As we age, the lower half of our face slowly begins to fall, causing despair and confusion over how to slow it down or reverse it. Anh Bridgewater, expert injector at LJC, walks us through the non-surgical options for lower face rejuvenation including threads and fillers. Hear how these innovative treatments work in tandem to contour the jawline for immediate improvement without surgery.
Recorded Announcement (00:07):
You’re listening to the La Jolla Cosmetic Podcast.
Welcome, everyone, to the La Jolla Cosmetic Podcast. I’m Monique, your hostess. And today we are speaking with Anh Bridgewater. Welcome back, Anh.
Anh Bridgewater (00:27):
Hi. Thank you for the warm welcome, Monique.
So today we’re going to talk about the lower face and neck, which is sort of a place that bothers people quickly. It’s like the first place you might notice aging. People start tugging on parts of their skin. They play with their little chicken wattle under their neck. So what are the usual concerns for somebody with the lower face and upper neck?
Anh Bridgewater (00:55):
It’s actually a very common concern. Typically, people will come in sometimes when they’re younger. They’re just wanting some more contour or definition in that area. Everyone really wants that really nice straight line from the angle of their jaw to their chin. And we do lose that with aging in some instances as well, you start forming those jowls underneath and just losing that definition from the jawline to the neck. And so that’s also a really common concern.
It’s like there’s three buckets, right? So you’ve got fat that can be a problem for some people. You might have a great jawline, but there’s fat and fullness so you don’t notice the jawline as much. And then sagging, you were talking about kind of the jowls or pre jowls. What’s the difference?
Anh Bridgewater (01:38):
Mm-hmm (affirmative). Yeah, so the pre jowl is just immediately in front of the actual jowl. The jowl is the actual pocket that you see kind of hanging down there.
And then the definition. Like you talked about whether it is the lack of definition sort of along the jawline but also, people don’t necessarily think about this for fillers, a chin or having a weak chin. And that’s something that you can also address.
Anh Bridgewater (02:05):
Yeah, so I think of jawline as not just the jawline, but the chin. They definitely do go together. It is a much more complicated process than you would think. It’s not just the skin laxity that we’re seeing. It’s actually also redistribution of the fat in the face, going down with gravity with aging, volume loss, even bone resorption. That all is taken into account when we’re filling a face or doing any sort of rejuvenation in the lower face.
Yeah, I just heard about that recently, about the bone resorption. I didn’t even realize that was a thing. And where does that typically happen? Does it happen all along the jaw or in certain parts?
Anh Bridgewater (02:43):
That’s actually happening pretty much all along the jaw, but more so on the anterior portion and kind of like the inferior border of the jaw.
And for the people at home like me, [crosstalk 00:02:53] anterior and inferior, where is that?
Anh Bridgewater (02:56):
In front and below, essentially. And even with dental work or tooth loss, it also affects the way the jawline has that support.
Oh, interesting. So injectable fillers are designed to treat volume loss primarily. Is that correct?
Anh Bridgewater (03:17):
Yeah, mm-hmm (affirmative).
And then if you’ve got laxity and sagging, does the filler still help with that or do you typically combine that with another procedure?
Anh Bridgewater (03:30):
That’s a lot more complicated than just revolumizing. So the skin atrophies as we age, so you see more of that skin laxity, loss of collagen, elasticity. So that’s where you really want to combine dermal fillers along with some sort of skin tightening, either with ultrasound, radio frequency and lasers. So it is kind of like an ongoing thing that you just… Because skin is skin. Skin is going to continue to get more lax and loose over time. So it is something that you do want to continue to maintain. Even for someone that’s had a facelift, they’ll need to maintain the quality of the skin, essentially. So think of the dermal filler as kind of like repositioning a soft tissue as well as kind of replacing bone that’s been lost. But it’s not going to do anything for the actual skin itself. So to optimize the results, you really do need to combine what we see on the surface, which is our skin, along with what’s going on below that and deeper.
I’m sure it depends on the person, because how much skin they have or whether there’s texture issues or fat or if they’re trying to lift. But kind of in general would you say, for that lower face, what are the things that might be an adjunct to the filler?
Anh Bridgewater (04:37):
This will really vary depending on the person. But I would say someone in their mid forties, fifties looking for some jawline definition, typically people say when they’re younger they had a really nice jawline and they start to lose that, start seeing skin laxity there as well as the formation of jowls, so that’s where I would recommend dermal filler just to replace that volume loss. Now, obviously as a clinician, when a patient comes in I’m looking at their face globally. So I’m not looking at just the jawline which is, I know, their primary concern, but really you have to also look kind of like at the midface and the upper face as well.
