SPECIAL TOPIC

The Cross-Cheek Depression: Surgical Causeand Effect in the Development of the “JokerLine” and Its Treatment

Val Lambros, M.D.James M. Stuzin, M.D.

Newport Beach, Calif.; and Miami,Fla.

Summary: Despite plastic surgeons’ best efforts, deformities can be seen followinga face lift. One of the most obvious signs of face-lift surgery is the cross-cheekdepression or “joker line,” which begins as an indentation in the region of theoral commissure and extends laterally and superiorly toward the ear. When thisdepression develops postoperatively, the face can appear harsh, pulled, andabnormal, creating a visual illusion that the corner of the mouth extendslaterally onto the cheek. There is a relationship between the preoperativecontours of a patient and the postoperative ones. Most patients who developcross-cheek depressions postoperatively exhibit a version of the problem pre-operatively. Inspection and light finger traction on the cheeks identifies andintensifies the abnormal configuration. The clinician needs to be aware of thepropensity for this complication preoperatively, as anticipation is the first steptoward prevention and treatment. The most specific treatment for the surgicalaccentuation of cross-cheek depressions is the use of volume to fill the areasof unnatural depression, either intraoperatively or postoperatively (Plast.Reconstr. Surg. 122: 1543, 2008.)

The popularity of face-lift surgery over the lastseveral decades has resulted in increasingnumbers of patients who appear “surgical.”

There is no secret that these cases occur; the pub-lic is very aware of these odd-appearing faces,which are instantly visible from a distance. Patientsconsidering facial surgery are fearful of lookingstrange or different postoperatively.

A particularly obvious and common deformityis the cross-cheek depression, which is sometimescalled a “joker line” by the public because it resem-bles a traditional representation of the joker in adeck of cards. There are abundant variations of thisdeformity in depth, breadth, and length and its ap-pearance with animation. In its fullest and mostobvious expression, the cross-cheek depressionappears as a slight indentation close to the cornerof the mouth, widening as the depression courseslaterally, hugging the inferior surface of the malarbone and extending laterally and superiorly to-

ward the ear (Fig. 1). After surgery, minor changesin elevation of the cheek surface unmask and elon-gate the preexisting indentation, producing thishallmark sign that the patient has undergone aface lift.

PREOPERATIVE MORPHOLOGICAPPEARANCE OF PATIENTS PRONE TODEVELOPING POSTOPERATIVE CROSS-

CHEEK DEPRESSIONSWhen looking at the preoperative images of

patients who have developed cross-cheek depres-

From the University of California and the University ofMiami School of Medicine.Received for publication March 2, 2008; accepted April 30,2008.Presented at the American Society for Aesthetic Plastic Surgerymeeting, in New York, New York, May of 2007.Copyright ©2008 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e31818894d3

Disclosure: The authors have no conflicts of inter-est with any product mentioned. Dr. Lambros wasonce on a Restylane expert users’ panel.

Supplemental digital content is available forthis article. Direct URL citations appear inAppendix 1; simply type the URL address intoany web browser to access this content. Click-able links to the material are provided in theHTML text and PDF of this article on theJournal’s Web site (www.PRSJournal.com)

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sions, one sees a pattern of similarity. These pa-tients typically share several features; they tend tohave prominent malar bones and a slight hollow-ing in the submalar area that is most noticeablejust lateral to the oral commissure (Figs. 1 and 2).Often, their cheeks are thin and flat, and on care-ful inspection, the incipient cross-cheek depres-sion lateral to the oral commissure may be visiblepreoperatively.1–4 Some patients will exhibit ranksof short, crescent-shaped wrinkles that parallel thenasolabial folds up the cheek (Fig. 3). The condi-tion is more noticeable in the presence of prominent

masseters, and as is common in the face, only oneside may display the tendency for the condition.

A time-honored maneuver by plastic surgeonsis to pull on the patient’s cheeks with fingers. Thishas a predictive effect and is useful for explainingthe effects of surgery to patients. On physical ex-amination of patients with the tendency for cross-cheek depressions, the deformity frequently be-comes more noticeable when finger traction isplaced on the lateral cheek; one does not need totug very hard on the cheek to see the depressiondevelop (Fig. 4) (see Animation, SupplementalDigital Content 1; hyperlink to view animation anddescription available in Appendix 1).

