In this episode of The Beauty Equation Podcast, Dr. Christelle Oliver-Dussault, Dr. Harpreet Lotay, and Amanda Manholt explore why many people start to look “sad” as they enter their 40s and 50s, even when they feel perfectly fine inside. They break down how changes in muscle activity, bone structure, and volume loss around the mouth, chin, and eyes can create a downturned or tired appearance. The hosts discuss treatments like lower-face Botox, dermal fillers, and structural support to lift the corners of the mouth, improve marionette shadows, and restore balance. They also explain why this area is technically challenging for injectors and why individualized assessment is key. The episode highlights how emotional attributes—sadness, tiredness, or intensity—often show up subtly in the face and how targeted aesthetic treatments can help people feel more like themselves again.

Disclaimer: The Beauty Equation is for informational purposes only and not medical advice. This podcast does not create a doctor–patient relationship. Always consult a qualified healthcare provider before making medical or aesthetic decisions. Information may change as the field evolves.

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About the Hosts:

Dr. Harpreet Lotay is a family physician specializing in aesthetic medicine. She is the founder of Sona MD in Kamloops, BC, and serves as Chief Medical Officer at Bios Wellness Clinics. Known for her artistic approach and comprehensive non-surgical treatments, Dr. Lotay combines medical expertise with an eye for natural results. She is also an educator, a national trainer and holds academic appointments where she shares her knowledge in clinical dermatology and aesthetics. You can get in touch with her on Instagram @hlotaymd

Dr. Christelle Oliver-Dussault is a family physician specializing in aesthetic medicine, women’s health, and psycho-education. She brings a holistic, whole-person perspective to her clinical work, blending science with a deep understanding of the mind-body connection.

She is also the founder of Reclaim The Pink Within, a movement that empowers women to rediscover themselves during life’s most transformative stages. In addition, she is passionate about medical education and mentors the next generation of family physicians through her work with the department of Family Medicine at the University of British Columbia.

You can connect with her on Instagram @drchristellemd

Amanda Manholt is a clinic manager, patient consultant, and co-host of The Beauty Equation Podcast. With over 30 years of experience in beauty, aesthetics, and leadership, she has guided patients and teams alike toward confidence, growth, and empowerment. Known for her ability to connect with people and simplify the often-overwhelming world of aesthetics, Amanda brings a warm, practical, and relatable perspective to every conversation. You can find her on Instagram @crowsfeetandconfidence.

Websites

https://sonamd.ca/

https://www.getyourpinkbackproject.com/

Lips is usually what I will do last. I tend to look at what we

call the perioral area, so the entire area around the mouth and from

different angles. And people often see me kind of walking from one side of the

bed and the other side and up and down and staring at them for a

long time to really understand what's going on. And

we do know that as you age, the bones will shrink, so the

chin will recess. But is there a lot of chin recession? Yes or no? And

then closer to the mouth that, like, just below your lips and above your lips,

what will support the corners? Often you'll lose volume

there. So starting there often will have the

biggest benefit. And then if there's still some loss there, you

can put a bit of a hydration in the lips, but you may not necessarily

need that much, depending on the person. Welcome back to the

beauty equation. I'm Dr. Christelle Oliver Dusseau.

I'm Dr. Harpreet Lotte. And I'm Amanda

Manhole. So the last few

episodes, we talked about to do when you feel

like you look angry or when you have that resting

B face. And there's a few tools that we went through and explained

why that happens as we get older. And today, we're going to explore a few

different facial attributes that also tend to appear as you go into

your 40s and 50s. So, Amanda, what's one of the common complaints

that people come into you with. That they

look sad? It's a. It's a very common

change that happens as we start to age and the

anatomy and structure changes. But, yeah,

oftentimes people say to me, you know, people are asking me, what's

wrong? What's wrong? You know, are you okay? And they're

literally, like I said, just thinking about, I don't know, they

need to take the car in for an oil change. But, you know, when they're

not grinning at people, they can have that impression of looking not so

happy. And a lot of people say I sort of have to force

myself to constantly be smiling. And that gets a little old.

So constantly focusing on keeping the corners of their mouth

upturned, which feels unnatural to them, but looks

neutral when other people look at them. And, you know, it's funny

how the human brain is so tuned to the very

minute changes in facial expression.

