Many people assume that Ultherapy can effectively lift all areas of the face. However, in clinical practice, there are certain regions where its effectiveness is inherently limited.
One of the most commonly misunderstood areas is the jowl region—the sagging lower cheeks that develop with age.
Understanding the Mechanism of Ultherapy
Ultherapy utilizes High-Intensity Focused Ultrasound (HIFU) to deliver concentrated energy to precise نقاط within the skin. This creates thermal coagulation points at depths of approximately 3.0 mm and 4.5 mm, targeting structures such as the SMAS layer and subcutaneous fat.
Through this mechanism:
Tissue contraction occurs immediately
Collagen remodeling follows over time
This is why Ultherapy is highly effective for improving jawline definition and general sagging.
Why Ultherapy Has Limitations for Jowls
A key distinction between Ultherapy and radiofrequency-based treatments lies in how energy is delivered.
Ultherapy: Focused, point-based energy
RF treatments: Broader, bulk heating
Because Ultherapy concentrates energy at specific areas, it carries a relatively higher risk when used near sensitive anatomical structures—particularly facial nerves.
The marginal mandibular nerve runs along the lower jawline. While it travels deeper beneath the SMAS layer in the outer face, it becomes more superficial as it approaches the mouth.
This superficial region corresponds to the marionette line area, which forms the inner boundary of the jowls.
For safety reasons:
This zone is designated as a “No-Treatment Area” on Ultherapy devices
Direct energy delivery to this region is avoided to prevent complications
If this nerve is affected during treatment, temporary complications may occur, including:
Facial asymmetry
Uneven smile
Difficulty controlling mouth movement (e.g., leakage when drinking or brushing teeth)
These symptoms can last for 1 to 2 months in some cases.
Key Insight
Because the central jowl region overlaps with a restricted treatment zone, Ultherapy alone cannot fully address jowl sagging. This anatomical limitation is the primary reason why results in this area may feel less dramatic compared to other parts of the face.
A Strategic Approach to Treating Jowls and Marionette Lines
Given the anatomical limitations of Ultherapy, achieving optimal improvement in the jowl region typically requires a multi-modal treatment strategy rather than relying on a single procedure.
(1) Fat Reduction (Lipolysis)
One of the contributing factors to jowl formation is the accumulation and descent of fat in the lower face. Reducing this volume can significantly improve contour.
Common approaches include:
Energy-based devices such as HIFU or RF systems (e.g., Onda lifting)
Injectable fat-dissolving agents (e.g., deoxycholic acid-based treatments)
By decreasing excess fat, the lower face appears more defined and less heavy.
(2) Retaining Ligament Tightening
Another critical component is the tightening of retinacula cutis (retaining ligaments), which play a key role in supporting facial structure.
Using deep-penetrating RF treatments such as XERF, it is possible to:
Strengthen ligament support
Improve overall lifting in the lower face
For patients with mild to moderate jowl formation, this step alone can produce noticeable improvement when combined with fat reduction.
(3) DAO Muscle Relaxation (Botulinum Toxin)
The Depressor Anguli Oris (DAO) muscle pulls the corners of the mouth downward. With aging, increased tone in this muscle can accentuate marionette lines and deepen the jowl contour.
By injecting botulinum toxin into the DAO:
Downward pull is reduced
The transition across the marionette line becomes smoother
The lower face appears more balanced
(4) Volume Correction (Fillers)
Bone resorption in the mandible is another factor that contributes to jowl formation over time. Strategic use of fillers can:
Restore lost structural support
Reduce the depth contrast across folds
Soften the appearance of marionette lines
Final Takeaway
In clinical practice, the most effective results are achieved not by repeating a single treatment, but by combining multiple approaches tailored to the patient’s anatomy.
Key Insight
Ultherapy remains highly effective for overall lifting, particularly along the jawline. However, due to anatomical constraints, jowl improvement often requires a combination of fat reduction, ligament tightening, muscle modulation, and volume correction.
For the safest and most predictable outcome, a personalized consultation with an experienced physician is essential to determine the most appropriate treatment plan.
This concludes the guide from
Do-hoon Kim, ODE Clinic.
Gangnam Dermatology Clinic, ODE Clinic
8th Floor, 340 Gangnam-daero, Gangnam-gu, Seoul, Korea
+82-2-569-0222
Author: Dr. Dohoon Kim, Chief Director of ODE Clinic
Specialty: Anti-aging (Lifting, Volumizing, etc.)
Medical Disclaimer: This post is for informational purposes only. All medical procedures carry risks of side effects such as bruising, swelling, infection, or nodules. Please consult with a qualified medical professional before undergoing any treatment.