Special Topic

The Aesthetic Jaw Line:

Management of the Aging Jowl
Edward M. Reece, MD; and Rod J. Rohrich, MD

The lower third of the face is often an afterthought in aesthetic plastic surgery. Aging across the mandibular
border may be described by several mechanisms: fat atrophy and volume loss; shifting of subcutaneous fat
compartments; and mandibular septum dehiscence with submandibular fat hypertrophy. Accurate diagnosis of

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the apparent mechanism of jaw line aging is critical to successful facial rejuvenation. Diagnosis directs the plas-
tic surgeon as to which key anatomic components in this region to manipulate to optimize rejuvenation. The
senior author’s technique for facial rejuvenation across the mandibular border is described with an algorithm
for facial rejuvenation of the jaw line. Several consistent patterns of facial aging are apparent and a theory of
their mechanism is suggested: (1) patients with thin skin and minimal jowling resulting from fat atrophy; (2)
jowl ptosis with normal skin and loss of submalar hollow and midface fullness, caused by displacement of fat
compartments; and (3) cascading confluent fat over the mandible, produced by septum dehiscence. Fat atro-
phy is treated with fat replacement, either injectable or autologous fat. Jowl ptosis is treated with septum
release and superficial musculoaponeurotic system elevation to restore jaw line definition. Confluent fat is treat-
ed by septum release, superficial musculoaponeurotic system elevation, and direct excision of fat over the
mandible. Application of techniques without proper analysis and definition may lead to an operated look with
a swept jaw line. Undertreatment may not achieve jaw line definition. (Aesthetic Surg J 2008;28:668–674.)

pproaches to rejuvenation of the aging face present allows for clinical interventions that can be introduced in

A a challenge to the aesthetic plastic surgeon.1

Whatever the technique used, facial analysis is the
cornerstone of optimal outcomes. Undoubtedly, analysis
depends on understanding of underlying anatomy and the
clinical implications that anatomy has for facial aging.2
There is no area of the face to which these strictures
apply more than to the mandibular border. Patients typi-
cally do not come to the plastic surgeon complaining of
their nasojugal grooves or their malar crescent. Instead,
they often present for consultation with the desire to
alleviate their jowls and improve the neck.3 Achieving
long lasting results in this area is demanding and
requires a site-specific approach.3-5 Current concepts of
the anatomy of the face reveal that subcutaneous fat
compartments and changes of these fat compartments
over time play a significant role in facial aging.5
Specifically, at the mandibular border, the anatomic
basis for jowl formation has been shown to involve sub-
cutaneous fat compartments in relation to the underly-
ing mandibular septum.4
One of the authors (RJR) has noted several patterns of
jowling that are consistent in all patients presenting for
facial rejuvenation. Applied anatomic understanding
From the Department of Plastic Surgery, University of Texas
Southwestern Medical Center, Dallas, TX.
a stepwise fashion in order to address the jaw line while
avoiding a “swept,” over-operated appearance. A theory
of jowl patterning with an algorithmic approach to reju-
venation in the lower third of the face is presented.
AGING AND JOWL FORMATION
The jowls are produced by the sum total of 2 jowl fat
compartments—the mandibular septum and sub-
mandibular fat compartments—and the overlying skin
(Figure 1).4 The interaction between these anatomic sub-
units with dynamic forces in aging leads to jowling.
Facial aging is poorly understood and has been theorized
to develop by the deflation of soft tissue over time,6
change of position of fat compartments,4,5 and septal
dehiscence.3 These theoretical mechanisms may be
applied to the jaw line: atrophy of the superior and infe-
rior jowl fat pads may reveal jowls that are present from
an earlier age; change of position of superior and inferi-
or jowl fat compartments may produce jowls (Figure 2);
and dehiscence of the mandibular septum may allow for
jowls and the flow of fat into the neck (Figure 3).
This theory applied clinically is seen in several types
of patients as observed by one of the authors (RJR).
Patients with jowling who have thin skin and little subcu-
taneous fat exhibit fat atrophy that reveals existing jowls
previously masked by superficial structures (Figure 4), in