It's one of the first things that babies sort of learn that when,

you know, brow is furrowed, what does that mean? And we're just innately

tuned to that. So as the corners of our lips sort of start to

Fall down. It's perceived as sadness.

So there's various anatomical things, as you said, that happen,

that we'll get into that, make that happen. And there's some solutions related

to that too. Are we going to

talk about dun, dun, dun. Lip filler.

Don't make me look weird. Potentially

anytime you say filler and lips, I think people get

scared. Right? They think they totally freak out. Yeah. That's bad enough when you

say filler. It's another thing when you talk about when, you know, you

know, we could add some volume to the lip and they all

panic. But I find it, it's

interesting when you ask them then to bring up a photo of them and say

their 20s and they're into you in their 40s and 50s, and you can

objectively see how their lip volume has shrunk.

And also the surrounding structures have shrunk too. You don't have the same support

around your mouth. And when they

see that, sometimes the penny will drop and their

guard may go down a little bit and be like, okay, I might be open

to this. Tell me more. Yeah, absolutely.

But I think that if sadness is really the key

emotional attribute they're seeing in the mirror, there's an easy

first step, or a less permanent first step, let's just

say, which is using Botox to treat the muscles

that get stronger at the corners of the mouth that tend to

pull the corners down. And we've talked about

how effective Botox is as an aesthetic treatment. And one of

the reasons that I love it as a physician is that it's not permanent. And

if you don't like it, it goes away. And it's really hard to harm

people. So, you know, first do no harm. It's hard

to hurt somebody with Botox. So it's a great first

intervent. It'll just make those downturn

strong muscles loosen up a bit so that it's easier

to smile and you don't have that subtle

emotional attribute showing through. Yeah, it's one of the treatments

I've really enjoyed on myself. Cause that's one of the findings that naturally.

And all the women in my family are like this. The lift the corners amount,

even when I was younger, naturally downturn. But what

was interesting, you know how you mentioned that you feel like

you're constantly smiling? It feels unnatural. Initially,

that's how I felt because the muscles that pull the corners of the mouth up

were very, very weak. And I constantly felt like they were on

because the muscles that pull the corner down were knocked out.

And it's something that I've gotten used to over time. And I usually warn patients

about that if they're. Because it will be an. It's an odd

sensation if you haven't had it done before. And if those muscles that make

you smile have weakened over time. Yeah,

absolutely. Because the perioral muscles or the muscles around our

mouth are really involved in so many different aspects of our

being. Not only speaking and emoting, but also eating

and chewing and so forth. And if you tend to activate those

downturn muscles more, then

you'll miss them. You'll notice their absence or absence of

strength. And it's interesting that you say that

many people in your family have that tendency.

And that tendency can also be structural

because if you have a shorter chin, and if everyone in your

family has a relatively shorter chin,

the mentalis or the chin muscle and the daos

or those muscles at the corners of the mouth are inherently going to have

more tone than people who don't have

chins that are as short. So it's an interesting little phenomenon that

happens. And then your aging trajectory, if you have a shorter

chin, will be predictable in a different pattern. And you

might be the person that comes in at 35, 40,

45, saying, you know, I look sad, and people keep asking

me what's wrong. So, yeah. So would you say

sad is predominantly a lower face

issue? I. I think

so. However, sometimes you see it in people whose

eyebrows tend to slope downwards. Yeah, I

think sometimes the temporal volume loss, when they start to get more

of a droop. Yeah, yeah. And eye shapes

are have a sadder appearance when the

contest of the outside of your eyes is set a little bit lower than the

inner bit of your eye. And that's just how people are born that way. That

will give that appearance of sadness.

Yeah, absolutely. So eyes can definitely impact that as well.

And then we can use Botox to help sort of, you know,

lift the eyebrow and release some of the muscles that

pull the corner of the eyebrow down a little bit. So definitely

that plays into it. But I would say between the two, I feel like the

lower face seems to be a little bit more impactful, or

at least something that brings people in. Because if you have a

natural eye structure that a little bit canted or

looks a little bit sad, it's something you've had since childhood, and it feels a

