A defined or ‘strong’ jawline is often cited as a desirable feature in a potential mate and, according to a 2021 study involving 50 men and 50 women, the chin is the facial feature that contributes most to our perceived view of facial attractiveness.1
Yet, a sagging lower face is an inevitable part of ageing. Everyone will experience a decline in collagen and elastin as they get older, while environmental and genetic factors can worsen jowling.
So why do the jawline and chin change as we get older? And what can you, as a medical aesthetic practitioner, do about it? Three practitioners share their advice.
Concerns and causes
Aesthetic nurse prescriber Lee Garrett, who works as the clinical lead at the Cosmetic Skin Clinic in London and Buckinghamshire, finds that many patients concerned with their jawline will comment on how much it has changed since they were younger. “They will share photographs in which their jawlines are much more defined and sharp,” he says, explaining that most want to regain that youthful contour.
Dr Dil Kassam, aesthetic practitioner and founder of The MediShed by Dr Dil in Wandsworth, adds that the 40+ demographic is most affected, with approximately 70% of her patients in that age group seeking lower face treatment. She notes that the increased use of video calling since the pandemic has really contributed to patients’ awareness of their sagging jawline.
So what causes this concern? Garrett explains that bone reabsorption, which occurs as we age, is the main factor, which leads to skeletal changes of the jaw itself. A decline in collagen and elastin also means that skin loses its firmness and tightness, so gravity then takes hold and causes it to descend on either side of the chin and along the jawline.2
Founder and medical director of Berkshire Aesthetics, Dr Selena Langdon, also treats patients with excess fat in the area. “We see patients across the age ranges; those who have a genetic predisposition to having a double chin, as well as those affected by hormonal changes,” she explains, adding that a double chin may not mean a patient is overweight.
The practitioners agree that assessing the patient carefully and, thus, selecting the most appropriate treatment for them as an individual, is imperative to successful results.
Injectable procedures can help build structure to an extent, but all practitioners interviewed recommend combining them with an energy-based treatment in order to boost collagen and re-contour the area for ultimate patient satisfaction.
Here we discuss three types of technology that have proven results and learn how they are best used in practice.
Ultrasound
Ultherapy – an ultrasound device – is Garrett’s go-to energy treatment for jowling. But before he gets started, examining the patient holistically is key. “I look at their diet, hormonal status, drug and alcohol use, and general lifestyle,” Garrett explains, ensuring he advises patients on healthy changes they can make prior to treatment. Garrett will then review how the patient sees themself in a mirror. “I get them to look down into the mirror so I can see what they see, to fully understand their concerns,” he says, which then helps him put together a multimodality treatment plan, involving Ultherapy, usually followed by treatment with the Belotero range of hyaluronic acid fillers.
The Ultherapy device uses advanced microfocused ultrasound energy to stimulate collagen production and tighten skin. According to research, 42% more collagen was produced in four weeks, while skin elasticity was significantly increased after 12 weeks. Ultherapy is FDA-approved and is suitable for all skin types, including darker skin tones.3
Garrett explains, however, that Ultherapy is unlikely to be effective in a patient who has a BMI of 30+ as it may not be able to reach the appropriate layer under the skin. Equally, he says that patients who are very slim without much tissue at all may not see a positive result.
When a patient is deemed acceptable for the procedure, Garrett will mark up the treatment area. “We avoid the nerves around the marionette lines as treating them can cause paralysis of the face,” he warns.
Using a gel-based applicator, Garrett will then perform the treatment. “In terms of pain, I would say it’s around five out of 10, but then some patients say they feel little, if anything at all,” he notes. It takes about an hour to treat the lower face and neck, and only one procedure is needed. “We’ll aim to treat again in around 18 months’ time,” says Garrett.
In terms of risk, Garrett explains that, as mentioned above, temporary paralysis can occur if you hit a nerve. He notes that patients could also experience pain if the treating practitioner hits a bone, which is why the visualisation that the device allows is so key to a comfortable treatment. “You can see the structures under the skin, which also maximises on patients’ results, says Garrett. Bruising is a common side effect of Ultherapy, but when bruises appear Garrett says they’re very faint and can be hidden with makeup straightaway, as the device does not break the skin.
For practitioners considering investing in a microfocused ultrasound device, Garrett reminds you that it shouldn’t be regarded as a standalone treatment. “For some patient indications, the results may not be the optimum outcome if you only use one treatment approach,” he says, emphasising the importance of addressing bone reabsorption, volume loss and collagen depletion through multiple treatment options.
Radiofrequency
Dr Kassam’s product of choice is Evoke. The bipolar radiofrequency device penetrates the subdermal layer and heats the fibro-septal network in order to remodel the dermis and subdermal tissue. It has two applicators – one for the face and one for the neck – which can both be used hands-free.4
“I am a big believer in the power of radiofrequency alone – especially if it is bipolar,” says Dr Kassam, who explains that Evoke can reach a depth of 5mm and offers really effective results. She adds that it can be used on any skin type and works well to improve skin laxity.
Again, patient selection is key, as some would benefit from other methods too. Evoke can be customised to a patient’s individual requirements, with adjustable patterns of treatment, depth of penetration and length of time it is administered for. Dr Kassam will generally offer 30-minute treatments to each area of concern, which are repeated three times, two weeks apart. She will review results three months later and finds that they can last six months to a year, with only maintenance procedures required after that.