The skin and superficial musculoaponeuroticsystem (SMAS) shift necessary to accomplish thebasic goals of the face lift are enough to accentuatethe appearance of the “joker line” in this mor-phologically prone type of face (Fig. 5). Statedagain, with face-lift surgery, this type of face ap-pears worse when subjected to the same lateralforces that make other faces appear better. Theyappear worse because of unmasking of featuresthat were already there.

FACIAL FAT COMPARTMENTS ANDTHEIR RELEVANCE TO CROSS-CHEEK

DEPRESSIONSAs noted by Rohrich and Pessa,5 the subcu-

taneous fat of the cheek is partitioned into an-atomical compartments. Facial aging is oftencharacterized by how these compartments changevolumetrically over time. In faces that thin withaging, the volume loss that occurs within a com-partment is typically not uniform, and the contourdeformities resulting from deflation tend to beregional, not compartmental.

Patients who are morphologically prone to de-veloping cross-cheek depressions typically are fullin the infraorbital and medial malar fat (medial fatcompartment) and exhibit prominent skeletalsupport of their malar eminences. The area ofinvolution most involved in these patients is the fatlocated directly inferior to the insertion of thezygomaticus major along the oral commissure.This submalar hollow presents as a depressionbetween the volumetrically intact malar and jowlfat pads and tends to directly overlie the anterioraspect of the buccal fat pad and modiolus. Anaccompanying loss of buccal fat volume within thecheek may accentuate subcutaneous submalarhollowing in these patients. From an anatomicalperspective, the region of the cheek where cross-cheek depressions develop represents a soft-tissue

Fig. 1. This patient has had two face lifts and illustrates the clas-sic deformity. Note the indentation seen as a shadow from thelateral oral commissure to the ear.

Fig. 2. This is the shape of face likely to develop the syndrome ofcross-cheek depression following face lift. The cheekbones arelarge and the cheeks are flat. In many patients, the deformity isvisible preoperatively.

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Fig. 3. A 67-year-old woman before secondary anterior face lift and dermabrasion (above). Two months after herface lift, a cross-cheek depression can be observed (center). (Below) Appearance 10 months after placement of 3cc of Restylane (Medicis Aesthetics, Inc., Scottsdale, Ariz.) in the right cheek hollow and 1 cc in the left.

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“watershed” between the muscular elevators anddepressors of the lip (Fig. 6).

RELEVANCE OF LATERAL TRACTIONIN THE DEVELOPMENT OF CROSS-

CHEEK DEPRESSIONSIn our opinion, the degree of release of both

skin and SMAS, and the vectors of repositioning ofthese two layers, influences the depth and prom-inence of cross-cheek depressions postoperatively.With face lifts, many faces appear better with ver-tical vectors by repositioning jowl fat and enhanc-ing the mandibular border. Vertical SMAS move-ment tends to increase submalar hollowing (whichis useful in the full, round face),6,7 but the samesubmalar hollowing accentuates and lengthenscross-cheek depressions in the morphologically

prone patient (see Animation, Supplemental Dig-ital Content 2; hyperlink to view animation anddescription available in Appendix 1). Vertical skintension tends to accentuate flattening in thepreauricular area, allowing the submalar cheekshadow to extend toward the preauricular region.Though not discussed here, vertical skin tensioncan also create unnatural skin creases and elon-gated pores curving up the face to the ear (i.e., thedrapery effect)8 (Fig. 7).

In our opinion, a more limited lateral releaseof SMAS and skin should have less effect on medialcheek depressions. Similarly, more laterally ori-ented vectors of both the SMAS and skin shouldminimize this problem.6 In general, we believethat the older the patient and the more wrinklesand pores present, the more posterior the vectorof skin closure should be (Fig. 7).

Fig. 4. Frequently, the deformity can be visualized by fingertraction. The genesis of the cross-cheek depression is very clearhere. The excess of skin at the commissure is flattened, exposinga continuous shadow from the corner of the mouth. An ani-mated combination of these two images is available online athttp://links.lww.com/A525.

Fig. 5. A 58-year-old woman before and 2 years after a face lift,small fat injection of the lip, and perioral dermabrasion. Thecross-cheek depression can be seen preoperatively and is ac-centuated postoperatively. Supplemental digital content isavailable online.