part of you. And it doesn't change

quite as rapidly as the lower face aspect

does when it comes to aging. But to your point,

Amanda, if you are quite lean and temporal volume loss

starts to play in at that point. Yes. Maybe the upper

eye will start to, you know, start to be

noticed as contributing to that, for sure. I think

lower face Botox is kind of one of my

favorite things because there's so many different things that you can

address and treat. It's a very complex part of the

facial anatomy in terms, you

know, maybe you could, maybe you could talk a little bit about

how it's not necessarily a treatment for beginner practitioners

and why, why is it a bit challenging, even though if

something went awry, I mean, it would be horrible, but it's not permanent, but,

you know, yes, it'll wear off. But one

of the tricky bits, and I know I've encountered this side

effect, I'm pretty sure. Doctor, most practitioners have at some

stage is we have the muscles at the corner mouth that you've heard mentioned,

Dao, that pull down. But really close to them, you have

muscles called the DLIs, and they overlap. So

knowing your anatomy is important. And the anatomy varies quite a lot

based on individuals. And certain markings can help. But

the location of the injection, the injection depth really matters in this

area. And if you're off just by a little bit, you

can end up looking. It can change your smile. It'll

almost look like one part of you smiling, the other one isn't.

And really hard to eat a sandwich.

Yes, you can do that too. Do you want to add anything to that? Harpreet?

Yeah. So the muscle, the dao, and the muscle that

pulls your lower lip just straight down, right, to open your

mouth, called the dli. So when you open your mouth really big,

the DLI pulls your lips down and the DAO

pulls the corner of your lips down. And those two muscles live very, very,

very close to each other, as Christel was saying. And in

some people, they kind of intertwine with each other. So, Al,

in anatomy books, we look and they look like, you know, very

well defined muscles. And, oh, I would just, you know, put my

Botox there. It doesn't work that way. They rest

together sometimes with the fibers crossing. And

depending on how you dilute your product and whether

you're using Botox, whether you're using Dysport, whether you're using

Xeomin, each of those products actually have a different

diffusion, meaning that when you inject a particular

volume, they affect a

predictable amount of tissue around it. So maybe it's

0.5 cm or 0.2 cm, and depending on how you

dilute it, the dilution can cause the

treatment area to spread or be bigger. And then. So you can

affect the DLI and the dao, so you can affect

a muscle you might not have intended to. And that can impact

how wide you can open your mouth or it can change the character

of your smile. I would say that doesn't happen very,

very often. But of the different things that can happen in

Botox, that's one of the more common ones. So before

a newer practitioner jumps into that treatment, they should feel very

confident and comfortable with their anatomy, and they should feel

comfortable with the dilutions they're using and how far the effect of

that product is going to spread. So it is a little trickier, to

your point, than other areas that we treat. Yeah. So let's say

someone. It's one that I continue to feel

whenever, before I inject, just to that muscle

contracting. Because you want to be so precise with that injection point.

Yeah, I've watched both of you do that, where you're asking

them to animate again. Again, again, again. Because, yeah, it would.

Nobody wants to have hit the dli, that's for sure.

So let's say somebody feels like they look sad in the lower part of their

face, or people are asking them that, you know, what's wrong, that sort of thing.

They come and see you, or they see us. And we start with

that very minimal little treatment. And it's improved a bit, but

it hasn't really sort of hit the mark for them. It's

something else other than the musculature. You know what.

Maybe talk about what the most common sort of. Next.

How do you assess? So is it the lips? Is it the chin?

So it depends, right? Yeah. I tend to.

Lips is usually what I will do last. I tend to look at what we

call the perioral area. So the entire area around the mouth and from

different angles. And people often see me kind of walking from one side of the

bed and the other side and up and down and staring at them for a

long time to really understand what's going on. And

we do know that as you age, the bones will shrink, so the

chin will recess. But is there a lot of chin recession, yes or no? And

then closer to the mouth that. Like just below your lips and above your lips,

what will support the corners? Often you'll lose

volume there. So starting there often will have

the biggest benefit. And then if there's still some loss there,

you can put a bit of a hydration in the lips, but you may not

necessarily need that much, depending on the person. I don't

know how pre. How do you tend to approach that area.

Yeah, it's so individualized. Right. So I

often will start with looking at muscle and muscle tone. So sometimes if

people have shorter chins, they'll hold a bit of tension in their lower face.

So you'll see pebbling of the chin and just a sort of

tense sort of affect when you look at the face.

And then I'll look for shadowing, or what we call

the marionette line. That usually makes people look sad.