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Figure 1. Subcutaneous fat compartments surrounding the mandibu-
lar border.
Platysma
Jowl Fat
Mandibular Septum
Figure 2. Descent of the superior and inferior jowl compartments.
Platysma
Jowl Fat
Mandibular Septum
Figure 3. Laxity or dehiscence of the mandibular septum leading to the formation of
jowls.
the same way that a low tide reveals a normally con-
cealed sand bar; this was previously shown by Lambros.6
Superior and inferior jowl fat compartment position
change is seen in patients with ptotic jowls (Figure 5).
Ptosis of jowl fat is apparent in cadaveric studies,4 and
subcutaneous compartment position change is supported
by the development of the submalar hollow accompa-
The Aesthetic Jaw Line: Management of the Aging Jowl
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Figure 4. Thin skin and volume loss through
atrophy reveals underlying jowls.
Platysma
Jowl Fat
Mandibular Septum
Platysma
Jowl Fat
Mandibular Septum
nied by ptotic jowls, suggesting a shift of volume inferi-
orly consequent to a change in position of a supporting
fat compartment.
The patient presenting with cascading fat across the
mandibular border represents the third theoretical mecha-
nism (Figure 6). Dehiscence of the mandibular septum
allows fat to flow across the jaw into the submandibular
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A B
Figure 5. Ptotic jowl fat representing displacement of the superior and inferior jowl fat compart-
ment. (From Rohrich et al,3 with permission.)

A B
Figure 6. Dehiscence or laxity of the mandibular septum might lead to a confluent fat mass
across the mandibular border, blurring its distinctive contour.

fat compartment. As the appearance of platysmal bands
and neck fat is thought to be associated with fascial dehis-
cence, similarly fat across the neck in a confluent mass
can blunt definition of the jaw line with dehiscence of the
mandibular septum. Identification of different jowl types
and the underlying theoretic cause suggests a method for
rejuvenating the jaw line that is mechanism-specific.
SUPPORTING EVIDENCE
In a retrospective review, 60 randomly selected photo-
graphs of the senior author’s preoperative aging face con-
sults were examined. Using the jowling classification
based on mechanism, patients were placed into 1 of 3
groups: jowling revealed by atrophy of subcutaneous tis-
sue and skin, ptotic jowling resulting from compartment
displacement, and confluent jowls produced by mandibu-
lar septum dehiscence. There was found to be a relatively
equal distribution amongst aging face consulting patients
(Table 1). Twenty-five patients representing approximate-
ly 42% of the group of randomly selected patients in the
senior author’s practice had thin skin and jowls revealed
by atrophic tissues. Eighteen patients (30%) showed

670 • Volume 28 • Number 6 • November/December 2008 Aesthetic Surgery Journal

Table 1. Mechanisms of aging in the lower face jowls resulting from fat atrophy may be corrected by
replacing volume in the region above the mandibular
Jowl Atrophy Compartment Septal
mechanism of tissue ptosis dehiscence septum, the sharp definition at the inferior margin of the
jowl.4 Dermal fillers or fat are also appropriate choices
Total (N = 60) 25 18 17
for rejuvenating the jaw line, as shown in Figure 8.
Percent 42% 30% 28% Ptotic jowls may be corrected with release of the
mandibular septum and superficial musculoaponeurotic
system (SMAS) elevation (Figure 9). Release of the
signs of ptotic jowls from the theoretical mechanism of mandibular septum is optimally achieved by sharp dis-
compartment displacement. Seventeen patients (28%) section from the angle of the mandible towards the men-
presented with confluent fat across the jaw line, repre- ton, 1 cm above the inferior mandibular border,
senting laxity or dehiscence of the septum. terminating with the release of the mandibular ligament.
The mandibular septum is adherent to the mandible and
MANAGEMENT OF THE AGING JAW LINE terminates with the mandibular ligament, which appears

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The management of jowling begins with analysis and to be a unified continuous structure.4 SMAS elevation
diagnosis. Diagnosis allows the plastic surgeon to treat reestablishes fat compartment position, rejuvenates the
jowl deformities with an algorithmic approach to define submalar hollow, defines the jaw line, and recreates the
the jaw line (Figure 7). Thin skin patients with minimal “ogee” curve of the youthful face.2

Jowling

Septum
Compartment
Fat Atrophy Displacement
Dehiscence
or Laxity

Manidbular
Mandibular Septum SMAS
Septum
Release Elevation
Release

SMAS SMAS Platysmal

Elevation Elevation Tightening

Platysmal Direct Excision

Tightening Jowl Fat

Figure 7. Algorithm for correction of the aging jaw line.

A B
Figure 8. A, Pretreatment view of a 62-year-old woman with jowl fat occurring secondary to vol-
ume loss. B, Posttreatment view 18 months after a lower SMAS plication face lift and autologous
fat compartment augmentation of the lateral mental hollow.