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CORRECTION OF SUBMALARDEPRESSION BY VOLUMETRIC

ENHANCEMENTA specific method to prevent or correct cross-

cheek depressions is by volumetric filling of the ac-

tual or predicted indentation. This may be treated atthe time of surgery or later. If the condition is to betreated at the time of surgery, the portion of thecheek requiring augmentation is marked as definedby physical examination. We typically inject thecheek depression with anywhere from 2 to 6 cc ofautologous fat per side in the deep subcutaneousplane. This region of the medial cheek is usually notundermined during the face-lifting procedure; if thelateral edge of it is undermined, we inject slightlydeeper2,4,9–15 (Fig. 8).

Though abundant and easy to use in the op-erating room, injected fat can be a problematicmaterial. It is not entirely predictable and can failto take. Worse, fat growth can occur with or with-out body weight gain, a condition that is distinctlyunattractive and difficult to fix. Used conserva-tively, injected fat is a reasonable solution,16,17

though we strongly recommend that this area notbe overfilled, as some submalar hollowing is typ-ically preferable to fullness or convexity. If thearea remains undercorrected postoperatively, hy-aluronic acid, other fillers, or additional autolo-gous fat can be further injected (Figs. 3 and 9through 11).

Off-the-shelf fillers18–20 can be very useful inthe postoperative patient with cross-cheek depres-sions who does not want further surgery. At thetime of this writing, our preference is to use hy-aluronic acid–based products. Normally, 1 to 3 ccof hyaluronic acid is required for correction oneach side, or for enough correction to fill part ofthe length of the indentation, which is visually asimportant. In our experience, 1 cc of hyaluronicacid gives roughly the same volume increase as3 cc of injected fat.

We have the strong impression that the par-ticulate hyaluronic fillers maintain projection bet-ter than the more liquid fillers. The injections areperformed radially in the subcutaneous plane andnot in the dermis. This is an easy and safe injectionperformed with vasoconstriction of local anes-thetic with epinephrine. The use of local anes-thetic does not impede our visualization of theextent and volume of injection.

As hyaluronic fillers have not been used verylong in the subcutaneous tissues of the face, theirduration is not yet known and remains to be clar-ified. We find that the longevity of hyaluronic acidfillers is decidedly site specific, and in the cheeksof a female patient, we usually find a duration of1 to a 1½ years, which is what we communicate topatients. We routinely see durations beyond 2 yearsin the brow and tear troughs. This is a subject forfuture study.

Fig. 6. A cadaver dissection illustrates the muscular insertions intothe oral commissure and modiolus. The small arrow overlies the fa-cial portion of the platysma and points to the risorius muscle. Thelarge arrow points to the depressor anguli oris in the region where itmerges with the platysma. Superiorly, note the insertion of the zy-gomaticus major into the lateral commissure with a slip of muscleinserting inferiorly into the modiolus. The medial component of thecross-cheek depression develops in the watershed between the el-evator and the depressors of the lip.

Fig. 7. This appearance (sometimes called the J deformity) is cre-ated by vertical traction on the skin at the time of closure. Note thevertical compression of skin wrinkles and the elongation of pores,which contributes to the linear appearance of the skin. Not all skinbehavesthisway,andthepredispositiontothisdeformityshouldbenoted preoperatively. As opposed to “lateral sweeps” and joker lines,filling has no part in the treatment of this particular deformity.

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We have not found calcium-based fillers21 tolast much longer in this location, and we like theflexibility and malleability of hyaluronic acid.Other fillers (e.g., poly-L-lactic acid) available atthis time have been used as well, and the choiceof which to use should be the clinician’s. Themore important point is to see the problem andtreat it appropriately.

DISCUSSIONIt is commonly understood by the practicing

plastic surgeon and the public that in breast aug-mentation surgery the preoperative appearance ofthe breast influences the final outcome. There aresimilar relationships in the face. Patients who ex-hibit cross-cheek depressions almost always have aversion of the deformity preoperatively. When pa-tients who appear like this preoperatively are sub-ject to finger traction on the skin (duplicating

some of the effects of a face lift), the cross-cheekdepression is reinforced (Fig. 4). It seems reason-able to point out this clinical association and toprepare for it surgically.