And that shadowing can be from tone in the

dao that we already talked about. But it can also happen

because they are losing volume and they're losing

elasticity in their skin, too. So when we talk about

shrinkage or volume loss, it's. It's global. It's not just in

one area. Yes, the chin does shrink more so than other areas,

but the entire skull shrinks. So if you think about,

you know, a balloon losing air and the sheet over it, what happens

to it? It starts to look a little bit saggy. So initially, when we get

that saggy appearance, it starts with subtle shadowing

at the corners of the mouth, what we call the marionette lines. And so

that can give the impression of sadness, too. So if that's a

contributor, we may look at dermal filler in areas that are

not close to the area that the patient is concerned about to just change

structure and so to

improve the overall sort of visual impression. So it

really is individualized. And then from there, I look

at the volume at the corners of the mouth itself.

So oftentimes when people lose volume in the lips, there's a pattern

to that too. You'll get global volume loss. But as we

get older, we lose volume in the very corners of the mouth.

That can add to this sort of like,

down turning, but almost like a turning in of the

lips. Like turning. We're turning under. Like the lip sort

of turns under. Yeah, they kind of fold in on themselves

almost. They fold in on themselves. So that's a

trickier treatment. And

again, it's something that when you get experienced with

lip dermal filler treatment, then

you learn how to do the corners. So, yeah,

I forgot to mention as well, and it came to mind when you were talking

about the global assessment, that oftentimes that volume

loss and that bone recession in the mid cheek can be

what's contributing that those shadows down below, really,

when we're looking around, we're not just looking at the lower face, the one area,

we're taking it all in. And oftentimes the support that's Lost

above. It tends to be the first contributing

factor. Yeah. It's a real

art and a skill, I think, to be able to assess a face

properly. I think that's half of it. Well, at

least a third of it. Okay. Part of it. But,

you know, your eye sort of. I think the longer you do it

and the better your eye gets, and it's easier to

sort of pick those little aspects out right away. It's always really

interesting, I find, when doing a consult and we've done someone's photos and we of

course, take pictures with various contractions of muscles, but the ones

that rest. Because nobody takes pictures like. Right.

With their face completely flaccid. But when we

do that and. And sort of were able to cover certain

areas, it's really exciting when they can sort of see,

like, when it clicks for them. Yeah. I find that's just.

It's. It's been very helpful in terms of navigating people towards

what might make them feel more like themselves. Really.

Absolutely. And I think that people are so

motivated by those changes that they see in the mirror, especially when they've

had life events that have been sad. Definitely. You

know, they don't want to be reminded of those events in the mirror. And

that is often a huge motivator for people. They've had a loss

or they've had some issue in their life that was

sad and appropriately so. And it's okay to have that

grief or those feelings, but over time, they really, really do

not want to see that in the mirror. And so that's really nice when we

can help improve that. Yeah. But it's a pretty

common aspect to aging, too, right? It is. I think as,

you know, as we enter perimenopause and menopausal years,

I mean, that's one of the hardest things. There's a lot of loss in that

stage. I feel like you sort of almost

lose a little bit of who you were, who you are.

You almost. It's like going through puberty all over again. It's horrible.

Yeah. It's a time of shifting identities, right? Totally.

Which is why sometimes people do come to us not having

done anything. You know, they're not in this Gen Z generation that

is very used to taking agency over their looks. They've kind

of grown up in an era where some of these

things were looked down upon, but they're going through this identity

shift, and gosh darn it, they want some agency, they want some

control. And so that's what this podcast is

about, too. So you know, sharing information with you so that you

have. Have that as a tool to make choices.

Yeah. To maybe have a better sort of understanding about what it is that's

making you feel like you don't like the inside and the outside don't

match exactly. That we've talked about before.

And sometimes it takes working on the inside first, then the outside.

Other times it takes working on the outside first to help you get to the

work on the inside. And there's always an interplay and a flow between the

two. For those who are listening, if you have a chance after the

episode, maybe put in the comments if you've noticed any

changes in your appearance and whether you've noticed feeling more angry or

like you have that resting B face, or is it more sadness that you've

noticed recently. Would be interesting to find out which one

you've noticed in yourself. One more so than the

other. I think personally, for me, one of the first changes I noticed, but again,

that's down to my anatomy, was that sadness in the corners

of the mouth and maybe a little bit of the tiredness. What about you two?

Well, for me, I would say I tend to have a bit of an intense

look to start with. And I would say

that it was that intensity. Right. I tend to look

more intense, or maybe angry could

be a word. Even though I'm botoxed up, let me tell you,

it's hard for me to frown, but. Amen.

