The Cross-Cheek Depression: Surgical Cause and Effect in the Development of the "Joker Line" and Its Treatment

Despite plastic surgeons' best efforts, deformities can be seen following a face lift. One of the most obvious signs of face-lift surgery is the cross-cheek depression or "joker line," which begins as an indentation in the region of the oral commissure and extends laterally and superiorly toward the ear. When this depression develops postoperatively, the face can appear harsh, pulled, and abnormal, creating a visual illusion that the corner of the mouth extends laterally onto the cheek. There is a relationship between the preoperative contours of a patient and the postoperative ones. Most patients who develop cross-cheek depressions postoperatively exhibit a version of the problem preoperatively. Inspection and light finger traction on the cheeks identifies and intensifies the abnormal configuration. The clinician needs to be aware of the propensity for this complication preoperatively, as anticipation is the first step toward prevention and treatment. The most specific treatment for the surgical accentuation of cross-cheek depressions is the use of volume to fill the areas of unnatural depression, either intraoperatively or postoperatively (Plast. Reconstr. Surg. 122: 1543, 2008.)