Marionette Lines, the Pre-Jowl Sulcus and Jowls Why the Corner of the Mouth Ages First and What a Deep Plane Facelift Actually Lifts There

Ask a roomful of people over fifty which part of their face they would change first and a surprising share will point to the same small territory. It is the stretch of skin between the corner of the mouth and the edge of the jaw. A line runs down from each lip corner toward the chin. A small dent sits just ahead of the jaw. Below it, a soft bulge of tissue breaks the clean line of the lower face. People call these marionette lines, a pre-jowl sulcus and jowls, and they tend to blame all three on the same culprit, usually gravity or collagen loss.

Dr. William Harris, a double board certified facial plastic surgeon in Beverly Hills, sees the three features as separate problems that happen to be neighbors. Each has its own anatomy, its own mechanism and its own most reliable fix. A patient who treats the marionette line with filler while the jowl keeps sliding is applying the right product to the wrong structure, and a patient who expects a facelift to erase a line that is really a volume problem will be disappointed by the right operation. This guide separates the three, explains what each is made of, and shows where an extended deep plane facelift does the heavy lifting and where it needs help.

Three different failures that look like one

The first thing to understand is that the lower face is a layered system, and the three features come from three different layers failing in three different ways.

Marionette lines are creases. They form where the skin around the mouth is anchored down by the muscle beneath it, while the tissue on either side drifts and deflates. A crease is what happens when a fixed point sits between two moving areas.

The pre-jowl sulcus is a hollow. It is the dent that appears along the jaw just in front of the jowl, between the chin and the area where tissue has descended. The hollow forms because the chin and the front of the jaw lose support while the tissue next to them falls forward and down.

The jowl itself is a descent. Fat and soft tissue that once sat on the cheek and along the jaw line slide below the edge of the mandible and hang. A jowl is mass in the wrong place, not a crease or a hollow.

These three features can occur together, separately or in any combination. A thin patient may have marionette lines and a pre-jowl hollow with very little jowl. A heavier patient may have pronounced jowls with soft lines. The mix decides the plan, which is why a mirror and a good consultation matter more than a diagnosis made from a social media photo.

The corner of the mouth: why the marionette line forms where it does

Marionette lines get their name from the hinged look of a puppet's mouth. The visual effect is real, and it often makes a person look sadder or more tired than they feel, because the line pulls the corner of the mouth downward.

Several things combine to produce it. The muscle that depresses the corner of the mouth pulls downward every time a person frowns, speaks or chews, and over decades that repeated motion etches the skin. The tissue beside the line, in the cheek and along the jaw, loses fat and support. The skin loses elastic recoil. And the cheek fat that once sat high on the face descends, leaving the fold at the corner of the mouth with less buffering and more shadow.

It follows that a marionette line is only partly a skin problem. Treating the crease alone, with a smoothing filler along its length, can soften the shadow for a time. But if the line is deep because the surrounding tissue has dropped, filler placed in the line fights the downward pull with a column of product that has nothing to hold it up. Patients who have had repeated filler in this area often describe a stiff or heavy look around the mouth over time.

A lift that raises the descended tissue reduces the pull on the line, and the line becomes shallower because the tissue beside it is back where it belongs. This is the logic of treating the cause. The honest limit is that a deep, etched crease will not disappear entirely. It will soften, and many patients combine the lift with a small amount of fat or filler to polish what remains.

The pre-jowl sulcus: the dent that makes a jowl look worse

Patients rarely come in asking about the pre-jowl sulcus. They come in saying the jaw looks broken or interrupted. The sulcus is the reason. When the bulge of a jowl sits next to a hollow just ahead of it, the eye reads a bump and a dent, and the jawline looks uneven even if the total amount of tissue is modest.

Two structures create this effect. The first is a firm ligament that anchors the skin to the jaw bone at roughly the point where the chin meets the jaw. It is a fixed point that does not move as the tissue around it ages. The second is the soft tissue in front of and behind the ligament, which moves differently with time. The tissue behind the ligament descends and bulges as a jowl. The tissue in front thins and deflates. The ligament holds the skin down between them, and the dent is the result.