Anh Bridgewater (05:09):
Because when people look at us, they’re kind of looking at our full face, not just our jawline. And so if there’s mid facial volume loss you do need to replace that. Or even for someone younger who doesn’t have the contour there you can absolutely still address the midface. And then you can kind of work down towards the lower face. Because by repositioning the midface, it kind of actually moves everything up with it. You might actually not need as much product as you would think once you kind of get to the lower face.
When you’re talking about the midface, is it sort of the cheekbone area?
Anh Bridgewater (05:39):
Yeah, definitely cheekbone area. Cheeks are kind of like the first place you start seeing that volume loss and then it just kind of trickles from down there.
I’m assuming things like threads can be a good adjunct to filler.
Anh Bridgewater (05:56):
Yeah, absolutely. I think of threads and fillers like peanut butter and jelly. They go great together, but they do two entirely separate things. So threads are mainly just for lifting. They don’t add any volume at all. They don’t help contour. They don’t structure, purely lifting. Which sometimes people come in and think that’s what they want. But when you lift with just threads, you actually kind of lose the contour of the face and you don’t see those highlights and shadows, which is what you would desire, right? And so that’s where kind of a dermal filler would come in. And so I really do like to combine the two procedures. And of course, both of these also don’t address the skin laxity. So that’s where your skin tightening treatments would actually come into play as well.
And that would be something like Ultherapy?
Anh Bridgewater (06:39):
Yep, Ultherapy, radio frequency, things like that.
Anh Bridgewater (06:43):
Lasers, I guess, do a little tightening, don’t they, or not really?
Anh Bridgewater (06:48):
Yeah, they definitely help with collagen stimulation.
So if somebody were thinking about sort of a lower face rejuvenation, I’m assuming you might have a plan because it might not be just one thing that’s going to help them. That you might say, “Okay, we’re going to work through A, B and C.”
Anh Bridgewater (07:08):
Yeah, for most people it will be mostly combination therapy and it will really vary depending on the person and the rest of their facial features.
Mm-hmm (affirmative). Now, as an injector, you’re assessing the lower face. And tell us about that process. What are you kind of looking at?
Anh Bridgewater (07:28):
Yeah, so as an injector, when a patient comes in, we would ask, “What’s your primary concern?” Because I want to know what’s most important to you. And if, say, they are saying, “These jowls bother me,” and that’s actually a very common complaint, obviously we’d have to kind of look through the entire face. And then a lot of times I do have to tell my patients, “We’re going to have to address the mid facial volume loss and reposition things upwards first. We’ve got to do some skin tightening treatments before we can actually kind of move on down towards chin and jawline.” That will be a conversation commonly that I would have with my patients. And so it, again, really depends on the person. If they have a lot of submental fullness, just a double chin or a lot of fat underneath their chin, then things like Coolsculpting or Kybella will be really helpful in that. Because even if you have a really strong jawline, if you have something below that then you’re not going to really see that jawline anyways.
That’s true. And so it might be a multi-step, “We do this this month and in two months we’ll do the next.” And I’m assuming that’s kind of how that conversation might go.
Anh Bridgewater (08:34):
It’s going to be an ongoing process in general. Because, for one, skin tightening treatments, you have to kind of maintain that. Same with dermal fillers, they’ll last anywhere from 12 to 24 months but that’s still something you would have to maintain. So in essence, it’s kind of temporary. And so it is something you have to continue to do, even after you’ve done the full treatment the first time around. But from there on out, you’re just kind of maintaining your results. So you won’t need nearly as much product or as much laser treatments as you did initially. But initially we’re kind of playing catch up.
Right. That makes sense. And for anybody in the audience who doesn’t know, when they talk about one syringe and two syringes or four syringes and people’s eyes get really big and they’re like, “Four syringes?” But a syringe is how much, in reality, the whole syringe?
Anh Bridgewater (09:24):
Yeah, so one syringe is equivalent to one milliliter. So if you cook a lot you would know a tablespoon. Five syringes would fit into a tablespoon. So it’s a very small amount. And so as a clinician, we’re actually working really hard to make that product go as far as possible. A lot of times it’s more of a challenge to try to achieve the optimal results using a limited amount of product. And that’s what I tell my patients all the time, “This is not something we’re going to do in one day. It’s going to take a few sessions.” But a lot of times it is going to be a multi-step process.
