There are a number of ways of improving the appearance of visible jowls – yet the choice of the treatment will entirely depend on the severity and the contributing causes.
The appearance of the jowl fat pad (the most inferior fat pad in the face) is found below the jaw line and has a number of contributing factors:
1. Occurs secondarily to volume loss (and therefore the loss of support). This includes fat compartments higher in the face (middle, & latero temporal cheek compartments).
2. Soft tissue egress resulting from gravitational pull.
3. Tissue laxity.
4. Elongation of elevator muscles in the face.
5. Laxity of the mandibular septum and Platysmal band ‘pull’.
Considering that multiple factors cause the appearance of the jowl below the jaw line, we need to use a combination of treatments in most patients. Taking into consideration the complexities of the causes and recommended surgical approaches, it becomes clear that using a single technology based treatment or injectable approach will not achieve the desired end results. It will also not meet the patient’s expectations.
Combination of Causative Factors = Combination Treatments = Best Results
There are several treatment approaches:
1. Dermal fillers (such as Juvederm® Voluma)
3. Technology based treatments
There are a number of fixation points and retaining ligaments in the face that can be used - not only to anchor certain facial structures, but also to lift these structures (this is including the jowl fat pad).
Considering the fact that the cheek area consists of three separate fat pads (each with their own fixation points), they can be used to our advantage when lifting and supporting the facial structures.
Small boluses of dermal fillers injected at these points will act very similarly to a tent pole. Not only does it increase volume, but it also anchors and lifts the more inferior fat pads. Further volumisation (if necessary) of the cheek area will only add to the lifting effect that can be achieved.
This approach will tackle our first two points listed under the causes. If performed correctly, a total lift of between 0.5 and 1 cm can be achieved on the jowl area (see Figures 1 & 2 demonstrating lifting of the jowl and neck structures).
Botox™ is a great tool to relax muscle structures. It can be used along the jaw line, while the platysmal bands reduce the downward pull that is created by these muscle bands.
Further relaxation of the depressor angulioris muscle (responsible for pulling the corners of the mouth down) will only add to the lifting effect achieved. By reducing these downward vectors, further improvements in lifting the jowl can be achieved - and this approach tackles point number four and five in our list of causes.
Technology Based Treatments:
These treatments should be divided into direct fat removal, skin rejuvenation & skin tightening devices.
Excess Show Jowl Fat Removal:
If the jowl fat pad is still visible below the angle of the jaw line (even after following the above two approaches), then the next step would be to remove the noticeable part. There are a number of technology-based treatments that can be used to achieve this.
1. Invasive Devices: Laser Lipolysis
A laser fiber is inserted into the fatty pad to deliver its energy directly into the fatty pad. The resulting buildup of heat will burst the fat cells, resulting in the permanent destruction of these cells. The fatty liquid released will need to be aspirated with the use of a cannula, and some downtime can be experienced including swelling, tenderness and bruising.
2. Non-Invasive Devices:
Today, patients have the choice between three separate technologies to reduce the appearance of unwanted fat:
• Low level laser energy (such as i-Lipo)
• Freezing devices or Cryotechnology (such as Zerona)
• High Frequency Ultrasound Cavitation Technology (such as Coccon)
Cavitation technology can be used to reduce and eliminate unwanted pockets of fat including the jowl area. Cavitation is a method which uses low frequency ultrasound waves to penetrate into the subcutaneous layers. This produces alternating waves of compression and decompression on the localised fat cells - as well as oscillating fat cell membranes. This results in the fat cells breaking up permanently with a resultant circumferential reduction, fatty pad contouring and shaping.
The added benefits include a quick (10 minutes per side), painless and comfortable treatment with no downtime.
Typically, patients feel a mild heat of the treated area and on bony areas (such as the jaw line).
The oscillating ultrasound energy can be heard in the auditory canal. The above approach will achieve similar results of the surgical removal of the inferior jowl fat pad.
Skin Rejuvenation & Skin Tightening:
Syneron’s e2 device can be used to achieve skin tightening and an overall improvement in the quality and glow of the skin.
This novel new device pairs two technologies: the sublative fractional bi-polar radiofrequency, and the combined infrared and bipolar radiofrequency. The direct effect of these technologies is to stimulate new collagen and elastin (neo collagenases) and to tighten and shorten existing collagen. Further visible improvements includes the improvement in the skin texture, reduction of pore size and number, a healthy youthful glow, and an overall improvement in wrinkles and skin tightening.