Rejuvenation of the lower face often involves treatment of the submentum and the jowls. Energy-based devices such as lasers, radiofrequency, radiofrequency microneedling, CoolSculpting, and ultrasound have been used in the tightening of the neck and jowls.

A patient before and after three deoxycholic acid treatments of the jowl overhang.A patient before and after three deoxycholic acid treatments of the jowl overhang.

However, the only noninvasive injectable treatment approved for the reduction of submental fat is deoxycholic acid (Kybella). The mechanism of action of deoxycholic acid has been documented as adipocyte lysis, followed by a local tissue response with neutrophil infiltration, septal thickening, neocollagenesis, and neovascularization within the subcutaneous layer, with no adverse changes in the dermis or epidermis. This treatment, which has a dose-dependent response, is highly effective for submental fat reduction and jaw contouring.

In my practice, I have found that multiple consecutive treatments with deoxycholic acid (an off-label use) are effective in permanently reducing the jowl overhang with minimal adverse effects.

Jowl fat is a common cause of sagging of the jowls, and there are few alternatives to treatment with surgery or liposuction. Jowl overhang results from multiple factors related to aging, including skeletal resorption, subcutaneous atrophy, superior and inferior fat pad compartment displacement, or mandibular septum dehiscence, which allows for the accumulation of fat pockets to migrate into the neck.

A prospective study published earlier this year describes results in 66 adults with excess jowl fat, who were treated with 2 mg/cm2 of deoxycholic acid. Injections were done in patients with “pinchable fat on the jawline” and “relatively” minimal skin laxity of 0.2 mL spaced approximately 1 cm apart or 0.1 mL spaced 0.5 cm-0.75 cm apart; the mean injection volume was 0.8 mL. After 6 months, 98% of the patients experienced improvement with a mean of 1.8 treatments. Common injection site adverse events included edema, numbness, tenderness, and bruising.

In my experience, injection volumes from 1.0 mL to 1.5 mL of deoxycholic acid can be used in each jowl with minimal adverse events if proper landmarks are followed. It is crucial that the correct patient is selected (one with minimal skin laxity), and that during injection, the fat and skin are pinched away from the underlying musculature and neurovascular structures to avoid injection near the marginal mandibular nerve. Volumes less than 1.0 mL have minimal visible improvements and will require more than 3-4 treatment sessions for optimal results.

Jowl contouring with deoxycholic acid (with or without treatment of the submental fat pads) should be considered in the treatment options for lower face rejuvenation. I often see a marked improvement in patients who present prominent marionette lines who have been unhappy with fillers in the lower face. Often, the marionette lines are a result of significant overhang from jowl fat and hyaluronic acid fillers are a temporary and often unsatisfactory treatment option. The use of deoxycholic acid in the treatment of the jowl fat is a highly effective option to minimize the appearance of marionette lines caused by displaced fat pockets in the aging lower face.

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