June 17, 2026 | Facelift, Facial Rejuvenation
A patient sat down across from me last week, opened her phone, and put a photo on my desk. She wanted to talk about her cheekbones. Specifically, she wanted to talk about how they were “less obvious” than they had been a decade ago. The photo on the right was from a wedding she had attended last month. The photo on the left was from a trip to Italy in 2014.
I listened, asked a few questions, and then did what I do at every consultation that starts with a single feature. I asked her if I could take a careful look at the lower third of her face.
That is where the actual story usually lives. The eyes will tell you what someone has been doing recently, the brows will tell you what someone has been worried about, and the cheekbones will tell you what genetics gave them at twenty. The lower third, the jawline and the cheek pad and the perioral region and the chin, will tell you what time, gravity, weight, sleep, and prior treatment have actually done to the face.
A national outlet last week ran a story about a public figure’s “transformation,” with two surgeons asked to give a technical read on the difference between the before and the after. One of those surgeons was me. I agreed with my colleague’s read because the lower third of that face was the part that had changed. So let me write the longer version of what a surgeon is actually doing in those five minutes across the desk, and why the lower third is so often where the planning starts.
What the Lower Third Actually Includes
The face divides into three thirds. The upper third runs from the hairline to the brows. The middle third runs from the brows to the base of the nose. The lower third runs from the base of the nose to the chin. Each third ages on a different clock and answers to different operations.
The lower third holds the perioral region, the marionette lines, the jowls, the labio-mandibular fold, the prejowl sulcus, the submental fat pad, the platysma, the submandibular gland border, the cervicomental angle, and the chin itself. The cheek pad, the malar fat pad, hangs at the top of the lower third and drops into it as the supporting ligaments lengthen with time.
When a surgeon reads a face, the lower third is the part that integrates almost every other change above it. Volume loss in the midface drops into the nasolabial folds and the marionette lines. Skin laxity above the jaw drops into the jowl. Loss of definition along the mandibular border erases the line that the eye reads as “young.” A small chin, set behind a normal lower lip, makes the entire lower face look heavier even when nothing else has changed.
That is why the patient who books a consultation for her cheekbones often leaves with a plan that addresses her jawline. The cheekbone is the symptom. The lower third is the engine.
The Five-Minute Read
In a consultation, I do most of the reading in the first five minutes, before the patient has finished telling me what she came in for. Here is the order, more or less, in which my eye works.
The jawline border, from the angle of the mandible to the chin. Does it draw a clean line that separates the face from the neck. Is the line straight or is it interrupted by a jowl that has dropped over the mandibular border.
The cheek pad position. Sit a 25-year-old version of the same face next to the current face in your head. The cheek pad in the younger version sits high, anchored to the zygoma. In the older version, it has slid forward and down, pulling the nasolabial fold deeper and softening the malar prominence the patient came in to discuss.
The perioral region. Lip volume, vermilion border, the philtrum, the upper lip length, the dental show in repose and in animation, the corner of the mouth and the marionette region.
The chin and the cervicomental angle. The chin projection in profile. The submental fullness or laxity. The platysma. The angle the eye reads as the line between face and neck.
That five-minute read is what shapes the rest of the conversation. If the patient came in to talk about her cheekbones and the read says her lower face has dropped, we are going to spend the next forty minutes on the lower face.
What Changes the Lower Third Over Time
Five forces, more or less, change the lower third over time. Most patients have more than one of them in play.
Bone resorption. The mandible and the maxilla both lose bone with age, and the lower face loses the underlying scaffolding the soft tissue used to sit on. The jaw narrows, the chin recedes slightly, and the soft tissue has more space to drift downward.
Ligament lengthening. The retaining ligaments that hold the cheek pad up to the zygoma and the jowl out of the mandibular border slowly lengthen. Volume that used to sit high slides into the lower third.