Despite considerable rhetoric to the con-trary, face lifts have more similarities than dif-ferences in their basic approach to the face.They use incisions around the ears, and the skinis undermined a variable amount onto the face.Most current procedures use the subskin layersof the face in some way to shorten the SMASlayer and overlying skin. This is not to say thatall techniques are identical, and any procedurecan be performed poorly or well, but most facelifts seek to achieve the same goals through thesame general means. The primary tool for ac-complishing these goals is the use of a lateralpull to “tighten” the skin and reposition subcu-taneous fat along the contour of the underlyingskeletal and fascial framework (we doubt that

Fig. 8. (Above) A 75-year-old woman before a secondary face lift. She had a cross-cheek depression before surgery thatwas accentuated by finger traction. At the time of surgery, 6 cc of fat was placed in each cheek hollow. (Below) At 3 yearsafter surgery, she has a much more normal-appearing cheek than would be expected with an unmodified face lift.

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any real tightening actually occurs; instead,slack skin and subcutaneous tissues are short-ened to normal resting tension).22 In most agingfaces, a modest amount of lateral skin shift is adesirable goal, as it is the essence of the face-liftprocedure, just as it is with fingers pulling in themirror.

Anatomical contours that appear normal ordesirable in a young face often appear less so in anolder one. In a young person, high cheekbones,hollow cheeks, and a cross-cheek shadow are adesirable appearance that many people try to du-plicate with makeup. Some sculptural definition ofthe midcheek can be desirable; it would be a dullworld if all cheeks were smooth and round. How-ever, the same configuration in a middle-aged per-

son can appear old and gaunt. In our opinion, anyextended nonsmiling indentation at the corner ofthe mouth appears unnatural in a face-lifted patient.

As in much of cosmetic surgery, careful phys-ical examination and observation are useful forpredicting outcomes. One cannot anticipate ortreat problems that one cannot or does not see.

What defines facial features in the world ofdaily life is the light in which one sees them or,more properly, the interplay of light and shadowsthat visually defines them. What catches the eye isnot necessarily the indentation, which is small, butthe magnifying effect of the shadows that the in-dentation causes.

This deformity is very subtle: it is usually onlya few millimeters deep but can have a profoundeffect on the gestalt of the face. Sometimes, it isseen as an elongation of a previously existingshadow, which in two components has less visualeffect than when joined to form a single one (seeAnimation, Supplemental Digital Content 1, 3,and 4; hyperlinks to view animations and de-scriptions available in Appendix 1.) It is strikingto see how much the appearance of the faceimproves with elimination of this long abnormalshadow when all or part of the indentation isfilled (Figs. 3, 8, and 11).

What we have described here is the purest formof the deformity. If the anatomy is different, theresult will be different as well, leaving an entire rangeof appearances from minimal and acceptable to thefull-blown cross-cheek depression. In looking at ran-dom unoperated groups of people, this pattern isnot particularly common; it stands out much moreafter a face lift.

We noticed the relationships of this defor-mity by looking at the postoperative appearanceand finding a characteristic preoperative ap-pearance. There may be more than one meansby which cross-cheek depressions are generated.We have no doubt that excessive traction oncertain faces can lead to this deformity, but inour opinion it is incorrect to consider the cross-cheek depression as solely a complication ofoverenthusiastic pull. We have seen cross-cheekdepressions develop after all types of face lifts inpersonal observations in the office and in pre-sentations and publications of different tech-niques. The common denominator in most face-lift techniques is that the skin is shortened orshifted away from the nasolabial folds, whichleads us to believe that it is the shortening of theskin (Fig. 4) that is the issue in these patientsrather than traction on other facial layers. Se-quential surgery of facial tissues seems to be an

Fig. 9. A 65-year-old woman after face lift surgery. (Above) Shehas an obvious and abnormal depression in her cheek. She wastreated in the office with 2 cc of Restylane on the right side. (Be-low) She is shown 5 months later.

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issue, as the deformity seems to occur morecommonly with secondary procedures.

Cosmetic surgery is no stranger to having com-plex and poorly understood contours treated bysimple means, and this situation is no different.The use of fillers in these cases is intuitive and easy,given experience in looking at the face and somebasic injection ability.

