thank you for your question. you submitteda photo and you described that you’re 51 and you're demonstrating the concern you haveabout jowls. and you're asking, “what happens to the jowl fat during the face and neck lift?â€and you're asking about the method whether it’s reposition or what is done, or is itcustomized. well, i think i can give you some perspectivefrom my – from what i do in my practice. i’m a board certified cosmetic surgeon certifiedby the american board of cosmetic surgery and a fellowship-trained oculofacial plasticand reconstructive surgeon practicing in manhattan and long island for over 20 years. face-lifting– face and neck lifting is a very significant part of my practice. and i can share withyou what my approach is and a little bit of
how it’s evolved over the years.to answer your question, essentially, the answer is it’s – it is – it has to becustomized. no two people can have exactly the same procedure. and when you do your researchand meet with doctors, you will get varied opinions on what is the best way to do whatyou want. and so you’ll have to kind of filter them and see which one you're mostcomfortable with. but to understand the jowls, it’s very importantto also understand anatomy. and it’s part of the reason why there’s a lot of peoplewho have had sub-optimal results. whether it is with the face-lifting surgery, whetherit’s with an injectable, or whether it’s with a thermal heating device that claimsto be able to lift the face. so let’s understand
the anatomy a little bit.you see the term jowl can mean basically one thing, it’s the absence of clear definitionof a jawline. what contributes to the jowl appearance is actually can be several things.we’ll start with the level of – at skin deep at the – right below skin. right belowthe skin where the skin hangs over, there can be a small amount of fat. now this fatcan be defined as fat that has shifted downwards. so the question about repositioning is certainlya valid question. some people would feel that the fat representsfat that is not only moved downward, but it’s kind of separate and we sometimes see thisin face-lifting surgery. and in certain situations like that, the fat can be excised. now howit’s excised, some people will do liposculpture
first and then do the lift or would do directexcision. the other factor that’s often under-appreciated is part of the jowl, theappearance has to do with something called the buccal fat.buccal fat is fat that’s in a very distinct compartment which is – which creates a certainamount of fullness. there’s actually two types of situations with buccal fat. one iswhere there is kind of like a diffused, localized fullness and then there’s something calledbuccal fat herniation where the fat protrudes out and almost – then creates this roundishlittle bulge. the point is that you don’t have a one standardapproach and system that is going to work the same for everybody. in my practice, wheni’m doing surgery, this is often a dynamic
process. yes, i have a certain – i makecertain observations and determinations before surgery. but doing surgery, as i’m doingthe work, as i’m lifting – as i’m moving the muscle, the layer, called the smas orsuperficial muscular aponeurotic system, i’m looking at the contour when i’m making decisions.i’m looking to see if buccal fat is prolapsing outward. sometimes i’ll take that buccalfat from the inside of the mouth before i actually do a lift. when i – when i mentionedabout the evolution of this procedure, in my practice, i can tell you that there wasa time where it was almost a given that any patient who have a little bit of jowl fatand a little bit of fat under the chin would get liposuction first before the beginningof the surgery.
in my practice, [in my?] – for me, it’sevolved. i’m actually more conservative about the application of liposuction beforedoing the face-lifting and more doing something like a liposculpturing with direct excisionwhere i’m not traumatizing the tissue as much. now that’s my style and my take. ido all of my facelifts under local anesthesia with light sedation. this allows me to dothis procedure with the patient more comfortable post-operatively and also it allows me toposition the face and not have a tube in the throat that gets in the way of me evaluatingthe angle. this is a very – just a dynamic process,the way i do it. and i feel like i get – i get more information and more ability to judgewhen i do it this way.
our patients appreciated it because they don’thave to go under general anesthesia and they also feel really good after their surgery.they don’t feel like they’re knocked out but that’s a separate topic.i think that when you – as i said, when you are meeting with doctors and when you'redoing research, you’re going to see a lot of claims of procedures by name like a deepplane facelift. i had someone to saying that their preferred method is another type offacelift. you know, a competent and experienced cosmetic surgeon knows all those methods andhas a lot of experience with all those methods. so really, it’s about the style and theaesthetic outcome. what is a great result for one surgeon who likes a more natural resultmay not be aggressive enough to someone who
wants a more exaggerated result. and thisis the why there’s a varies – there’s a variability in the aesthetics and stylein doctors. we’re all individuals with our own style. and then, of course, you can judgethat by looking at the doctors’ before and after pictures and getting a sense of yourrapport in conversation in – during consultation. so to once again, to answer the question,in my practice i feel it’s very important to customize. it’s very important to understandthe different options. and then last, i would also mention that somethingthat’s also under appreciated is that the bone at the point where the jowl is, rightin front of the jowl, is called the mandibular notch. this is an area which is indented.so when you think about it, even when you
lift, if the bone is still indented, you mayfeel that there’s a little bit of a jowl left.so – to example of how we approach this, we can approach it by putting some type offacial implant like a pre-jowl implant or you can do it later after the surgery. andit’s something that we do more, you know, with our patients it is we advise them thatthere’s the presence of this indentation. and what we do in our practice non-surgically,it’s something called the wire lift. and for people who are good candidates who aregoing to go and have face-lifting surgery, the wire lift is a great option where we usefillers such as juvã©derm, ultra plus, and juvã©derm voluma to place under the muscularlayer to create more continuity in the jawline.
and for people who’ve had facelifts in thepast, who have this little notch area and think they need a lift again, they reallysee the benefit of doing this procedure that takes less than 30 minutes. it’s not evensurgery, it’s actually an injection procedure and creates great results.so when you think about the jowl, yes, it’s one term to describe the lack of continuityof a jawline. but there are at least three distinct factors: there’s fat under theskin, there’s fat from the buccal fat pad, and then there’s the upset, a resorptionof bone. remember, facial aging is a combination ofvolume loss from bone, muscle, and fat, as well as dissent. so understanding all of thati think will help you really make the right
decision when the time is right for you.so i hope that was helpful. i wish you the best of luck. thank you for your question.
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