Releasing that ligament during a deep plane facelift is one of the main reasons the technique can improve jowls where a simpler lift does not. The earlier article on the retaining ligaments of the face explains why these anchors determine how freely tissue can be repositioned. If the ligament stays in place, the lifted tissue can only rise so far before it hits the anchor, and the hollow remains.

The sulcus is also where volume can matter. A hollow created by a combination of descent and thinning often looks best when the lift is paired with a small amount of volume restoration to the pre-jowl area and the chin border, so the jawline reads as a smooth continuous curve.

The jowl: why mass moves, and how the deep plane brings it back

Jowls are the feature most people think of first when they think of facial aging, and they are the one a facelift is best suited to correct. They form as the cheek's fat compartments loosen from their attachments, descend and drape over the jaw. The supporting layer of the face, the muscle and fibrous sheet called the SMAS, stretches along with them.

The way a surgeon addresses that layer determines what happens to the jowl. In techniques that tighten the SMAS in place, the layer is folded or trimmed and secured, and the skin is pulled separately. The lift works, but the tissue is anchored by the ligaments that tether it, so it can only move so far. In a deep plane facelift, the surgeon releases those tethering ligaments and lifts the skin and the SMAS together as a single unit, so the tissue can move upward and backward as a whole into its younger position. Dr. Harris describes his version as an extended deep plane, meaning a full elevation of the deep plane rather than a short release that carries the name without the substance. The comparison between layers is laid out in more detail in the article on deep plane versus SMAS facelifts and the windswept look.

For jowls specifically, the practical result is that tissue that had hung below the jaw is brought up and back, and the edge of the jaw is clearer. The lift is directed along a more natural vector than a pure sideways pull, which avoids the stretched, windblown expression that patients associate with an obvious facelift.

Where the mid-face joins the lower face, and why the order matters

The lower face does not age independently. The cheek fat that has descended into the fold beside the nose and deepened the marionette line came from higher up. If the mid-face stays low, the lower face is working against gravity with a heavier load on top of it.

Dr. Harris includes mid-face manipulation as part of his extended deep plane technique, which raises the cheek fat and lessens the drag on the lower face. This is one reason his approach differs from a procedure that works only on the lower face and jaw. The patient who wants less jowl may find that the jowl improves in part because the tissue above it is no longer pushing down.

For patients who are younger or whose descent is mostly confined to the lower face, a smaller operation may be appropriate. The practice's overview of the mini facelift explains who that approach fits, and the broader facelift page describes the range of options. The judgment is made on examination. The surgeon is asking how far the tissue has traveled and which layers are involved.

What patients in their forties, fifties and sixties usually see

The same three features show up at different ages in different proportions, and the timeline helps explain why consultations in each decade feel different.

In the forties, the first change is usually subtle. A faint line begins at the corner of the mouth, and the edge of the jaw loses a little of its crispness. Descent is mild, and many patients in this group do well with a smaller lift or with volume support. The article on facial aging by decade walks through how these early changes progress.

In the fifties, the jowl becomes visible in photographs, the pre-jowl hollow appears and the marionette line deepens enough to stay visible at rest. This is the age at which most patients seriously consider a deep plane lift, because the tissue has descended far enough that repositioning it produces a clear difference.

In the sixties and beyond, skin quality and bone support become bigger factors. The skin is thinner and less elastic, the jaw and chin bone have remodeled, and descent is more advanced. A lift still does a great deal, but the plan often includes more attention to volume and to the quality of the skin, and the results are best described as a restoration of structure and a softening of lines, not a return to youth.

The part behind the ear and under the jaw that rarely appears in brochures

The jowl line is also shaped by structures that most patients never see on a diagram. Dr. Harris describes several steps in his approach that address the transition between the jaw and the neck.

Work at the mastoid crease behind the ear helps give depth to the angle of the mandible, so the jaw looks more defined when viewed from the side. Reduction of the submandibular gland, the salivary gland that sits under the jaw, is a step many surgeons avoid because of the risk and the extra time it takes. When the gland is enlarged or prominent, leaving it in place can blunt the jawline no matter how well the skin is lifted. Dr. Harris has extensive experience operating around this gland from his head and neck surgery training, which is why he includes it where the anatomy calls for it. Reduction of the digastric muscle, a band beneath the chin, is another step that is often skipped but can help define the junction of the chin and neck.

