Contouring the Jawline
- Medical Community - July 30th 2019
Patients seeking rejuvenating procedures for their aging face often present with prominent nasolabial folds, marionette lines, perioral lines, loss of volume to the lips, and changes along the jawline. Subtle changes along the jawline reveal advancing age. A patient’s appearance is significantly affected with the loss of definition of the mandibular border. There is a general perception that a well-contoured jawline is the hallmark of a youthful face.
Aging is a natural phenomenon and the skin bears the first obvious signs of the passing of time. Gravitational forces, increased tissue laxity, and progressive bone resorption all play a role in the manifestations of facial aging. Atrophy and resorption of the malar, submalar, and buccal fat pads lead to volume loss in the midface. With aging, the jawline’s shape becomes less aesthetically appealing. As a result, there has been a significant increase in the number of non-surgical and minimally invasive procedures available to help contour the jawline and restore lost facial volume.
Dr. Kate Goldie, an aesthetic practitioner, utilizes a full-face consultation to educate patients about the complex interplay and changes of different facial structures including the skin, fat, ligaments, bones, and muscles. During a consultation, it’s important for a practitioner to discuss with their patients the cause and effect of each aesthetic concern. This allows patients to understand that addressing mid-face deficits is necessary to come up with an overall positive effect. As the demographics of cosmetic surgery patients evolve, many patients now seek less invasive treatments that result in less side effects and faster recovery time. Although there is a plethora of therapeutic options available today, natural-looking results and patient safety have become the focus of modern aesthetic procedures.
The chin and jawline are common areas of concern among patients. Patients, in particular, are concerned with the loss of jawline definition, the formation of jowls, and deepening of the pre-jowl sulcus. The redistribution in volume and position of the soft tissue of the lower face create undesirable shadows that detract from a patient’s appearance. Knowledge of age-related anatomy is vital in trying to restore a youthful face. Furthermore, a practitioner must recognize the form of an attractive chin and sculpted or well-contoured jawline.
Apart from age-associated volume loss that is now known to contribute to the structural changes of the aging face, the process of aging is also visibly manifested in the skin. It is essential to come up with a multipronged approach in contouring the jawline to deal with sagging, jowl formation, and chin widening. Distinct age-related changes at the lower third of the face and neck can be dramatically addressed with traditional face-lift or genioplasty. It is currently the only treatment modality that allows maximum jawline contouring with reliable long-term results.
However, the last decade has seen minimally invasive procedures evolve as the gold standard for facial rejuvenation. Soft tissue augmentation in the form of dermal fillers and botulinum toxin are some of the most current options that many patients desire. Plastic surgeons and aesthetic practitioners must include minimally invasive techniques in their treatment strategies for the lower face and neck. Both surgical and non-surgical procedures used in sculpting the jawline have varying degrees of risk and invasiveness. Minimally invasive methods may soon go head to head with traditional aesthetic procedures or become a worthy replacement.
Soft Tissue Fillers
There are different dermal filler materials available for soft tissue augmentation, but not all are suited for jawline contouring. Hyaluronic acid (HA) is the most popular and widely used material for dermal filler treatment; it restores volume loss efficiently and can be reversed with hyaluronidase should overcorrection occurs. But many physician’s treatment of choice is Radiesse (Merz Aesthetics)—a Food and Drug Administration (FDA)-cleared injectable filler made of small calcium hydroxylapatite (CaHA) microspheres. The 25–45μm microspheres of synthetic calcium hydroxylapatite are suspended in water, glycerin, and carboxymethylcellulose and can be used for lip augmentation, as well as in treating the nasolabial fold. Not only does it provide immediate volume and wrinkle correction, it also stimulates collagen production, resulting in reduced wrinkles and improved skin elasticity.
Calcium hydroxylapatite fillers
Although CaHA can replenish lost volume in the mid and lower face and create a youthful, sculpted jawline, appropriate injection techniques are crucial in achieving optimal results. The evaluation of the problem area should be performed with the patient in an upright position. Photographs should be taken prior to treatment and the patient should be informed of any facial asymmetries before starting the procedure. The patient should be counseled about the limitations of the product, potential risks and side effects, expected duration of effect, and post-treatment care. Consent should be obtained after adequate briefing and counseling. The filler is injected supraperiostally above the ala-tragus line and deep dermally below the ala-tragus line. In both areas, a 1:1 correction factor is enough and overcorrection is not necessary. Thread multiple tracks through one puncture using fanning technique to minimize the number of injections. Treatment results usually last for 12-18 months.
Hyaluronic acid fillers
Patients with thicker skin and poorly-defined bony structure of the mandible require incompressible or stiff fillers, such as Radiesse, to support the overlying tissues while contouring the bony structures of the jawline. However, those with thin skin over a well-defined mandible require a highly elastic HA filler such as Restylane Lyft (Galderma) and Juvederm Voluma XC (Allergan). The injector should be able to determine, by thorough examination of respective bony and soft tissue structures along the patient’s jawline, the best product or combination of products to use. In a patient with thick skin and a reasonably prominent mandibular structure, either product or a mixture of HA and CaHA fillers in varying concentration can be used. One should be aware that only HA dermal fillers are reversible with hyaluronidase.
Dr. Goldie, like many practitioners, recommends the use of cannula when treating the jawline to avoid vascular compromise. Superficial muscular aponeurotic system, also known as SMAS, protects the facial artery in that region. Injectors would unknowingly go underneath the fascia using a long needle. With the use of cannula; however, one can stay in the plane where no major arteries are present and can easily feel if they are going out of the area.
