Can Deep Cheek Fat Around the Mouth That Rapidly Sags from the Late 30s Be Restored with Lasers?

Hello, this is Bellevue Clinic. Many people experience the area beside the mouth becoming bulged like bulldog jowls from their late 30s, along with deeper nasolabial and marionette lines. When people ask whether this can be restored with lasers, the conclusion is that it can be improved considerably with laser treatment, but it may be difficult to see results if the cause is misidentified. Today, we will explain this in detail.

Rapidly Sagging Deep Cheek Fat Around the Mouth from the Late 30s

Natural Beauty Bellevue Clinic

1. Why Does Deep Cheek Fat Around the Mouth Sag Particularly Rapidly in the Late 30s?

At a glance, there are terms that are often confusing because they may seem either identical or different. Examples include deep cheek fat, jowls, and marionette lines.

First, let us look at the relationship between deep cheek fat and jowls. As the ligaments supporting the deep cheek fat stretch, the fat flows downward and gathers as a bulge along the jawline beside the mouth. This is commonly called a “jowl” or “bulldog fat.”

Then what is the relationship between jowls and marionette lines? When the jowls—the mass of fat—sag and gather downward, a shadow forms along the boundary with the areas where the skin is fixed, creating a deep vertical groove. This indented line is the “marionette line.”

Category	Deep Cheek Fat (Bichat's Fat Pad)	Jowls (Bulldog Fat / Jowl)	Marionette Lines
Concept	Anatomical tissue that is a structural cause	A bulging “mass of flesh” caused by sagging fat	A “groove/wrinkle” formed between sagging tissue and the surrounding tissue
Location/appearance	A mass of fat deep inside the cheek, on the inner side of the muscles—a plump tissue beside the mouth in the central face, as if holding candy in the mouth	Bulging tissue protruding along the boundary from beside the corner of the mouth to the jawline; tissue that feels as though it has sagged downward beside the mouth	A vertical, indented wrinkle extending from the corner of the mouth toward below the chin
Analogy	A sandbag spilling downward	A rounded mound formed where the bag has dropped and accumulated near the jawline	A deeply indented, shadowed valley right beside the mound

To find a solution for sagging deep cheek fat around the mouth, we first need to understand the cause. This is not simply a matter of the skin surface becoming stretched. Three structural changes occur simultaneously.

[1] Weakened Support from the SMAS Layer

The mesh-like fascial layer beneath the skin that supports the fat and muscles becomes loose and sags in the direction of gravity. The SMAS layer acts as a “natural corset” that anchors the skin and fat to the bones. As people enter their late 30s, the bands of this corset lose their elasticity and stretch. As a result, the entire skin structure resting on top can no longer resist gravity and settles downward as if sliding.

[2] Loosening of Retaining Ligaments and Descent of Fat

The deep fat pad inside the cheek (Bichat's fat pad) and the subcutaneous fat are pulled downward and gather above the corners of the mouth, along the marionette lines. Deep cheek fat (Bichat's Fat Pad), located deep within the cheek, is firmly anchored toward the front cheekbones when we are young, creating youthful fullness. However, when the retaining ligaments weaken, it slides downward and gathers beside the corners of the mouth, as if propping up the chin with the hand. This gathered tissue is a primary cause of “marionette lines and jowls.”

[3] Sharp Decline in Dermal Collagen

As the dermis becomes thinner, the outer skin can no longer support the weight of the fat flowing downward. If the skin of your 20s is like taut tent fabric, the dermis in the late 30s is like fabric that has become thin. As the internal support structure collapses, the outer skin cannot withstand the weight of the heavier fat and sags downward along with fine lines.

2. A Common Mistake When Receiving Laser Treatment: “Insisting on a Single Treatment”

Sagging deep cheek fat is a combined problem involving the “weight of the fat” and “loosening of the fascia.” Therefore, it is rare for laser treatment alone to work well. When there are multiple causes, the solution should not consist of just one approach either.

▶ The Problem with Insisting on Ultherapy Alone

Ultherapy can lift the collapsed fascial layer, but if it does not reduce the volume of the heavy mass of fat already gathered around the mouth, it may not sufficiently define the jawline. Ultherapy strongly contracts the fascial layer to tighten the “frame,” but it does not destroy or dissolve the mass of fat that has already spilled downward and become heavy.

