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How to treat jowls and a sagging jawline

While a number of aesthetic treatments can treat jowls, it's vital you choose the right one for your face shape, our experts warn

Zoom, the scourge of our collective self-confidence, has made us hyper-aware of many facial ‘issues’, chief among them jowls. The saggy bits framing our chins that deface a once-taut jawline like to make a glaring appearance when you look slightly down – just where your camera screen usually finds itself.

And while this tends to make the situation look worse than it is, there is something to say for tackling relatively early-onset jowls, as they’re so much easier to tackle with tweakments than very loose skin or severe jowls, which are often better off with surgery.

The good news? There are a number of treatments that get real results. The caveat? Picking the wrong option for your face shape and the state of your tissues can make you look worse, not better. Being armed with the facts and the right questions will ensure you choose wisely, so we asked top specialists to explain all.

Are fillers a good option?

Perhaps surprisingly, dermal fillers are often a first port of call for jowls. “What happens in the lower face is a result of changes through the mid-face,” says Julie Scott, EV Expert and Clinical Director at Facial Aesthetics.

“As we age, the underlying facial fat that provides the ‘scaffolding’ over which skin tautly lies is lost or migrates downward, ending up where we don’t need or want it. If this deep-lying volume under the cheeks and around the jawline has clearly been lost, replacing it will visibly tighten jowls, whether your face is skinny or full.”
Dr Ifeoma Ejikeme, Founder and Medical Director of Adonia Clinic, adds that “an inadequate amount of bone in the places that matter (think, for example, a recessed chin), either genetically or through age-related bone loss, can be another cause of jowls. This is also best corrected with fillers.” Often, the use of viscous fillers such as Sculptra is combined with muscle relaxing injections in the areas that pull the skin and fat down, such as the neck and chin.

What about radio frequency tightening?

If early loss of skin elasticity is your problem rather than fat loss, tightening skin with multi-polar radio frequency (RF) energy (Venus Freeze and Endymed Tighten are examples) is a painless but effective strategy, says Scott. It works by heating the collagen-generating dermis to a point where the production of these plumping, firming cells is seriously revved up.

“I love it especially for those in their 30’s and 40’s who are maybe just beginning to lose some firmness around the jaw,” she says. “You need six treatments over eight weeks; the majority of patients find them quite relaxing as you feel deep warmth but not intense heat.”

For dramatic tightening of more seriously aged and slack skin, radio frequency microneedling, which ‘shoots’ intense RF heat into the dermis through tiny needles to tighten collagen structures and, over time, produce more of the stuff, is Scott's go-to option.

Put on the map by Judy Murray, who was treated with the Morpheus8, this procedure requires numbing cream and comes with some downtime in the form of swelling and redness – although how much depends on the patients and the make of machine used.

Intracel, Profound and Endymed Intensif are just three other options, the latter preferred by Scott, who gets results over the course of “three treatments, four weeks apart, with only some pinprick bleeding and redness.”

Like other practitioners, she often uses her RF protocols in conjuction with facial fillers: “for a lot of people, loss of subdermal fat and thinning and slackening of the skin go hand in hand, so optimal results for jowls as for other parts of the face are to be had with combined therapies.”

The catch with radio frequency energy, particularly if you have very little subdermal fat in the face (through age or just skinniness) is that RF microneedling comes with a small but nonetheless reported chance of unintentional fat loss, making some unlucky people’s faces look more droopy and jowly.

Scott, who uses Endymed for both multi-polar and microneedling RF treatments, has never seen this, explaining there are strict protocols and settings that ensure the heat and needle depth are precisely controlled to reach only the dermis and never the underlying fat layer.

“You need a great machine designed to prevent these things, and an experienced practitioner who understands the technology and the patient’s skin,” she says.

Nevertheless, some RF machines have settings that target the fat layer specifically (as people with fuller faces can actually benefit from fat loss, acquiring a more ‘sculpted’ face), while the Morpheus8 actually advertises itself as a ‘subdermal adipose remodelling device’ that contracts fat and coagulates connective tissue.

It is also thought that in some cases, the heat in the dermal layer can cause a ‘chain reaction’ of tissue contraction or even cell death that reaches into the fat layer. Again, it’s rare, but it does happen.

The takeaway? Full, round or heart-shaped faces with slackening jowls skin are perfect candidates for RF, while those with long, bony or gaunt faces can get great results if they choose their practitioner and machine carefully – do resist cut-price Groupon deals and, for RF microneedling in particular, “get a very careful assessment to make sure you have the right indication for the treatment,” says Ejikeme.

Is ultrasound tightening effective?

