Management of the jowl

Abstract

Dr. Gerber: The first patient is a 52-year-old woman who complained of a loss of jaw line (Figure 1). She gained weight after she quit smoking 7 months ago. Dr. Little, how would you create mandibular definition and reposition the soft tissues on this patient? Dr. Little: Although I don't usually bring this up during facial rejuvenation consultations, the first question in this case is whether to enhance the appearance of her skeleton with a chin implant. She has a birdlike face now, with a sharply convex facial profile. I would suggest a wide-based implant as a nice way to balance her face. The key issue is to get a good neck correction, whether or not an implant is used. I think the jowl is an important but secondary issue. I would elevate only the small amount of immediate sub-mandibular fat that is sagging below the jaw line. I would use the old-fashioned technique of plication, using 5.0 absorbable sutures performed through the subcutaneous approach to the face. That would move about 2 cm of fat back above the jaw line where it belongs. Diane L. Gerber, MD J. William Little, MD Dr. Gerber: Would you remove fat from the neck as well? Dr. Little: I would remove all of the neck fat down to the level of the platysma. The only remaining subcutaneous fat is about 3.5 mm that I leave on the cervical flap, which will be dissected from ear to ear. After removing the fat, I would divide her platysma transversely at the level of the thyroid, from the lateral end, until I reach the sternocleidomastoid, then swing up vertically anterior to the sternocleidomastoid and stop when I near the angle of the jaw. I always look underneath the muscle, because one third of patients have significant …