Yeah, for people who might not know, with our GLAMfam there’s a Plump Package. So for people who are doing that, something for the first time where, like you say, you’re playing catch up a little bit and maybe you’re going to have five syringes or something or four because you’ve got cheeks and you’ve got jaw and you’re maybe doing something with your lips, then that helps. And we have financing so you can do it over 12 months with no interest. Those kinds of things can help with that first… Like you say, where that first injection or that first treatment might be more and then over time you’re just sort of maintaining it. Now, another question I had is I’ve heard that people can use Botox in the lower face and what is that for or who is that right for?
Anh Bridgewater (10:44):
Yeah, that’s actually a really good question. I had forgotten to mention the muscles play a really important role in this lower face area as well. So as the tissues are kind of descending downwards, the muscles in the lower face are actually kind of pulling that tissue further down because our muscles actually get more overactive, the lower face muscles, as we age. And so as commonly, due to bone resorption and muscles getting stronger in that area, you’ll see a lot of people as they age their chin actually starts to protrude forwards a little bit more and almost kind of like turn upwards, almost like a witch chin. That’s actually pretty common. And so in that case, a lot of times you can Botox these areas to see some mild improvement in the lower face. Things like injecting your chin, your mentalis muscles, will kind of relax that muscle a little bit, pulling that chin back down. But this won’t replace that bone resorption that you’re seeing. And so that’s still something you would need to replace with a dermal filler.
Anh Bridgewater (11:44):
Same thing with the pull down muscles or these two little triangular muscles on the corner of your mouth that pull down the corners of your mouth making you look like you’re very unhappy. And when you inject that muscle, it will just make the face look more pleasant to the eye of someone else. Like when they look at you, it doesn’t look like you’re unhappy. It doesn’t look like you’re frowning. So it can make a difference. But again, it kind of just addresses the muscle layer. Again, we’re talking about skin, bone, subcutaneous tissue. And so all of these all kind of play a role in the aging process. And so addressing one area will be helpful, but it’s not going to be the full picture.
Mm-hmm (affirmative). You kind of have to take a holistic approach.
Anh Bridgewater (12:22):
Getting back to about the fillers and how long they might last, does it depend on which filler you’re using? Or are there certain fillers that you typically might use in the lower face more than others?
Anh Bridgewater (12:37):
In most cases when you’re filling, think of bone, so you’re losing some bone contour there. So you’re going to want something with a lot of G prime, meaning it has a lot of strength, it’s firmer. So we’re going to be looking for a filler that’s a little bit more firm to be able to replicate that bone that we have there. And so these fillers typically are more hearty. And so the particular one that I like lasts 18 to 24 months. So it is a really long, I mean I think it’s pretty long, in that area.
And let’s say you have a filler treatment and then a few weeks go by and you want a little more, is that normal that you guys might reassess after a few weeks, you and the patient?
Anh Bridgewater (13:18):
That’s very common. As clinicians, we do our best to kind of estimate what a patient would need or want in one sitting. And so the nice thing about fillers is that you can always add more. So if they come back at their two week, one month follow up and they feel that, “I like this, but I could use more,” then we can always add more at that point.
Let’s say for people who they went somewhere, they had some fillers put in, how do you know what they might have in there already? Does it matter or are you just looking at the person and what’s going on there? Are we putting filler on top of other filler, or how does that work?
Anh Bridgewater (13:59):
I do ask patients what was put in there to begin with, how many syringes. Just to kind of get an idea as to what their baseline was and how long the filler has been in there just to gauge when they’ll need to come back to replace that. But otherwise what I’m working with is what I’m seeing at the moment. So it doesn’t matter a whole lot.
Because you’re just like, “What you see is what you get.”
Anh Bridgewater (14:23):
Yeah, yeah, I’m trying to make whatever I see right now better. So given a history, it will be more helpful for me.
Interesting. So how long would an appointment take in general?
Anh Bridgewater (14:38):
That’s a tough question, because again, it depends on how many things we have going on. But in general I would say if we’re doing, say, a Botox treatment, the consultation is going to be the longest part of an appointment just to set the expectations so that they know what exactly is going to happen. But the injection itself, maybe Botox 15 minutes and dermal fillers maybe 30 minutes. And if we were to do threads it might take an additional 30 minutes or so. Say we were to do Ulthera on top of that, it could take definitely more time on that. So it really depends on the person and what the plan is.
And let’s say you had Ultherapy in your plan in addition to the fillers, would you do them on the same day or do them at separate treatments and which would go first?
