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INTRODUCTION
The lower third of the face reflects many of the most prominent changes of aging. The loss of structural support is reflected by the corner of the mouth, which falls downward creating a depressed triangle, accentuating the appearance of the jowl and the labiomandibular fold, also known as the marionette line. All these changes in the perioral area can give an impression of sadness and aging that is unpleasant for the patient.1 In many cases their correction is insufficient or inadequate due to the presence of creases, lines, wrinkles, skin irregularities, and muscle hyperactivity. The Happy Face technique provides a better solution for these problems.ObjectiveThe diverse irregularities of the perioral area, the marionette lines and the downward corner of the mouth are the main problems. Thus, the two main objectives of the happy face treatment are: (1) Turn the corner of the mouth upward or as minimum horizontal oral commissures. (2) Homogenize the amount of volume of both sides of the labiomandibular fold in order to achieve uniformity and evenness.Anatomical BasisConventionally, in the upper half of the face, the main problem is wrinkles secondary to muscle hyperactivity, which can be treated with botulinum toxin type A.2 In the lower half of the face, there are lines and folds secondary to skin laxity and loss of volume. The proper treatment is to restore this volume with dermal fillers. However, how should one address the dynamic component of lines and wrinkles in the lower third of the face due to muscle hyperactivity without the frequent unpleasant paresis associated with neuromodulator use?There are more muscles involved in the regulation of movement of the aperture of the mouth than muscles in the upper and midface combined. There are ten muscles around the perioral area and at least seven of them have the same fixation point called the modiolus, located about 1cm lateral to the oral commissure.3The depressor anguli oris (DAO) is one muscle particularly responsible for the downward pulling of the oral commissure. The most medial border of the DAO has cutaneous insertions forming the labiomandibular ligament. The superior limit of the labiomandibular ligament is the oral commissure. The inferior limit of the labiomandicular ligament is the mandibular ligament. The labiomandibular ligament is not a true osteocutaneous ligament,4 but defines an anatomically distinct area and creates the labiomandibular fold. The ligament also impedes further medial and inferior displacement of the jowl fat compartment, creating greater volume compared to the scarce superficial fat found between the two labiomandibular folds.5,6
