How to Avoid the Joker Smile: Avoid Overlifting

Treating Downturn Mouth Without Overlifting

The Unintended Consequence of Well-Meaning Treatment

A common problem I see in aesthetics is the effect of a joker smile when trying to correct a downturned mouth. This type of result can look bizarre and represents one of the most challenging complications in aesthetic medicine.

Many practitioners will be thinking, “But I can’t even lift a downturned mouth anyway”. It is actually one of the most challenging areas to treat in facial aesthetics.

The mark of a good injector is not just knowing how to perform techniques, but understanding when treatment has gone too far. This blog covers both the strategy for treating downturned mouths and, crucially, how to recognize and avoid overtreatment that leads to the dreaded joker smile appearance.

Understanding the Joker Smile Phenomenon

What happens when you over-lift a downturn mouth? The result is rather strange – patients look constantly happy, but they’re really not. Essentially, they develop a slightly disingenuous look where they appear happy, but you can tell that they’re not genuinely expressing that emotion. This creates an uncanny valley effect that’s immediately recognizable as unnatural.

This happens when there’s a little swish on the corner of the oral commissure – essentially an upward flick on the end of the mouth where it should be tapering down naturally. The end result is an upward lift that comes after the natural shape of the mouth, creating a visible disconnect. You can see the natural mouth contour, and then you see the artificial upward lift that follows, creating what looks like a Nike swoosh appearance.

How Practitioners Fall Into This Trap

The problem begins with the consultation process. Many patients come specifically asking to lift a downturn mouth because it makes them look sad when they’re not. They experience the opposite problem to what they want – they feel neutral or happy, but they look sad. This concern becomes the focus of the entire consultation, with the practitioner thinking, “How do I make the patient look happy?”

This singular focus leads practitioners to go digging in their bag of techniques to find something that will lift the corner of the mouth. The problem with this approach is that it becomes so focused on just one area that if you put all of your effort into just that single location, it’s very hard to get the desired result without causing a sense of overtreatment or disharmony.

The Traditional Approach That Creates Problems

Let’s examine how this problem typically develops. Fifteen years ago, when a patient presented with a downturned mouth saying “I look sad when I actually feel neutral or happy. What can you do to make me look neutral or happy?” the response would have been entirely focused on the oral commissure itself.

The traditional approach involves several targeted interventions:

First, practitioners would focus on the shadow at the oral commissure, thinking they need to support this tissue with struts of dermal filler to push it up in the opposite direction. This direct approach seems logical but creates problems.

Second, they might treat the depressor anguli oris (DAO) with toxin – perhaps three to four units – attempting to reduce the downward pull on the mouth corners.

Third, they might look at the lip itself, thinking they can use volume in the lip to support the oral commissure and provide additional lift.

The Problematic Results

What might practitioners actually achieve with this targeted approach? The strategy employed would be so focused on lifting the oral commissure that they would probably succeed in their immediate goal. However, this lifting in an unnatural way starts to cause a slight upturn with a flick – the characteristic joker smile appearance.

The practitioner successfully elevates the corner of the mouth without making the patient any more attractive. In fact, they create an incongruous upward push next to a mouth that should be tapering down naturally. This disconnect between the natural mouth shape and the artificial lift creates the telltale sign of overtreatment.

Why This Approach Fails

The fundamental problem with the traditional approach is that it’s problem-focused rather than aesthetic-focused. When practitioners become fixated on solving the specific complaint (the downturn mouth) without considering the broader facial context, they create isolated treatments that don’t integrate well with the patient’s natural anatomy.

This focused technique requires trying too hard in one specific area. Because all the effort is concentrated on lifting one small region, the practitioner must use more aggressive techniques or higher volumes to achieve the desired lift. This intensity of treatment in a localized area creates the unnatural appearance that characterizes the joker smile.

The Missing Framework

There’s a missing piece in medical aesthetics training, and this is why overtreatment is so common and why disappointing results happen. The problem lies in not understanding how to approach facial treatment holistically rather than focusing on isolated complaints.

The issue is that practitioners don’t have the right strategy or holistic understanding, and they don’t know how to bring their patients onto the journey to see the problem in the same way. Without this broader perspective, even well-intentioned practitioners who are trying their best will struggle to achieve natural-looking results.

A Better Approach: Seeing Connections

The solution requires learning to see all faces as one structure with independent components that can be tweaked. There’s a systematic approach where you look at the shape and curvature of every part of the face and start to see that there is a structural connection between different parts of the face. This means you can use nearby structures to elevate structures that were once treated only in isolation.

When examining a patient with a downturn mouth, look at the midface and lower face together. You can see the lack of support happening in the cheeks and how this results in downward pressure on the oral commissure. This superficial fat in the cheek pushes downwards on the area that you’re trying to lift, creating the very problem the patient is complaining about.

The Holistic Treatment Strategy

If you’re more holistic in your treatment plan, you’re much more likely to generate a natural-looking result. This applies both above and below the downturn mouth. Interestingly, it’s actually one of the reasons why you should consider treating the chin as part of downturn mouth correction.

It all boils down to the overall balance of muscle, fat, and tissue in the lower third of the face. If you project a chin outwards, it causes relaxation of the mentalis muscle, which also decreases resting tone of the DAO. This creates a synergistic effect that supports the mouth corners without direct intervention.

Step-by-Step Holistic Approach

When treating a downturn mouth holistically, start by assessing what the ideal shape of the chin should be. Determine if it needs to be better defined, and establish whether you’re working with an ideal straight line in the lower face profile.

Next, evaluate whether the cheek needs to be better defined. Feel confident to add volume and support the upper part of the face, which adds structure and support to the lower third. The nasolabial fold is also part of a treatment that supports the lower third of the face.

Once you’ve addressed these supporting structures, you may then proceed to what would have been the first step fifteen years ago – adding small struts of filler for additional support. However, because you’ve done so much other preparatory work, you don’t have to try so hard with the very focused technique.

You can add a little bit in the oral commissure directly, but this whole structure is now supported by surrounding replaced volume above, below, laterally, and medially. This means you need to try a whole lot less hard with the direct approach.

The Key Principle

By tweaking the face a little bit in lots of different areas, you put less filler in each individual area to get a more natural overall result. A holistic treatment plan may use overall more filler, but it will use less in each individual point and create more natural-looking results.

This approach prevents the overlifting that creates the joker smile because the mouth corners are supported by the entire facial structure rather than being forced upward by concentrated treatment in one small area.

Conclusion: The Mark of Expertise

The mark of a good injector is knowing not just how to perform techniques, but understanding when enough is enough and recognizing when there are better ways of getting more natural results by thinking more broadly than just the specific complaint.

Understanding how to avoid the joker smile while effectively treating downturn mouths requires this broader perspective. It means moving away from problem-focused treatment toward aesthetic-focused treatment that considers the entire facial structure.

By learning to see the face as one three-dimensional structure with many points that can be tweaked synergistically, practitioners can achieve the natural-looking results that patients truly want while avoiding the unnatural complications that arise from overly focused treatment approaches.

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