Dr Laurent Benadiba
A sagging oval means sagging in the lower face along with the appearance of jowls. Over time, the V of youth is inverted and becomes a V of old-age, with jowls and cheek ptosis.
Demands according to gender
Patients often ask us to make their oval look good again, because it is associated with several other signs of aging, such as expression lines (marionette lines), a receding chin, a crumpled chin, a saggy neck, platysma cords and excess fat in the neck. These can all be improved by rejuvenating the oval. Men and women do not suffer from the same signs of aging. In women, the skin quality changes with the menopause and it is often at this time that women ask for some rejuvenating procedures. The skin becomes thinner and weight fluctuations affect the face and make the jowls, lines and sagging in the oval look worse.
In men, facial aging tends to appear later and their requests are often linked with a desire to look more “masculine” by strengthening the jaw or correcting a weak chin, or it might be excess weight, a fat neck and a double chin that causes them to seek help.
Fillers: Filler injections cannot lift the jowls, but can camouflage them. It is therefore a useful technique to employ in the early stages and allows us to hold off surgery, which is the only way of lifting the sagging skin and muscles that create jowls. The theory is straightforward: inject hyaluronic acid in front and behind the jowl to make a more horizontal jawline. We might also inject into the expression lines, any tension points on the jaw and the mandibular angle, as well as the jaw itself to make it more defined and give a natural rejuvenating effect.
Radiofrequency: This acts by heating up the skin in a focalised way, which stimulates collagen production and gives a firming effect after several weeks. Depending on the machine used, one to several sessions are required. The treatment is more uncomfortable than painful, it requires no downtime and can be coupled with other local treatments.
HIFU: High Intensity Focused Ultrasounds. HIFU can improve the lower face and the area under thechin. The heat produced by the HIFU acts upon the collagen fibres, which retract, leading to an immediate tightening effect. Then, gradually, the body makes new collagen which restores the skin’s support structure.
Liposuction: We can suck out the fat from underneath the chin, usually under local anaesthetic. The best thing about neck liposuction is that it causes the skin to tighten, which improves the area’s appearance even when just a little fat has been removed. This liposuction can be carried out on its own or combined with a neck lift, which tightens up the muscles and removes any excess skin. Remember that fat is stored underneath the skin but sometimes underneath the muscle too. In this case, more invasive surgery is required, with an incision underneath the chin that enables us to rehang the excess skin (turkey neck).
Today, Renuvion or J-plasma, a revolutionary new technology, allows us to avoid performing a lift, with its resulting scars, by tightening up the skin after liposuction (see below).
Tensor threads: Like their name suggests, these have a ten-sing effect rather than a lifting effect. They allow us to tighten up the skin in cases of mild sagging and can be combined with other localised techniques (HIFU, liposuction, etc.). In practice, they can be used on the oval if we have only a little or no excess skin. 2 to 4 threads are usually required per side to improve the jowls. However, they are not recommended for the neck because it is difficult to tighten up a curved area of skin, such as the neck, using threads: we risk unsatisfactory results on the midline, and the threads might even be visible if the skin is very thin.
Botulinum toxin, the “Nefertiti lift”: Originally described by a French doctor as a “Nefertiti lift”, this procedure is named after the famous Egyptian queen, the archetype of female beauty, who had a perfect oval-shaped face. The idea is to reduce the platysma muscle’s contractions using botulinum toxin. When it contracts, the lateral fascicle of the platysma muscle pulls the sagging cheek tissues downwards.
Over time, this muscle becomes stronger when it is at rest and the lateral platysma becomes shorter and no longer creates the cervi-co-mandibular support angle, which makes the submaxillary gland drop. The oval of the face is therefore altered and jowls appear. We inject a few drops of toxin along and underneath each mandible and on the upper part of the lateral platysma cords. We should also inject the DAO when we inject the subjacent lateral platysma because the motor plates stretch right up to this point. If the treatment is effective, the edge of the jaw will be better defined and the oval of the face will look better.
Cervicofacial lift: Lifts still scare people because they are often synonymous with a visible change, taut skin, a deformed mouth, etc. Modern face lifts are nothing like the aggressive techniques performed over the last 20 years. They are tailored to the patient and their age. The action is always a mixed one: tightening up the muscles, rehanging the skin, and rebuilding any loss of fatty volumes, if required. The operation can be carried out under sedation and local anaesthetic, and even in outpatient surgery. The after-effects are mild, with the patient back to normal after 8-10 days. It makes the oval look youthful again and keeps it that way for several years. Nowadays, you can have up to three face lifts over your lifetime. Each time, the procedure is adapted to your age and how your face has aged, which is why it is lighter.
Renuvion or J-Plasma: This new, revolutionary technology uses radiofrequency coupled with helium gas to tighten the skin without scarring. Often used on the body (belly, thighs, arms, etc.), Renuvion can now be used on the neck and oval of the face. It can be carried out under local anaesthetic and may be coupled with liposuction to deal with any excess neck fat. The firming effect is almost immediate and the patient is back to normal after 48 hours. The oval of the face is a symbol of youth, and we can now preserve it as long as possible through a combination of light medical procedures, which are becoming more and more in-novative and effective. When the sagging or jowls become too severe, “tailored” sur-gery can offer an effective and long-lasting solution.
Dr Laurent Benadiba: Plastic surgeon in Paris and Geneva. Qualified in Plastic, Reconstructive and Aesthetic Surgery over 20 years ago. Teaches Aesthetic Medicine at the Paris medical faculty and is co-supervisor for the DUTIC and DUMEG diplomas.