Mandibular Ligament and the Prejowl Sulcus Explained

Abstract Background The exact relationship between the jowl and the mandibular ligament as well as causes for jowling remains unclear in the literature. The anatomic basis for the jowl is multifactorial and disparities in descriptions of the mandibular ligament and prejowl sulcus have resulted in variations in its management. Objectives The aim of this paper is to clarify the anatomy and aging around the prejowl sulcus and the mandibular ligament and review our experience with its management in facial rejuvenation. Methods We performed a retrospective blinded review of patients in a high-volume private practice comparing patients who underwent mandibular ligament release in a subdermal plane during facelifting versus those who solely underwent fat grafting of the prejowl sulcus with facelifting. Blinded surgeons graded 25 patients who had undergone mandibular ligament release vs. 25 patients who did not. Patient photographs were scored on a 1-4 graded scale of correction on the degree of jowling, prejowl sulcus depth and color. We also performed a literature review to describe the anatomy of the mandibular ligament and its implications in jowls, and techniques to address it in facial rejuvenation. Results Patients who had fat grafting with minimal or no release of the skin around the prejowl sulcus or mandibular ligament had a greater degree of correction of their jowls in their postoperative photographs compared to those who had a mandibular ligament release without fat grafting (p=0.046). Adverse sequelae were also lower in the group with less skin dissection around the mandibular ligament. Conclusions Our findings support the theory that the appearance of tethering and depression in the prejowl sulcus is more likely the cause of atrophy in the subdermal soft tissues rather than a consequence of ligamentous contracture. Volumetric replenishment with fat grafting provides a more direct solution to the cause of the issue, providing more universal improvements with less risk. Surgeons should consider volumetric fat grafting with or without subsequent subdermal release if needed.