In contouring the jawline using injectable treatments, practitioners should take into consideration the patient’s cultural differences, acknowledging that not everyone prefers the same jawline aesthetic. Patients seeking cosmetic procedures are influenced by culturally determined standards of beauty. An ideal female face, for example, is generally perceived as delicate, contoured, and oval-shaped while a square lower face is considered masculine looking. In some cultures, an increased lower facial volume is seen as “rude.” The main causes of a square face are muscle hypertrophy and prominent mandibular angle. In the Asian population, masseter hypertrophy, resulting in short, wider faces, is frequently observed while Caucasians often possess long, narrow faces.
Botulinum toxin injection is a non-surgical approach of correcting masseteric muscle hypertrophy. In the past, surgical resection of the masseter or bony angle of the mandible was the only option to reshape the lower jaw. But surgery is associated with a number of side effects like pain, hematoma, infection, and facial nerve paralysis; thus, it was not very popular. In 1994, Smyth, Moore, and Wood introduced the injection of botulinum toxin type A into the masseter muscle; the results were decreased masseteric girth and a gentler, more rounded jawline.
Kim and colleagues were able to treat 1,021 patients with botulinum toxin to reduce the volume of the masseter muscle in 2005. The team concluded that neurotoxin injection for aesthetic purposes is not a complex technique, with few side effects, reduced recovery time, and is a better alternative to surgical masseter resection. A few studies also claimed that botulinum toxin injection to the masseter could treat bruxism, indicating reduced frequency of teeth grinding events and decreased bruxism-associated pain, as well as high anecdotal patient satisfaction.
Threads can be used as a safe and effective alternative for traditional lifting methods. According to Dr. Jacques Otto, polydioxanone (PDO) threads made of biodegradable synthetic polymer is a good product for lifting and tightening the jawline. In addition, sutures aim to stimulate collagen synthesis and elastin production for an overall rejuvenated effect. The importance of extracting thorough history before treating a patient cannot be stressed enough. Surgical treatment is more beneficial in a patient with very lax skin. The same is true for patients with severely wrinkled skin, as threads tend to pucker when you tighten it.
Using an 18G needle is recommended in creating an entry point before inserting the threads with a blunt cannula. Practitioners should avoid using needles for thread insertion due to the risk of injuring blood vessels or nerves. In treating the lower face, combining thread lifting with botulinum toxin will produce even better results. Dr. Otto recommends injecting botulinum toxin at least two weeks before thread lifting to relax the platysma muscle. Thread lift side effects can include bruising, swelling, puckering or rippling, asymmetry, and visible threads under the skin; however, extensive training should definitely lower these risks.
Patients should be informed that a thread lift is not a one-time treatment, as biodegradable threads are absorbed by the body over time. Good results from a thread lift should be maintained by following post-treatment care and consistent follow-ups. Anti-inflammatory medications to minimize swelling must also be avoided as they can interfere with collagen formation.
Radiofrequency and Ultrasound Therapy
In the medical aesthetic industry, minimally invasive methods have become popular because they allow for faster operating time and fewer post-procedure complications. However, some patients may be needle-averse and unsure about receiving injectables. ULTRAcel is a non-surgical facelift therapy, which is a great initial treatment for patients with lower face concerns but don’t want any form of injectables or threadlift. An ULTRAcel machine combines high intensity focused ultrasound (HIFU) technology, radiofrequency, and fractional microneedling to lift and tighten facial contours without the downtime associated with surgical procedures. Radiofrequency goes through the needles to stimulate fibroblasts and promote the production and remodeling of collagen. Only trained practitioners should perform microneedling + radiofrequency because it can cause burns and pigmentation changes.
In contrast with ULTRAcel treatment, Ultherapy is an FDA-approved procedure that uses microfocused ultrasound energy to target different depths in the skin to lift and tighten the jawline and neck. The collagen-boosting procedure incorporates ultrasound imaging, which allows practitioners to visualize the layers of the tissue being treated, ensuring precise administration without needles or incisions. Ultherapy may be combined with dermal filler injection, although a two-week interval is required. Patients may experience slight bruising or redness, but nothing significant or persistent.
In aesthetic practice, skincare is an important part of any successful treatment. A healthy and functioning skin barrier protects the skin against dehydration, penetration of allergens, irritants, microorganisms, and radiation. While daily skin care regimen that increases skin regeneration is necessary for a smoother and more radiant skin, preventing the degradation of primary structural constituents, such as elastin and collagen, is all the more crucial. Counseling patients about the importance of sunscreen to protect the skin should be every practitioner’s priority.
The cosmeceutical market is notorious for offering false claims, but some products are indeed better than others. The use of products containing Vitamin A is recommended because it stimulates the production of collagen, glycosaminoglycans, and elastic fibers. Alpha Hydroxy Acids (AHA) are also beneficial as an anti-aging ingredient as they increase skin cell turnover, resulting in reduced discoloration and evenly pigmented skin, as well as reducing pore size and softening the appearance of lines and wrinkles. Keeping the skin hydrated with a good humectant maintains the skin’s natural barrier and is an important after care regimen in every cosmetic procedure.
Aesthetic practitioners must recognize patient’s motivation in seeking less invasive procedures. If deemed appropriate, one should offer alternative non-surgical treatments in addressing the lower face and neck. In the surgeon’s preoperative evaluation, proper patient selection is critical to a successful treatment. The practitioner can only plan the best treatment strategy if he or she is familiar with the benefits and limitations of each minimally invasive technique.