Other traction deformities of the face lift thatresult in indentations of the skin may be correctedin a similar way. Hamra15 described the lateralsweep, transverse creases above the mandible inthe lower cheek following face-lift surgery. Al-though he described complicated secondary sur-gery to correct them, a simpler technical solutionis to level the surface depressions (Fig. 11). An-other similar indentation that may be corrected isthe face lift–induced extension of the sublabialgroove seen in some patients. Traction deformi-ties involving misdirection of the skin wrinkles andelongation of pores are not correctible with vol-ume (Fig. 7).

Many of the problems seen with face lifts are aresult of having only one tool for improvement (trac-tion) and using it for any contour of every aging face.One can see the cross-cheek depression in manyface-lift articles and textbooks and at almost everynational face-lift meeting. It is as if plastic surgeonshave been blind to the deformity. Once the rela-tionship is seen, it is instantly obvious.

We are surprised that this pattern of tissuebehavior has not been specifically addressed in theliterature, although face-lift surgeons have dis-cussed methods to correct submalar contour de-pression in both primary and secondary facelifting.2,4 We would emphasize that although plas-tic surgeons tend to focus on surgical techniqueand will accept as normal or unavoidable the sec-ondary changes that can accompany surgery, theobjective of face-lift surgery is to improve the ap-pearance of the patient. There is no beauty insurgical distortions, no matter how common. Inour opinion, plastic surgery of the aging face can-not progress without a clear realization of its lim-itations and how to overcome them.

SUMMARYThe message of this communication is simple:

there are relationships between preoperative andpostoperative contours in the face. One of themost obvious complications of face-lift surgery canbe anticipated by observation and physical exam-ination, and it can be treated simply in or out ofthe operating room with any number of volume-generating substances. The association of skinshifting on the face and cross-cheek depressions isone that anyone who regularly examines agingfaces can confirm for themselves.

Fig. 10. A 44-year-old woman 10 years after a “maintenance” lift. (Left) She shows signs ofcross-cheek depressions and hollowed upper lids and an irregular jawline. (Right) Appear-ance at age 50, after fat injections to the brows, polylactic acid in the cheeks, and Restylanein the brows and perioral area.

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Val Lambros, M.D.360 San Miguel, Suite 406

Newport Beach, Calif. 92660lambrosone@aol.com

REFERENCES1. Ellenbogen, R. Free autogenous pearl fat grafts in the face:

A preliminary report of a rediscovered technique. Ann. Plast.Surg. 16: 179, 1986.

2. Guerrerosantos, J. Simultaneous rhytidectomy and lipoin-jection: A comprehensive aesthetic surgical strategy. Plast.Reconstr. Surg. 102: 191,1998.

3. Binder, W. J. Submalar augmentation: An alternative to face-lift surgery. Arch. Otolaryngol. Head Neck Surg. 115: 797, 1989.

4. Little, J. W. Applications of the classic dermal fat graft inprimary and secondary facial rejuvenation. Plast. Reconstr.Surg. 109: 788, 2002.

5. Rohrich, R. J., and Pessa, J. E. The fat compartments of theface: Anatomy and clinical implications for cosmetic surgery.Plast. Reconstr. Surg. 119: 2219, 2007.

6. Stuzin, J. Restoring facial shape in face lifting: The role ofskeletal support in facial analysis and midface soft-tissue re-positioning. Plast. Reconstr. Surg. 119: 362, 2007.

7. Stuzin, J. M., Baker, T. J., and Baker, T. M. Refinements in facelifting: Enhanced facial contour using vicryl mesh incorporatedinto SMAS fixation. Plast. Reconstr. Surg. 105: 290, 2000.

8. Baker, T. J., Gordon, H. L., and Stuzin, J. M. Surgical Reju-venation of the Face, 2nd Ed. St. Louis, Mo.: Mosby, 1996.

9. Erol, O. O. Facial autologous soft-tissue contouring by ad-junction of tissue cocktail injection (micrograft and mini-graft mixture of dermis, fascia, and fat). Plast. Reconstr. Surg.106: 1375, 2000.

10. Coleman, S. R. Long-term survival of fat transplants: Con-trolled demonstrations. Aesthetic Plast. Surg. 19: 421, 1995.