In addition, he uses netting sutures, an internal suture technique designed to reduce bleeding risk and help hold the tissue in its new position. He also incorporates PRP during the facelift, and he is particular about how fat is prepared and placed when grafting is part of the plan.

None of these steps is dramatic by itself. Together they are part of why one deep plane facelift is not the same as another, and why it is reasonable for a patient to ask a surgeon exactly which components are included. Patients curious about how the platelet-rich plasma step works can read the practice's discussion of PRP during a facelift.

The neck is part of the same line

The jaw does not end where the jowl ends. The edge of the jaw continues into the neck, and a lower face that is lifted while the neck is left alone will often look unfinished, with a clean jawline above a soft, hanging area below. Many deep plane facelifts therefore include work on the neck as part of one coordinated plan, and the practice's neck lift page explains the options. In patients whose main problem is the neck and who have little descent in the lower face, an isolated neck procedure can be the better fit. The choice depends on where the tissue has moved.

When fat belongs in the plan

A lift repositions tissue. It does not add what time has taken away. In the lower face, the most common missing ingredient is volume in the right place: the front of the jaw, the area beside the chin and sometimes the tissue just outside the mouth.

Fat grafting is a natural partner to the lift. Dr. Harris performs micro and nano fat transfer, and the practice's page on facial fat transfer explains the approach. Grafting works best when it supports the new position of the tissue instead of trying to do the lifting itself. A small amount of fat placed along the pre-jowl border and at the chin line after the lift can smooth the transition and soften a residual marionette crease.

The question of when fat or filler alone is enough, and when it signals that a lift is the real answer, is covered in the article on facial fat transfer versus filler. The general principle holds in the lower face: volume can disguise early descent, but once the tissue has moved, volume alone starts to look like a stuffing exercise.

A caution about removing fat from a face that is already thinning

Another route to a hollow lower face is the removal of fat from the cheeks earlier in life. Buccal fat removal creates a lean look in the twenties and thirties, and in some patients the loss shows up years later as a gaunt midface, deeper lines at the corners of the mouth and a heavier appearance to the jowls by contrast. The practice has written about this pattern in its article on buccal fat removal regret. For patients who carry that history, a facelift alone may not be enough, and volume restoration may be a larger part of the plan.

Weight loss has a similar effect. Rapid loss deflates the face, and the tissue that remains is looser. A patient who has lost significant weight and now sees marionette lines and jowls may have a different mix of problems from one whose weight has been stable, and the treatment has to account for that.

Why more filler in the lower face often ends in a heavier look

It is common to meet patients who have been treated with filler along the marionette lines and jawline for years. The first sessions often produce a nice improvement. Over time, the product accumulates or migrates, and the lower face becomes broader and heavier. The mouth corners look softer but the face loses definition. Those patients often describe the feeling of a face that is slowly widening.

The mechanism is simple. Filler adds mass to a region that is already losing structural support. The extra weight pulls the tissue down further, and the jaw line blurs. When a lift is eventually chosen, the old filler has to be considered and sometimes dissolved first, a topic the practice has addressed in its article on what happens to old filler when a facelift is done.

This does not mean that filler has no place around the mouth. A small amount in a patient with early marionette lines and no descent can be a perfectly reasonable choice. The point is that filler is a tool for a deficit, and descent is not a deficit. Dr. Harris's stated aim in his work is to restore patients to how they looked at an earlier point and not to create features they never had, and that principle argues against over-treating the area with product.

The role of the upper lip and the lower face as a unit

Patients who focus on the corners of the mouth sometimes overlook the length of the upper lip. A long upper lip, or one that has lengthened with age, adds to the downturned look and can accentuate the marionette line by making the mouth appear to droop.

A lip lift shortens the distance between the nose and the upper lip and can restore the show of the upper teeth at rest. It does not replace a facelift, because it does not address the descent of the cheek or jowl, but the two operations complement each other. A patient who has a long upper lip, marionette lines and mild jowls may find that a lift of the lower face combined with a lip lift produces a more balanced result than either alone.