Volume loss in the midface and around the perioral region. The deep fat compartments that gave a twenty-year-old face its upholstery shrink unevenly. The lower face flattens, the nasolabial fold deepens, and the lateral cheek loses its highlight.
Skin laxity. Collagen and elastin both decline, the dermis thins, and the skin loses its grip on the underlying structures.
Weight change and prior treatment. Significant weight loss, especially the rapid loss now common with GLP-1 medications, can age a lower third by ten years in eighteen months. Years of filler placed in the wrong plane or at the wrong volume can create a lower face that reads as heavier and older than it would have aged on its own.
When I look at a lower third, I am sorting all five of those forces in the same glance. The plan is different depending on which combination is in play.
What the Plan Usually Looks Like
The plan is almost never one thing. It is a sequence.
For most patients in their forties with the early jowl, the early marionette, and a cheek pad that has dropped a few millimeters, the right operation in 2026 is a deep plane facelift. The deep plane procedure lifts the cheek pad back to the zygoma, repositions the jowl behind the mandibular border, and restores the line that the eye reads as “young.” It does not stretch the skin. It moves the deeper structures back where they were a decade earlier and lets the skin redrape.
For patients with significant bone resorption, a chin implant or a genioplasty can do the lower-third work that a facelift alone cannot. For patients with significant perioral volume loss, a targeted, conservative filler plan, placed by a surgeon who understands the plane and the volume, can restore the perioral region without overfilling the lower face.
For patients with significant skin quality issues, a layered plan that combines surgery with skin-quality work, microneedling, resurfacing, or topical regenerative protocols, is more durable than any single intervention.
The plan starts with the read. The read starts with the lower third.
What I Will Not Do
I will not chase the cheekbone with filler in a face whose lower third has dropped. That makes the lower face look heavier, not the upper face younger. I will not place a filler pillow under a marionette fold that needs the jowl repositioned. I will not deepen a chin that needs the soft tissue above it moved, not augmented underneath it. And I will not perform a facelift on a patient whose ligaments are still intact and whose lower face is still well-defined, because that patient does not need one yet.
The honest consultation starts with the honest read.
How I Talk About the Lower Third at the Consult
Most patients have never been asked to look at the lower third of their own face. Asking the right questions is the first job of the consultation. Do you feel like your jawline is less defined than it used to be. Do you tug at the skin under your chin in the mirror. Do you feel like the corners of your mouth turn down even when you are not sad. Do you feel like your cheeks have dropped, even though you came in to ask me to lift them.
The answers to those questions, paired with the five-minute read, almost always produce a plan that matches the patient’s actual face rather than the feature she walked in to discuss. The result is a better consultation, a better plan, and a better outcome.
Why Choose Dr. Agullo
Double board-certified, American Board of Plastic Surgery and American Board of Surgery. American College of Surgeons Fellow. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center Paul L. Foster School of Medicine. Affiliate Professor at UTEP. Castle Connolly Top Doctor for thirteen consecutive years. Editorial Board Member at Aesthetic Plastic Surgery. Trained at the Ponytail Academy intermediate course in Pittsburgh and the advanced course in Santa Monica. A facelift consultation in my office starts with the lower third, ends with a plan that addresses the whole face, and never starts with the feature that was easiest to talk about first.
Ready to Talk?
If you are weighing a facial procedure and you are not sure where to start, start with a consultation. We will look at the lower third, the middle third, the upper third, and the way they sit together. The first conversation costs you nothing but an hour, and it is the most useful hour you can spend before any operation on your face.
For the surgeon’s editorial take on this same conversation, see The Lower Third Tells the Story: A Surgeon’s Read on drworldwide.com. For the practice-program version that lays out the surgical and non-surgical continuum at Southwest Plastic Surgery, see The Lower Face Program at Southwest Plastic Surgery.
Call (915) 590-7900, text 1-866-814-0038, or book online at agulloplasticsurgery.com. #StayBeautiful.
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