Dr Kassam will advise patients not to do anything strenuous on the day of treatment; they can go back to their normal routines almost immediately, although they may experience a little redness from the pressure of the device.
As with any radiofrequency procedure, burns can occur so careful monitoring of the patient’s skin and device temperature is essential. “With Evoke there’s a stop button that kicks in immediately, offering plenty of reassurance if it does get too hot,” says Dr Kassam.
For the most effective results, Dr Kassam says skin optimisation is key. “Ideally, maintaining skin health is key to maximising results,” she says, advising that patients should be following an appropriate skincare routine alongside any aesthetic treatment you offer.
Cryolipolysis
Dr Langdon is an avid user of CoolSculpting. She uses the new Elite device, which launched last year, and has dual applicators available in seven shapes and sizes.5 Having undergone a complete redesign, Dr Langdon explains that the Elite device is now slicker, delivers results faster and has improved contours for a more comfortable treatment.
The device works by delivering precise controlled cooling that targets fat cells underneath the skin. The cells are frozen, destroyed and disposed of naturally by the body. Studies have indicated that the number of fat cells can be reduced by up to 27% after six months.6
Dr Langdon says that the non-invasive nature of the treatment appeals to patients, although there is still an assumption that it will correct all of their neck and chin concerns, which isn’t always true. “You’ve got to be the right candidate for treatment,” she says, explaining, “Skin laxity can cause the appearance of a double chin, so we need to educate them that this isn’t caused by excess fat and address each issue accordingly. While CoolSculpting does offer a degree of skin tightening alongside fat removal, it cannot be used solely for skin retraction.”
In Dr Langdon’s clinic, she has a CoolSculpting suite where patients can relax and watch Netflix while they undergo treatment. “We advise patients to come in makeup free and to wear comfortable clothes, although patients are offered a gown and slippers to ensure anyone coming during their lunch break or planning to head out afterwards can really come dressed however they want,” she explains, adding that she will also warn them that it can be a slightly uncomfortable procedure. Once the treatment area is marked out, Dr Langdon will begin the 45-minute procedure. Upon completion, she will massage the treated area for two minutes by hand to help break down fat. “Afterwards, patients can look a little bit red and swollen, but this will subside not long after. We will then share advice on the importance of massage and hydration following treatment to enhance results,” she says. In addition, Dr Langdon will advise patients to avoid anti-inflammatory supplements, foods and medications for six weeks following treatment, as they can suppress the body’s natural inflammatory process that is working to remove the damaged fat cells from treated areas.7
Patients usually have two rounds of treatment, six to eight weeks apart, before being reviewed 12 weeks later. “Having selected the right candidate, we can get some really lovely results,” explains Dr Langdon, highlighting that those with a healthier lifestyle generally see better results. “Even as early as six weeks we are seeing lots of changes with the new Elite system, which gives patients confidence in you and the technology,” she says.
In terms of side effects, Dr Langdon explains that the treated area may be a bit tender and have a little bruising, but nothing too excessive. “We usually say patients can go back to their normal activities straightaway; they don’t need to take any time off work and they can wear makeup,” she says. Patients can return to exercise the next day if they feel able to do so.
As part of her role as a CoolSculpting Advisory Board member and Allergan CoolSculpting Faculty & UK Complications Expert, Dr Langdon oversees any complications that occur in CoolSculpting clinics across the UK. She highlights that issues in the chin area are rare, but freezeburn injuries can occur. “This is often due to operator error or incorrect patient selection, such as when a patient doesn’t have enough fat to treat,” she explains. Post-inflammatory hyperpigmentation is another concern, so Dr Langdon always advises that skin preparation is key, while noting that if any hyperpigmentation occurs it can be treated with topical creams or Q-switched laser. As with the other devices mentioned, nerves can be damaged so, again, appropriate placement and assessment is essential.
And if you follow the news, you will be aware that CoolSculpting has received negative press recently as a result of former supermodel Linda Evangelista sharing her story of paradoxical adipose hyperplasia. The condition leaves the treated area feeling thicker and firmer, while hard lumps may develop and it may gradually grow in size.8 Dr Langdon notes, “There are other technologies and devices that can cause paradoxical adipose hyperplasia as have been reported in the literature, so it’s not just CoolSculpting. Allergan (Abbvie) are very supportive if a case is reported, and it is definitely something we are trying to understand more about. Like so many other complications we see, I do wonder if poor patient selection has an influence and the very action of trauma itself could be a trigger.”
Generally, Dr Langdon has found that complications are usually a result of the user. “For a very long time, I think practitioners have been under the impression that CoolSculpting is easy to perform – you just stick the applicator on and get lovely results. However, poor results or complications will occur if the practitioner doesn’t know how to select patients appropriately or how to utilise the device safely and effectively,” she warns.
Safety first
This sentiment is echoed by all three practitioners, who cannot emphasise enough that appropriate patient selection is key. “If you don’t have an appropriate treatment for them, then you shouldn’t be treating,” says Dr Langdon, highlighting that, “You’ll end up leading patients down a rabbit hole and they’ll be very disappointed at the end of it.” Dr Kassam adds that bad treatment will not only affect the patient, but your reputation too, emphasising, “Not wasting a patient’s time and money is extremely important.”
As discussed, the practitioners also stress the value of combination treatments, “A multi-modality approach will offer the most effective results,” concludes Garrett.
