Aesthet Surg J. 2024 Oct 15;44(11):1131-1139. doi: 10.1093/asj/sjae151.
The exact relationship between the jowl and the mandibular ligament and causes for jowling remain 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. The aim of this paper was to clarify the anatomy and aging around the prejowl sulcus and the mandibular ligament and review our experience with its management in facial rejuvenation. 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 facelift with those who solely underwent fat grafting of the prejowl sulcus with facelift. Blinded surgeons graded 25 patients who had undergone mandibular ligament release and 25 patients who did not. Patient photographs were scored on a 1 to 4 graded scale of correction on the degree of jowling and prejowl sulcus depth and color. We also performed a literature review to describe the anatomy of the mandibular ligament and its implications for jowls, and techniques to address it in facial rejuvenation. 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 than those who had a mandibular ligament release without fat grafting (P = .046). Adverse sequelae were also lower in the group with less skin dissection around the mandibular ligament. 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 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.
中面部韧带与下颌韧带之间的确切关系以及导致下颌松弛的原因在文献中尚不清楚。导致下颌松弛的解剖学基础是多因素的，并且对下颌韧带和下颌前皱襞沟的描述存在差异，导致其处理方式也存在差异。本文旨在阐明下颌前皱襞沟和下颌韧带周围的解剖结构及其在老化过程中的变化，并回顾我们在面部年轻化中处理该部位的经验。我们对一家高容量私人诊所的患者进行了回顾性盲法研究，比较了在面部提升术中在皮下平面行下颌韧带松解术的患者与仅行下颌前皱襞沟脂肪移植术联合面部提升术的患者。盲法手术医生对 25 例行下颌韧带松解术的患者和 25 例未行该手术的患者进行了分级。根据患者下颌松弛和下颌前皱襞沟深度和颜色的改善程度，对患者的照片进行了 1 到 4 分的分级评分。我们还进行了文献回顾，以描述下颌韧带的解剖结构及其对下颌松弛的影响，以及在面部年轻化中处理该问题的技术。与未行脂肪移植术且仅行下颌前皱襞沟或下颌韧带周围皮肤松解术的患者相比，行脂肪移植术且少量或不松解下颌前皱襞沟或下颌韧带周围皮肤的患者，其术后照片中下颌松弛的改善程度更大（P =.046）。在未行下颌韧带松解术且仅行脂肪移植术的患者中，手术相关不良后果也较低。我们的研究结果支持这样一种理论，即下颌前皱襞沟的束缚和凹陷外观更可能是导致皮下软组织萎缩的原因，而不是韧带挛缩的结果。脂肪移植术的容量填充为问题的根本原因提供了更直接的解决方案，并且风险更低，效果更广泛。如果需要，外科医生应考虑行脂肪移植术联合或不联合随后的皮下松解术。