Anh Bridgewater (15:22):
Mm-hmm (affirmative). Typically, you’ll do the Ulthera first to help with the skin tightening. It will take some time before the skin starts to tighten in that area and it starts responding from the Ulthera. And then thereafter you can add the fillers. So while the Ulthera is kind of working in the background, forming that collagen and tightening everything underneath, then we add the fillers so that people can see that immediate satisfaction. But then as the collagen and the skin is getting tighter, then the results will continue to get better.
That’s the hardest part is waiting.
Anh Bridgewater (15:55):
Is waiting, yes, especially in this day and age. Instant gratification is everything.
I know. I know. And that’s where I think it’s good sometimes taking those before and after pictures, taking those baseline pictures, and then do it in a month and do it at two months. Because sometimes it is subtle, but yet stunning when you see side by side. You’re like, “Wow, okay. That really did get better.” But when you’re looking at your face every day in the mirror, sometimes it’s harder to know.
Anh Bridgewater (16:22):
Yeah, definitely. But I would say most people are very aware of their face and when they see an improvement. Because we look at ourselves too much, especially with selfies and everything, I feel like people are more hyper aware of their face and what can be done.
It’s funny you say that. So I’m on SnapChat the other night playing around and there’s the craziest filters. You see the ones with glitter, they make you look softer. There’s ones that completely change your face. I actually took screenshots because I thought it was hilarious. It was like this weird progression of alien. It’s like all of a sudden my nose was different. My eyes were bigger. But do you have people kind of bringing in a filter and going, “I would like this look?”
Anh Bridgewater (17:12):
Yes, yeah, there has definitely been patients who come in and say that, “I want to look like my filter.” And some filters are very exaggerated, but it depends on the filter.
Right. Some of them you don’t want to look like.
Anh Bridgewater (17:29):
Nonsurgical intervention has limitations. If there’s quite a bit of severe laxity in this area and very severe jowling then I would discuss with them about surgical options and have them speak to a plastic surgeon. Because my hands are kind of tied when it comes to non-surgery options.
So what do you do to help make the patient comfortable and not have a lot of pain when you’re doing fillers in the lower face?
Anh Bridgewater (17:57):
I never promise that there will be no pain. It definitely can be uncomfortable. I’ve been in the chair before so I can really relate to my patients that I’m injecting. There are things as providers that we do to keep our patients as comfortable as possible. Topical numbing fillers nowadays have lidocaine in them to continue to numb the area as we’re injecting you. And I feel like a lot of times it’s just also reassurance. Talking to my patients to keep their mind off of the fact that they’re getting poked with the needle. I feel like that really helps. Most of my patients don’t really seem to have an issue with getting injectables. Even if it’s their first time coming in, they’re actually surprised at how little pain they had versus what they were anticipating.
Mm-hmm (affirmative). Now, do you ever use numbing cream in an area or is that more just for the lips, or where do you use topical numbing?
Anh Bridgewater (18:51):
Definitely for lips, otherwise that would be pretty brutal. A lot of times other areas, I don’t feel that topical numbing is necessary. But if a patient feels like it would make them feel better, then I absolutely will do the numbing for them. But most people do just fine without some sort of topical numbing in this area. It really depends on the person. Some people hate that feeling of being numbed, whereas others want as much possible pain relief as possible.
And then we also have Pro-Nox.
Anh Bridgewater (19:23):
Yeah, we do.
And so tell us about Pro-Nox.
Anh Bridgewater (19:27):
Yeah, it essentially just takes your mind off of the pain. You’ll still feel it, but you’re just in a better place and so you don’t really think about it too much. I call it a distraction. I do the same thing by talking to my patients. I think that’s sufficient.
Yeah, I think sometimes, for me personally, when getting a treatment, when the provider is talking to me and explaining what they’re doing as they’re doing it, then it’s like, “Oh, okay.” You’re not so scared. If you just feel poking from different angles you’re like, “Ah, I don’t know what’s happening.” But you’re right. The talking is sort of its own painkiller and helps you relax a little bit.
Anh Bridgewater (20:04):
Yeah, although I must say some people don’t want to know what I’m doing.
Anh Bridgewater (20:08):
They don’t want to hear it at all. It just freaks them out. [crosstalk 00:20:12] Everyone is so different.
That’s true. That’s true. So now is there swelling afterwards? If you’re doing, let’s say, jawline filler or filler around the chin to kind of make the chin more prominent, is that going to be something that swells typically?
