Episode 33: Why Do I Look Angry All the Time? (Part 2)
Why do I look angry all the time? This is part two of a two part episode. Last time, in part one, we looked at features of the upper facial third that could cause an angry or tired or aged appearance. And in this episode, we're going to focus on features of the lower facial third that can contribute to an angry or tired or aged appearance. And if you're wondering what happened to the middle facial third, we're just not focusing on that here, because this tends to be an area that is very critical in the appearance of aging, but at least in my experience, in terms of giving off the impression that one is angry or tired, these are impressions that are most powerfully generated by features of the upper and lower facial thirds.
Why does my lower facial third make me look angry?
And there are two critical structures or landmarks when we're talking about the lower facial third that can really contribute to this angry look in a very powerful way. And the first one is what we call the oral commissure. And there's one on the left side of your mouth and on the right side of your mouth. And these are essentially the left and right corners of the mouth. And if you think about this intuitively, it makes sense that the vertical position of the commissures, the oral commissures on the face have a lot to do with conveying your emotion. So when we talk about a smile, we raise the corners of our mouth. And when we talk about a frown to connote an angry appearance, we lower the corners of our mouth. So if your oral commissures adopt a relative downward, vertical position at rest, this is going to make you look angry or tired.
The other feature that plays a major role in conveying emotion in the lower facial third is the presence of marionette lines. Marionette lines are the lines that can develop from your oral commissures, from the corners of your mouth that go down to the jaw line. And they got this unflattering nickname after old time marionettes, where they had the lower jaw that would open and close, and you could see the seam in the puppet between the lower jaw and the cheek, so those are the marionette lines. And heavy or pronounced marionette lines can definitely contribute to the appearance of angriness or tiredness.
The resting frown
So let's look at each of these features one at a time, so first in terms of the position of the corners of the mouth or the oral commissures. So how can we lift the corners of the mouth? Let's take a quick, deep dive into the anatomy of this region so that we can answer this question from a functional perspective. So if we think of the lips and we look at the corners of the lips, and we mentioned that those are called the oral commissures, and that's what they're called at the level of the skin. Beneath the oral commissures at the level of the skin, there's another structure called the modiolus. And the modiolus is where a bunch of different muscles come together in the face.
And there are essentially two kinds of muscles that come together here. There are muscles that come from above, and these are called lip elevators. And there are muscles that come from below, and these are called lip depressors. So you can imagine that when the lip elevators contract, when those fire, they make the modiolus and therefore the oral commissure go up. When the lip depressors contract or those fire, they make the oral commissure go down. So it's the lip elevators that make you smile, and the lip depressors that make you frown. And the position of the corners of the mouth, the position of the commissure at rest, when you're not actively trying to smile or frown, is determined by a balance of the strength of the lip elevators and the lip depressors.
So if you can imagine over time as we age, we lose skin and soft tissue elasticity. So our skin and soft tissue becomes lax and everything tends to droop and fall over time with gravity. So the resting position of our oral commissures of the corners of our lips migrates down with time. So those lip depressors went out over the lip elevators at rest. So then the question of how can we raise the corners of the mouth at rest to prevent them from being low, from giving us this frowning appearance at rest, really becomes a question of how can we rebalance the relative strength of the lip elevators and the lip depressors?
And there are two main ways to do this, and it really depends on the severity of the problem. For relatively minor issues with the resting position of the oral commissures, if they're just a little bit too low at rest, and there's not a severe resting frown present, we can weaken the lip depressors. Specifically, we're aiming at a muscle called the depressor anguli oris, or DAO. And if we weaken this muscle selectively with Botox, we can return the mechanical advantage to the lip elevators so that the oral commissure or the corner of the mouth rises, and it is no longer in a frowning or lowered position at rest. Sometimes we can also help in these mild cases by carefully placing a little filler, or by doing some fat grafting to provide a bit of a platform for the oral commissure so that it doesn't drift as far down at rest. So between Botox and filler or fat grafting, we can often make a nice difference for mild cases of a depressed oral commissure that's giving us a tired or angry look.
For more severe cases, we can actually address this problem surgically, and we can reset the position of the oral commissures at rest by performing some soft tissue manipulation with carefully hidden incisions. Now, this is a relatively extreme procedure that we don't undertake lightly, and this was reserved for really the very most severe cases of a resting frown. And it's something that should not be undertaken without a thorough conversation with your surgeon to understand the risks and benefits, and to make sure that this is the procedure that your surgeon has a lot of experience with and has good results with.
How can I fix marionette lines? What are marionette lines?
In terms of the other structure that can be contributing to the appearance of tiredness or angriness at rest we'll address the marionette lines. And as a reminder, the marionette lines are the lines that span from the corners of the mouth to the jawline. And again, we treat these based on their severity or their depth, and we divide this severity into three categories. So first we can talk about superficial marionette lines, and then there are intermediate marionette lines. Then there are these really deep, severe marionette lines.
So superficial marionette lines can be addressed pretty effectively with things like a chemical peel. And I really like a nice TCA peel for this purpose or with laser resurfacing. And the gold standard here is probably a carbon dioxide laser, or even with radio-frequency micro-needling such as with the Morpheus 8 device. And this is something we've addressed in depth in an earlier episode. So any of these three things will provide some superficial resurfacing, which will decrease the prominence of superficial marionette lines.
When we start talking about lines are a little bit deeper, these intermediate marionette lines, we need to actually alter their topography. We need to change how deep they are, and this is something that we can achieve with fillers. And I like the hyaluronic acid based fillers for these procedures. Or for people that want a more permanent approach, we can also treat them with this with fat grafting. And we've talked about fat grafting at length in earlier episodes.
But just as a brief review, to perform fat grafting, we perform a little bit of liposuction under local anesthesia, and we harvest fat from one part of the body. We then process those fats cells to get rid of any extra lipids or blood products or other things that can damage take of the fat graft, and then gently inject the fat graft as a biological filler into the area that we're trying to treat. And in this case, it will work very nicely for marionette lines and it can also improve the overlying skin quality in the region due to the presence of the adipose derived STEM cells in the fat graft. So for these intermediate marionette lines, fillers or fat grafting are both very reasonable approaches.
When we start to talk about truly deep marionette lines, when we start seeing soft tissue folding over itself and causing real ridges in this region that are often associated with jowling or the descent of soft tissue along the jawline itself, then we're talking about truly invasive surgery that would be most beneficial in addressing these deep marionette lines. And these are things like facelifts or extended neck lifts that we could use in this kind of case.
So between this episode and the previous episode, we've tried to cover the various anatomical features that could be making you look angry, even when you're not, and discussing the different procedures that we can perform to correct these issues. And as always, we encourage you to rate and review the podcast and to reach out to us at darrensmithmd.com with any other questions or comments that you might have.