Facing up to ageing in the ‘lower third’

While the upper face receives its fair share of aesthetic attention, the ageing process is equally, if not more, unkind to the lower third. Most will be well aware that we have long possessed reliable treatments to improve the appearance of age- and disease-related changes through the upper and mid face. Skin care, muscle relaxants, soft tissue fillers, lasers and light all work well  to improve the issues presenting in these areas of the face:  skin texture, colour and vascular changes; expression lines and furrows;  soft tissue volume loss and scars.

The lower face is, however, an entirely different ball game.  At our clinic we jokingly refer to the area encompassing the mouth, chin, jawline and jowls as the Bermuda triangle, for many a therapist has lost their way attempting to negotiate safe passage through the challenges this region presents. Call it what you will, there is no denying the lower third of the face is one of the most challenging areas of the face in which to face and stave off the ravages of time and lifestyle.

Certainly, many of the conditions mentioned in relation to the upper facial zones are equally present in the lower face. But ask any individual regarding lower facial concerns, and skin laxity is first off the tongue.  This laxity is perceived in various ways, and is generally thought by the public to relate to a stretching and sagging of the skin. This is partly true, but most of the changes in this region of the face relate to a combination of factors, with a loss of supporting soft tissue and bone loss being the most important.

It is equally important to realise that, like Atlas carrying the world on his shoulders, so too the lower face carries the weight of the zones above it when they fail. As their collapse and changes weigh heavily upon the lower face, it must therefore be assessed as a whole. Successful improvement of the lower face will often derive from careful targeted treatment of the areas above it.

So, to answer the question ‘What about the lower face?:

1. Think deeply. Literally. Think of the deep supporting structures and how best to conserve and replace them.
2. Remember to look up. Assess the anatomical zones higher up in the face for remediable factors contributing to a cascade of failing structural support that flows downhill to become most obvious in the lower face. An example is temple and mid face volume loss. This is quick to contribute to deep nasolabial folds, drooping of the angles of the mouth, an ill-defined jawline and sagging of the jowls.
3. Adopt a multi-modality approach to address the various layers of the face. Work from the inside out and outside in.
4. Don’t forget prevention. Engage in a healthy balanced lifestyle, free from extremes and known evils such as recreational drugs, alcohol and smoking. Cleansing and moisturising are mainstays. Remember that sunscreen is important for the lower face as well; despite the tendency to only apply this to the forehead, nose and cheeks. Men may be afforded additional protection by their facial hair; but women and clean- shaven men are encouraged to consistently apply sunscreen to the lower cheeks, chin, jawline (and neck) to prevent future regrets.

Let us now consider the common issues presenting in the lower face and how best to remedy them.

1. Perioral lines: Otherwise known as smoker’s lines, barcode lines and lipstick bleed lines. Use soft tissue filler to support the lip margin. Picture creating a strong curtain rod to better support the skin of the lip such that it is less likely to crumple and fold. Fine filler may also be used to efface the fine lines themselves.
2. ‘Sad clown’ drooping of the corners of the mouth: Not only is this visually displeasing as it gives the impression the subject is always morose and down; there may also be a functional consequence with collection of spittle, food and other debris in the corners of the mouth. This unfortunate change may be remedied with careful placement of appropriate filler substance to support the corners of the mouth, and if appropriate to replace the supporting mid-face volume in the region above. Wrinkle relaxants may also help to relax overactive muscles anchoring the corners of the mouth.
3. Lateral cheek lines: Also known as accordion lines and marionette lines; these are often the fading tribute to previously youthful dimples and cheeky smiles. They are exacerbated by hypermobility and loss of soft tissue substance as well as bone support in the cheekbone region. Appropriate intense moisturising and active skin care, together with soft tissue filler placement, fractionated erbium and CO2 laser, radiofrequency (RF) and ultrasound (US) can be very helpful. Advanced practitioners may also consider judicious use of muscle relaxants in advanced cases. This should only be administered in small doses as any excess muscle paralysis may have dire consequences for the individual’s smile and mastication.
4. Hypermobile chin: The ‘wobbly jelly chin’ that adds a weak, quizzical and frustrated flavour to facial expression. Muscle relaxants are a quick initial fix. Soft tissue fillers represents the best long term solution as it addresses the underlying cause through replacement of lost soft tissue and bone mass at the chin.
5. Mental (chin) crease: This deepens over time due to the rotation of the jaw upwards as a result in changes in dentition and bone resorption with age. Once again muscle relaxants are a quick fix, but replacement of underlying structural support with soft tissue filler substance and dental work is the key.
6. Jawline laxity and sagging jowls. As described above, this dreaded change starts with loss of structural support in the upper and mid face, and is compounded by loss of ligamentous and bony support along jawline and through the area in front of the ear. It is very easy to throw one’s hands up helplessly when confronted with advanced changes in this area as it can be hard to know where to start. But truly this is an area where the comment ‘You will need a facelift for that’ very much short-changes our patients. In fact we are increasingly seeing patients encouraged by GPs and plastic surgeons to attend for consideration of pre face-lift skin tightening. The results can be so impressive when a carefully structured, multi-pronged and layered approach is deployed, that this surgery is often deferred; in many cases indefinitely so. Correct soft tissue filler placement to replace lost support is essential and micro-focussed deep tissue ultrasound is a recent and striking advance.

We hope that with a little thought and planning, the Bermuda Triangle of the lower face will be rendered a welcome destination for you!

• Dr Sheridan is a dermatologist specialising in Mohs micrographic surgery and medical lasers.Visit www.sdsl.com.au