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V line surgery is a well known technique of reductive contouring of the lower third of the face. It is based on reducing the size of the lower jaw from front to back with more bone removed at the jaw angles than at the chin. There are several different types of v line surgery but in its traditional form there is removal/amputation of the lower jaw with the most bone being removed at the jaw angle area with a near 45 degree cut

While the procedure is very effective at changing the lower third of the face to a more tapered shape, there is a tradeoff for the removal of a back part of the lower jaw. Soft tissue sagging along the jawline, otherwise known as jowling, can occur. While this is rarely a large amount of bowling, by facial aging appearances in older patients, jowling that occurs in the young face is seen as significant.

There are numerous non-surgical energy-based skin tightening devices as well as thread lifting techniques that are available to try and improve the jowling. In a young person with good skin elasticity these are reasonable approaches to try  first. But if ineffective or the patient wants go right to the most assured solution a facelift is the procedure.

There are many different types of facelift techniques but the goal in any facelift is to not do more than is needed. This is why the jowl tuckup or more limited facelift is often touted for this type of iatrogenic facial tissue laxity. While the general concept is that extensive or deep plane facelifts are not needed to the bowling I would also be cautious about not doing enough. For this reason the most effective approach is a SMAS short flap technique. This addresses the root cause of the laxity front the jaw angle reduction.

But it is also important to appreciate that the length of the incisions in and around the ear is also going to affect the degree of jowling improvement.To keep the preauricular tuft of hair and the temporal hairline from being elevated a blocking approach to the anterior incision is often needed. Whether it be female or male the preauricular incision should be retrotragal. (behind the tragus) There almost always  has to be a postauricular (behind the ear) incision with some degree of backcut which stops at the edge of the occipital hairline.

Not every V line surgery patient will experience sagging along the jawline…but many do. This is not anatomically surprising given that the jawline acts as a solid line of separation of the face from the neck. When some of that support is reduced the overlying soft tissues will drift downward, exactly what happens with age-related aging which occurs for a different reason. (loss of tissue elasticity.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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