Anh Bridgewater (20:29):
I wouldn’t say it’s substantial swelling. It’s definitely not like the lips where you’re really swollen, but you will be swollen. It’ll go away and subside in the next few days. Nothing extravagant.
Now, could somebody go out afterward or would they lay low for a bit? Or what are the things that you would not want them to do after having their appointment?
Anh Bridgewater (20:49):
Just as with any dermal filler, you definitely aren’t going to be working out for the first 24 hours, just taking it easy. But otherwise I would say a lot of this is going to be social downtime versus actual downtime. So they can go back to work. They can kind of go back to normal activities. There really is no restriction. Ideally, you would sleep on your back at a slight elevation to help just kind of drain some of that swelling. But you can go out and you can pretty much do anything you need to do that day. Just really taking it easy for the next 24 hours.
And then are there any side effects that people need to know about or that they should watch out for or are most fillers pretty well tolerated?
Anh Bridgewater (21:32):
Side effects, so the most common one would be bruising and swelling. Swelling, which we already had discussed. And then there’s bruising, of course. Anytime you inadvertently hit a vessel and it bleeds and you’ll bruise. Thankfully, we have a laser in the clinic that just zap it and it’ll just kind of take two to three days to fully go away. Otherwise those are the two most common ones that I would kind of look out for.
So that sounds pretty easy then for most people. So I’m a person who loves to go get a massage every so often. And I know that after maybe threads or filler or certainly laser you wouldn’t be putting your face down in a massage table for a couple weeks maybe or what…
Anh Bridgewater (22:15):
Yeah, that’s actually a really great question. Yeah, so just the skin has an open wound there. So just to avoid any chances of getting infected, we tell people not to immerse themselves in… We’re injecting the face so it’s not likely that you’ll put your face in dirty water. So no hot tubs, say if you were to get a laser treatment on the body. And then if they were to wear makeup, I would hold off for the first 24 hours. But as long as you’re using sanitary brush or hand to apply your makeup, there really isn’t an issue with that as long as you’re just keeping the skin clean so it doesn’t get infected.
Yeah, this was so interesting. I think, especially, it’s cool to know that there’s so many different ways and so many different tools in the toolbox, so to speak, of ways to kind of approach the lower face and the aging of the lower face and jowls and neck. And that you have all those tools at your disposal to make a plan for somebody to help get to their goal. So where you can find out more about Anh would be on our website. She has her whole profile, it’s Anh Bridgewater. And then she has an Instagram account which is Anh, which is A-N-H, Anh, the Beauty PA. She’s a physician assistant and a very accomplished lady that we’re so happy to have in our med spa as a provider. So tell us, if somebody was ready to get started and have you do an assessment what’s the process?
Anh Bridgewater (23:51):
Yeah, first of all, if you check out my Instagram, you would see some before and afters of the jawline that I did with fillers as well as threads. And so that would be a great resourceful area to look. In terms of seeing me for a consultation, typically we would either meet in person or via Zoom to do a consult. Because, like I had talked about, this area is not in isolation of the rest of the face. You’re kind of looking at the whole face globally. I’m looking at your mid face as well as your lower face as well as your neck. And then we’ll talk through what options we have and what the treatment plan will be.
Anh Bridgewater (24:24):
And again, this is not going to be something that you’ll see me once for. You’re probably going to see me for as long as you want to kind of maintain this anti-aging process. So we’re going to build a relationship together. And it’s really just depending on the speed that you want to get these treatments done as well as how slowly we should take it. So this will be so different depending on the person.
Yeah, all right. So look at Anh the Beauty PA on Instagram and read her bio. And then as you all know, we have lots of before and afters on our website and we’re adding more every day. And we have other podcast episodes. We have a Meet Anh podcast so that you can do all kinds of homework. And then, of course, reviews from our patients as well. So our consultations are free and we have links in the show notes where you can schedule that. And we’d love to have you leave a review if you learn something from this podcast, and hopefully you did. And leave us a review and give us any questions you might have. And we thank you, Anh, for coming on.
Anh Bridgewater (25:34):
Thank you, Monique. It’s always so fun to talk to you every time.
Recorded Announcement (25:42):
Take a screenshot of this podcast episode with your phone and show it at your consultation or appointment or mention the promo code PODCAST to receive $25 off any service or product of $50 or more at La Jolla Cosmetic. La Jolla Cosmetic is located just off the I-5 San Diego Freeway in the Ximed Building on the Scripps Memorial Hospital campus. To learn more, go to ljcsc.com or follow the team on Instagram at LJCSC. The La Jolla Cosmetic Podcast is a production of The Axis.