What non-surgical options can and cannot do

For patients who are early in the process or who are not ready for surgery, non-surgical tools can help at the margins. Radiofrequency and similar energy treatments tighten skin and can improve fine laxity along the jaw. The practice offers XERF™ treatment for skin tightening, and the logic behind its use is covered in its own article. Skin tightening improves texture and mild looseness. It does not reposition fat or release a ligament, so a true jowl will not reverse.

Biostimulating injectables such as Sculptra build volume gradually and can support the pre-jowl and chin region in patients whose main issue is deflation. Neuromodulators can relax the downward pull of the muscle at the corner of the mouth in selected patients, reducing the repeated etching of the line. Each of these has a legitimate role, and none replaces the lift when descent is the main problem.

Patients choosing among these options may be interested in the article comparing a med spa with a surgeon's office for Botox and filler, which explains how the assessment differs.

What recovery looks like and when the lower face looks its best

The lower face is where patients first notice recovery. Swelling and bruising along the jaw and neck are visible, and the skin may feel tight. The existing extended deep plane page states that patients can be restaurant ready after about two weeks and look their best at two to three months. The procedure does not require an overnight stay, though someone should stay with the patient for the first one to two nights.

Surgery is performed at an accredited surgical center in Beverly Hills, and Dr. Harris operates on one full-face rejuvenation case per day, which he considers important for the time and attention each patient receives. He also sees patients personally for follow-up visits in the first week to ten days, which is more frequent than many practices, and patients have access to him directly. The detailed day-by-day picture is in the deep plane facelift recovery timeline, which is among the most visited pages on the site.

Results from the extended deep plane typically last between ten and fifteen years, according to the practice, with the understanding that everyone continues to age. The marionette line and jowl do not return to where they started, because the tissue has been repositioned, but time continues to pull gently on the face.

Incisions, scars and why the lower face still looks natural

Patients often worry that a lift strong enough to improve the jaw line will leave visible scars or a pulled look. The incision pattern and the direction of the lift matter more than the amount of tightening. Incisions are placed in and around the natural contours of the ear and hairline, and the tissue is repositioned along the direction in which it descended, which is up and back, instead of being pulled sideways. The practice's discussion of facelift scar placement explains how incision choices affect what is visible later.

The goal, as Dr. Harris frames it, is a refreshed version of the patient and not a different face. Patients should still look like themselves, only rested, as if ten or fifteen years had been quietly taken off. That aim shapes how much is lifted, how much volume is added and what is left alone.

Reading your own lower face before a consultation

A few minutes with a mirror and a phone camera can sharpen a consultation.

Stand in front of a mirror in good light with the face relaxed. Place the heel of each hand on the cheeks, and gently lift the tissue upward and slightly back toward the ears. If the jowl and the marionette line soften significantly, descent is a major component, and a lift is likely to help. If the line stays deep while the jowl lifts, the crease has a volume or skin element that may need supplemental treatment.

Take photographs from the front, from a three-quarter view and from the side, with a relaxed face and with a gentle smile. Photographs from ten years ago show where the tissue used to sit, which is useful for a surgeon whose aim is to restore a person to how they used to look. Notice what bothers you most, because the order of priorities affects the plan. A patient who dislikes the corners of the mouth most may need a different emphasis than one who dislikes the jaw line.

Men and women both develop these changes, though men often carry more weight in the jowl area and have thicker skin and a beard line to consider. The same general principles apply, with surgical planning adjusted for hair patterns and skin thickness.

Questions that separate a thorough plan from a generic one

When meeting a surgeon about the lower face, a handful of questions are worth asking. Which layer will be lifted, and are the retaining ligaments released? How is the mid-face included in the plan? What happens to the area in front of the jowl, and will volume be added? How is the neck handled, including the structures under the jaw? What combination of procedures does the plan assume, and what does the surgeon recommend leaving out?

Dr. Harris trained in head and neck surgery and completed a facial plastic surgery fellowship with extensive focus on deep plane techniques, and patients can read more about him on his biography page. Before and after photographs of deep plane patients, including the lower face, are in the deep plane facelift gallery on the site. Patients who cannot visit in person can begin with a virtual consultation.