522.