11. Coleman, S. R. Structural fat grafts: The ideal filler? Clin.Plast. Surg. 28: 111, 2001.

12. Coleman, S. R. Structural fat grafting. In F. Nahai (Ed.), TheArt of Aesthetic Surgery: Principles and Techniques. St. Louis, Mo.:Quality Medical, 2005.

13. Chajchir, A. Liposuction fat grafts in face wrinkles and hemi-facial atrophy. Aesthetic Plast. Surg. 10: 115, 1986.

14. Bucky, L. P., and Kanchwala, S. K. The role of autologous fatand alternative fillers in the aging face. Plast. Reconstr. Surg.120: 89S, 2007.

15. Hamra, S. Frequent face lift sequelae: Hollow eyes and the lateralsweep. Cause and repair. Plast. Reconstr. Surg. 102: 1658, 1998.

16. Lambros, V. S. Fat injection for the aging midface. Oper. Tech.Plast. Reconstr. Surg. 5: 129, 1998.

17. Lambros, V. Aging, facial shape, and fat injection. In E. O.Terino and R. S. Flowers (Eds.), The Art of Alloplastic FacialRecontouring. St. Louis, Mo.: Mosby, 2000. Pp. 221–240.

18. Carruthers, A., and Carruthers, J. Non-animal-based hyal-uronic acid fillers: Scientific and technical considerations.Plast. Reconstr. Surg. 120: 33S, 2007.

19. Fagien, S., and Klein, A. W. A brief overview and history oftemporary filler: Evolution, advantages, and limitations.Plast. Reconstr. Surg. 120: 8S, 2007.

20. Rohrich, R. J., Ghavami, A., and Crosby, M. A. The role ofhyaluronic acid fillers (Restylane) in facial cosmetic surgery:Review and technical considerations. Plast. Reconstr. Surg.120: 41S, 2007.

21. Gravier, M. H., Bass, L. S., Buss, M., Jasin, M. E., Narins, R.S., and Tzikas, T. L. Calcium hydroxylapatite (Radiesse) forcorrection of mid-and lower face: Consensus recommenda-tions. Plast. Reconstr. Surg. 120: 55S, 2007.

22. Forrest, C., Forrest, C. R., Phillips, J. H., Bell, T. A., and Gruss,J. S. The biomechanical effects of deep tissue support asrelated to brow and facelift procedures. Plast. Reconstr. Surg.88: 427, 1991.

APPENDIX 1Supplemental Digital Content 1, http://links.lww.com/

A525. Animation of the patient seen in Figure 4.Supplemental Digital Content 2, http://links.lww.com/

A526. Animation which demonstrates the changes insubmalar hollow with direction of finger traction on

Fig. 11. This patient exhibits “lateral sweeps” many years after aface lift (above). This is not a cross-cheek depression, and we believethatthemechanismforthetwoconditionsisdifferent.Theseimagesare included to show the power of volume fill for certain tractionindentations of the skin. Although complicated surgery has beendescribed to correct this problem (which is visible from across aroom), the more direct answer is to fill the indentations. (Below) Ap-pearanceofthepatient10monthsafterinjectionof2ccofRestylaneon this side. The injections were not in the dermis but in the deepsubcutaneous layer. Although parts of the deformity are still visible,breaking up its length diminishes its visual impact.

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thecheek; themorevertical thedirectionof the lift, themore the submalar hollow is acentuated and the morea cross-cheek depression will be reinforced.

Supplemental Digital Content 3, http://links.lww.com/A527. Animation which shows the anteroposterior viewof the patient shown in Figure 5.

Supplemental Digital Content 4, http://links.lww.com/A528. Animation which is a three-quarters view of thepatient shown in Figure 5. Note how the modest mid-cheek fullness in the preoperative image flattens out,joining two inconspicuous areas of depression into anobvious single one.

Contacting the Editorial OfficeTo reach the Editorial Office, please use the following contact information:

Plastic and Reconstructive SurgeryRod J. Rohrich, M.D., Editor-in-ChiefSt. Paul’s Hospital5909 Harry Hines BoulevardRoom HD01.544Dallas, Texas 75235-8820Tel: 214-645-7790Fax: 214-645-7791E-mail: PRS@plasticsurgery.org

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