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A B

C D
Figure 9. A, C, Preoperative views of a 58-year-old woman with ptotic jowls as a consequence
of superior and inferior jowl fat compartment descent. B, D, Postoperative views 24 months after
release of the mandibular septum and superficial musculoaponeurotic system excision/advance-
ment face lift. (From Rohrich et al,3 with permission.)

The patient with cascading fat across the jaw line rep-
resents mandibular septum dehiscence and fat forming a
confluent amorphic mass. This is corrected by complete
release of the mandibular septum, SMAS elevation, later-
al platysmal plication, and sharp excision of fat from the
submandibular fat compartment. Complete release of the
mandibular septum is required in order to achieve cor-
rect redraping of skin and fat at the mandible. Elevation
of the SMAS repositions fat compartments to affect the
lower third of the face, as previously mentioned. Lateral
platysmal plication sweeps tissue posteriorly away from
the jowls, and sharp excision of submandibular fat
allows for final definition of the mandibular border
(Figure 10).

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A B

C D
Figure 10. A, C, Preoperative views of a 55-year-old woman with mandibular septum dehis-
cence and confluent neck fat. B, D, Postoperative views 15 months after release of the mandibu-
lar septum, superficial musculoaponeurotic system plication face lift, lateral platysmal plication,
and sharp excision of submandibular fat.

CONCLUSIONS tion—are best served by volume replacement. Ptotic

Jowling is a common problem that the plastic surgeon
must address in the facial rejuvenation consult. It is
among the most common complaint of patients, and
among the most difficult for which to attain long lasting
results. Accurate analysis is the cornerstone of jowl cor-
rection and an understanding of jowl anatomy guides
the plastic surgeon to harmonious facial rejuvenation.
Three patterns of jowling are presented and are theo-
rized to be caused by three different mechanisms. These
mechanisms were found to correlate to retrospective pre-
operative face consult photos.
Patients with thin skin and minimal jowls resulting
from volume deflation—the most common presenta-
jowls consequent to the changing position of jowl fat are
corrected with septum release and SMAS elevation and
were found approximately as often as confluent jowl fat.
Confluent jaw line fat is caused by septum dehiscence
with fat cascading across the mandible and was the least
frequently observed mechanism. It is best corrected in
additive fashion: septum release, SMAS elevation, lateral
platysmal plication, and direct excision of submandibu-
lar fat. Jowling with inferior migration probably occurs
secondary to volume deflation.5,6 However, it should be
noted that any of the theoretical mechanisms could
occur independently or additively to produce jowls.
Therefore, practicing plastic surgeons must accurately

The Aesthetic Jaw Line: Management of the Aging Jowl Volume 28 • Number 6 • November/December 2008 • 673
analyze the face and apply techniques to optimize reju-
venation in a stepwise fashion in order to avoid an over-
operated look and a swept appearance of the face. ◗

ACKNOWLEDGMENTS

The authors would like to thank Joel E. Pessa, MD, for his contri-
butions to this paper. His ideas form the foundation for this treatise
and without him it would not have come to fruition. We would
also like to thank Holly Smith and Stephen Brown for their help
with figures and illustrations.

DISCLOSURES

The authors have no disclosures with respect to the contents of this

article.

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REFERENCES
1. Yousif NJ. Changes of the midface with age. Clin Plast Surg
1995;22:213–226.
2. Little JW. Volumetric perceptions in midfacial aging with altered priori-
ties for rejuvenation. Plast Reconstr Surg 2000;105:252–266.
3. Rohrich RJ, Rios JL, Smith PD, Gutkowski KA. Neck rejuvenation
revisited. Plast Reconstr Surg 2006;118:1251–1263.
4. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical
observations of the jowls in aging-implications for facial rejuvenation.
Plast Reconstr Surg 2008;121:1414–1420.
5. Rohrich RJ, Pessa J. The fat compartments of the face: anatomy and
clinical implications for cosmetic surgery. Plast Reconstr Surg
2007;119:2219–2227.
6. Lambros V. Observations on periorbital and midface aging. Plast
Reconstr Surg 2007;120:1367–1376.

Accepted for publication June 25, 2008.

Reprint requests: Rod Rohrich, MD, Department of Plastic Surgery,
University of Texas Southwestern, 1801 Inwood Rd., Dallas, TX 75390-9132.
E-mail: rod.rohrich@utsouthwestern.edu.
Copyright © 2008 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$34.00
doi:10.1016/j.asj.2008.09.007

674 • Volume 28 • Number 6 • November/December 2008 Aesthetic Surgery Journal