This is like pulling the straps of a bag packed with heavy items as tightly as possible. Another analogy would be wearing a thick padded coat in the middle of winter and fastening only a belt tightly around the outside. Because of the volume of the clothing itself, it would be difficult to create a smooth, slim line no matter how tightly the belt was fastened. In other words, tightening only the supporting frame does not reduce the volume of the fat that has already descended, so the slimming effect on the jawline may be reduced.

▶ The Problem with Insisting on Fat-Dissolving Injections or Fat Destruction Alone

Even if the fat is reduced, the skin that has already become considerably stretched may remain, which can also be a problem. If only the fat is reduced, the skin becomes loose like a wrinkled shell where the fat has been removed, resulting in fine lines and reduced elasticity like a deflated balloon. People who lose several dozen kilograms sometimes undergo surgery to remove loose skin. The same applies to the face: “volume reduction” and “skin contraction (tightening)” must take place together. The greater the reduction in volume, the greater the need for skin tightening.

3. A Multidirectional Solution for Deep Cheek Fat in the Late 30s

Target layer	Treatment goal	Optimal treatment
Fascial layer (4.5 mm)	Lift the sagging frame	HIFU (focused ultrasound lifting such as Ultherapy): Creates thermal coagulation points in the deep 4.5 mm fascial layer with high-intensity focused ultrasound to firmly contract and lift the loose corset
Fat layer (Deep & Shallow Fat)	Refine the bulky excess fat gathered around the mouth	Ultra-short-wave / radiofrequency treatments (Onda / InMode FX): Target fat cells for selective volume reduction and selectively destroy fat cell membranes to reduce the weight of the bulging jowls around the mouth
Dermal layer (Dermis)	Restore reduced skin thickness and elasticity	Radiofrequency (Thermage/Titanium) & skin boosters: Increase collagen density to provide firm support and induce collagen production in the dermis, making the thin outer skin thicker and denser

※ This does not mean that you should receive all of the treatments above. It means that improvement requires finding the solution suited to your current condition. When the causes and problems are complex and varied, you should understand that a combination of treatments may be necessary. Conversely, if you are considering a treatment that you do not need, that should also be adjusted. This is why consultation with a doctor is essential before treatment.

4. Important Points to Check Before Treatment for Deep Cheek Fat

[1] Avoid Areas at Risk of Hollow Cheeks

If the area below the cheekbones—the side cheeks—loses too much volume, it can make you look older. Therefore, avoid applying energy too strongly there and focus the energy design on the sagging marionette lines around the mouth and the boundary of the jawline for better results. In fact, some people have become more concerned after deep cheek procedures or laser treatment because of this issue. There is no need to insist unconditionally on an extremely slim line. Overall facial harmony is the most important consideration.

[2] Select Devices According to the Amount of Fat

For a type with little fat and thin, sagging skin, focus on dermal elasticity rather than fat destruction (Thermage/skin boosters). For a type with visibly thick tissue, combine fat reduction and lifting (Ultherapy + Onda/InMode).

Sagging around the mouth in the late 30s

Rather than “pulling everything upward as strongly as possible,”

removing the weight of unnecessary fat

and using a dual approach to secure the sagging fascia in its proper position

creates the most natural contour.

In other words, the key to lifting deep cheek fat is a customized vector design that “removes what should be removed and preserves what should be preserved.” Energy should be excluded from the area below the temples, where side-cheek hollows can easily develop, while the lifting vectors should be precisely set in vertical and diagonal directions, focusing on the marionette lines and double-chin line that form the axis of sagging. This is how a smooth, egg-shaped contour is created.

The solution for deep cheek fat is surprisingly difficult and the content is somewhat complicated. Was it easy to understand? Based on what we explained today, we hope you will ask about anything else you are curious about during an actual consultation, then choose the treatment you need.

This procedure may be accompanied by temporary redness, swelling, bruising, or other effects depending on the individual, so a thorough consultation with medical staff is necessary.

Please note that every Wednesday is a regular closing day when the clinic is closed, and keep this in mind when coordinating your appointment schedule. At Bellevue Clinic, where procedures are performed quickly and safely, we hope you will care for firm, clear skin and a beautiful facial contour throughout August without sagging. We hope you enjoy a comfortable final day of the rainy Liberation Day holiday weekend. Thank you very much for visiting Bellevue today as well~!

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