Keywords

The lower face exhibits some of the earliest and most telltale signs of aging with the start of jowls, loose neck skin, unwanted submental fat deposits, and a blunted chin-neck profile. Several factors are critical in achieving an aesthetically pleasing neck, including a defined lower mandibular border and a cervicomental angle of approaching 90°. There are a wide variety of choices in rejuvenation of the jawline, and it is critical to match the correct procedure to the individual.

Factors responsible for aged appearance in the lower face include bone loss along the mandible, the effects of gravity, deflation of the face, and skin damage, along with unwanted fat accumulation. An assessment of all the contributing factors allows the surgeon to best match the most appropriate procedure that will provide the most natural result. Clinical exam of the lower face should include assessment of skin tone and laxity, amount and location of neck fat, a submental skin crease and presence of scars, the presence of platysmal bands, and facial nerve function (Fig. 178.1).

Fig. 178.1
figure 1

Clinical exam of the lower face should include assessment of skin tone and laxity, amount and location of neck fat. Palpation and a skin pinch test helps to assess this

Full size image

It is paramount to assess the chin which is intimately related to the neck. A retrusive chin can be corrected with an anatomical chin implant at the time of lower face rejuvenation to create a stronger jaw angle. Additional anatomic factors which may limit successful lower face correction may include a low hyoid bone position, large submandibular glands, and the presence of large digastric muscles.

Surgical corrections for lower face rejuvenation from least invasive to most include neck and jowl liposuction, mini-lift with liposuction, face-lift with liposuction, face-lift with anterior platysmaplasty, and lastly face-lift with subplatysmal surgery with deep fat removal for heavy necks.

Neck and jowl liposuction work best on younger patients aged 20–35 years old. The ideal patient has a small pocket of submental fat and excellent skin tone with good elasticity. Tumescent anesthesia is used, and a 2 mm stab incision is placed under chin and below the ear lobes. Liposuction is performed with small spatula wands (3–2.4 mm) with a sweeping motion in the pre-platysmal plane. The end point is visualized and palpated for remaining fat pockets. The procedure takes less than 15 min on average. No sutures are placed, the wounds are left to drain, and an elastic compressive garment is worn for 2 weeks. Bruising and pain should be minimal (Fig. 178.2a, b).

Fig. 178.2
figure 2

(a, b) Neck liposuction on a patient with good skin quailty can create a more defined chin area

Full size image

A mini-lift is performed for early signs of jowling and facial descent. A small incision in front of the ear allows SMAS tightening along with skin removal. Liposuction is also performed in the submental area, and the suctioned fat can be reprocessed and injected into facial folds and cheeks as needed. Patients benefitting from this are in the age range of 36–54 years old (Fig. 178.3a, b). The procedure takes about 1 h and recuperation is 10 days.

Fig. 178.3
figure 3

(a, b) A mini-lift benefits patients in the age range of 36–54 years old

Full size image

A face-lift is the correct procedure for more advanced signs of aging including jowling and neck laxity. A typical face-lift patient is in the age range of 55–85 years old. The incision is placed in front of the ear as well as extending behind the ear in the sulcus. The longer incision allows for a more complete correction and removal of the lax neck skin. SMAS lifting along with liposuction of the neck helps to further define the jaw angle (Fig. 178.4a, b). If platysmal bands are present, then the neck should be opened and explored under direct visualization through a 2.5 cm incision in the submental crease. Platysmal bands are identified, cleaned, and trimmed and sutures together in the midline with an anterior platysmaplasty (Fig. 178.5a, b). The procedure takes between 2 and 3 hours, and recovery is typically 2 weeks. It is important to preserve facial fat while removing fat below the jawline to restore a more defined cervicomental angle. Fat is typically reinjected to into the cheeks and folds to reinflate lost volume and recreate a youthful ogee curve to the face. For those challenging patients with short, thick, full necks, the subplatysmal space should additionally be explored and subplatysmal fat removed and digastrics muscles reduced to create a more 90° jaw angle (Fig. 178.6a, b).

Fig. 178.4
figure 4

(a, b) A facelift along with liposuction of the neck helps to define the jaw angle in patients with more advanced signs of aging

Full size image
Fig. 178.5
figure 5

(a, b) This patient exhibits platysmal bands. During a facelift platysmal bands are identified, cleaned, and trimmed and sutures together in the midline with an anterior platysmaplasty

Full size image
Fig. 178.6
figure 6

(a, b) For those challenging patients with short, thick, full necks, the subplatysmal space should additionally be explored and subplatysmal fat removed digastrics muscles reduced and a platysmaplasty performed to create a more 90° jaw angle

Full size image

Choosing the right procedure will yield higher patient satisfaction. The decision on which is best is based on anatomic knowledge, a thorough exam, sound surgical principals as well as an understanding of the typical aging changes anticipated at various milestones.