Like radio frequency, ultrasound energy can be directed, via a high-intensity focused ultrasound (HIFU) device, right into the deeper skin layers, where the heat that’s generated ‘shocks’ the tissues into producing far more collagen.

Also like RF, there are many different HIFU machines out there, some a lot better and more precise than others – two of the biggest names are Ultraformer and Ultherapy. Unlike RF, HIFU homes in on your SMAS, a layer of muscular tissue below the dermis. The treatment head doesn’t physically puncture the skin, but the discomfort or pain can be intense nonetheless. Denser, stronger, tauter skin ensues after a month or two, smoothing and tightening jowls.

Ultherapy is the only machine FDA-cleared to say it ‘lifts’ skin, promising a ‘lower face lift’ in a single session (other HIFU machines require two or three sessions).

The caveat? Same as with RF: unwanted fat loss. But arguably, the risk is greater. Most HIFU machines are used for skin tautening but also for fat-melting: your fat layer lies between the dermis and the SMAS, and ultrasound energy is said to ‘explode’ fat cells in a direct hit. The devices have separate settings for these two protocols, so, practitioners say, fat loss should never occur if the machine is used correctly.

But, says Cosmetic Doctor and EV Expert Vincent Wong of VinDoc Aesthetics (voicing the sentiments of many top clinicians who love the procedure for those with heavier faces but not for bony ones): “Generally speaking, I wouldn’t treat someone with a relatively gaunt face with HIFU.” Some machines, he says, cause more fat loss than others, but the risk of it happening unintentionally cannot be 100 per cent eliminated.

Ultherapy, which allows doctors to see inside the skin through ultrasound imaging to help them precisely target the thin SMAS layer, potentially offers the strongest insurance against ‘accidents’.

Can threads make a real difference?

Here, it is important to distinguish between collagen-boosting ‘free-floating’ threads, which are injected in a grid or fan pattern underneath the skin, and a thread lift, which involves barbed threads (like all threads, they are made of surgical polymers) that are injected and anchored to literally pull up areas of the face.

“Free-floating or ‘mono’ threads are great for collagen simulation; the longer they stay in the skin before they naturally dissolve, the better,” says Wong. As there is no chance of unintended fat loss, they are a decent alternative to RF or HIFU for lean-faced people with slackening, thinning skin: over the space of several months, they can add density and so mildly tauten early-onset jowls.

But not if skin is too thin, warns Wong, or they will be visible under the skin (and can even poke their way back out). “If a patient has very thin skin, this should be treated first with something like skin boosting injections with uncrosslinked hyaluronic acid (such as Profhilo or Teosyal Redensity-1).”

The material the threads are made of can make a big difference: “PDO (polydioxanone) threads last 6-12 months, whereas newer polylactic acid (PLA, such as Silhouette Soft) and polycaprolactone (PCA, such as Definisse) threads can last over two years,” says Wong.

As for thread lifts, they can be used to ‘reposition’ facial tissues and so hoik up jowls – “generally speaking, this works better for fuller faces,” says Wong. “If the jowl tissue is too heavy, though, this is the wrong procedure – so as always, it’s best to get a thorough assessment with a practitioner who can offer a choice of options, and is very experienced in all of them.” Threads can be, and often are, combined with fillers so as to correct both volume loss and tissue slackening.

Is fat ‘dissolving’ an option?

“I find that submental fat [a double chin] and jowls tend to go together,” says Ejikeme. When you are addressing one, it’s always good to address the other, and my go-to way to do this is injections to the submental region with high-intensity Belkyra, followed by skin tightening in the form of HIFU or RF.”

Belkyra is a fat-dissolving solution based on deoxycholic acid (or sodium deoxycholate), which in the body is a constituent of bile. It is administered with a number of injections and is considered well-researched and safe, but alternative fat-dissolving ingredients are not (and illegal), and could dissolve other tissues as well.

It is extremely important that you choose a well-respected doctor for this who’ll go through a thorough check of your medical history. Expect to have swelling and pain for several weeks, and a wait time of six weeks before you see results. Many people need a course of sessions (often three). The payoff is that the fat loss is permanent.

As an alternative to jabs, you could opt for fat freezing such as CoolSculpting to get rid of the fat permanently. Your chin will get sucked into a handpiece, freezing the fat like a slab of meat (literally). One treatment kills off roughly 20-30 per cent of fat in one area, and results take two-three months to start showing.

It’s a bit uncomfortable but not painful, with swelling and some bruising for about a week as a side effect. As with fat-dissolving injections, you could be left with loose skin, requiring tightening treatments once the fat loss has been achieved.

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