But looking intense is something I've noticed,

and that can be coming from a little bit of temple volume

loss and other structures contributing to it.

I would say when I made the transition into

medical aesthetics and the idea of considering an emotional

attribute in terms of. I was clueless. I

had never really even thought about whether I looked tired

or sad or saggy or angry. I just circled all of

them. When I. When I read the questionnaire, I was like,

I don't know. I need work. Right. So sometimes

that's hard. People don't. People don't understand this

stuff, and they don't necessarily think that.

And I think that's the other thing that's kind of

interesting is they. They'll come in and they'll ask to address

a specific line, a specific spot, as if

if we just corrected that thing, they would feel

like themselves again. And sometimes what I'll do is I'll, you know, on

their photos, on the iPad, I'll just take my thumb or my finger and I'll

cover that one line and I'll say, so this is better.

This and and they'll either be like, yes, or more often

than not they'll be like, well, not really.

So. But I certainly had no kind of

thought one way or the other about an emotional attribute until I did this work.

I think sometimes they don't even know. Like I've had a lot of people saying,

I don't know what's wrong. I just, something's off

and I feel like I'm fading away a little bit and I

just don't like the change I'm noticing, but I can't put my finger on what

that change is. Yeah. And I don't sleep well

anymore and every joint in my body hurts. And

you know, and, and, and all of these things. Yeah,

well, I think these are tools, you know, using different

types of language to express to people what

they might be seeing. Different things are going to resonate to other people, to

certain people. You know, for some it's visual. When we give

them a diagram and say circle, that's gonna resonate.

For other people, talking about the emotional aspect of what they

see in the mirror, that might resonate. And for other people it's very

structural. They might be very analytical and they might come in

saying, it's around my eyes and it feels and they

might describe it in very structural ways. So really

it's about understanding all of that.

And then as a clinician, because you know what can address those

concerns? Using the right tools for that.

Would you say it's. Is. Is it fair to say that often when

there is an emotional attribute or a concern that it is

often associated with volume loss?

Well, I'm not sure that's true when it comes to

anger because oftentimes that's muscular.

I would say for sadness,

it's a contributor. For resting B face

or looking harsh, that often is

muscular as well. They might have tension in the mentalis, thin

lips. So that part is structural. It might not be volume

loss. I feel like

we all come to the world with a certain

aspect. Like I mentioned, I've always looked a little bit intense.

Right. So someone else might say I've always kind of looked like a sad kid.

Right. So I don't think it's always

100% associated with volume loss. Some of it is how

you activate your muscles and some of it is. Will be

exacerbated by aging. I think we're ready to wrap it

up. I think we are ready to wrap it up. I think that covers the

most of it. I think the take home for the lower face is that it

is quite complicated. What happens? And there's usually an overlap of multiple factors.

Before we wrap it up, I did have one question that has now popped back

into my head. We talked about Botox and fillers,

but we're seeing a huge move towards regenerative aesthetics.

Are there any regenerative tools that you would consider using in someone

who doesn't want to do Botox or fillers.

For sad? For sad?

I think that most people when they come in with a specific complaint

and it has to do with looking sad or angry,

most of those people, their psychology is such that they want to see a

more immediate change. That's just, you know.

And a lot of our regenerative therapies require time

and patience and you will.

It takes six to 12 months to create collagen

and you will see an overall global improvement for people.

But it takes a lot of time. And if you're coming in telling me you

look sad and you don't like it, we may need to do

something that works more quickly. Yeah.

Anything else to add? Don't be sad.

Just walk around grinning all the time. No, I

think, I think it's important to know, and

I'm sure we've said it before at some time, at some point

that these changes happen to every single human being

on the planet that's lucky enough to live beyond

35, 45, 50. You know what I mean? Like, yeah,

there's nobody that's not going to notice these

changes at some point unless they're completely not self

aware. And you know, those people are out there too. And

I'm thinking ignorance is bliss. But sadly now I know if it. Doesn'T bother you,

then you don't need to do anything about it. But if you are feeling alive.

Exactly. You see, you wake up, you look in the mirror and

you just feel like you look sad, but you don't feel sad.

We have a few tools that we can use for that next time

we do to the saggy look,

the melted cake. So stay tuned

and if you like today's episode, let us

know and subscribe so that you don't miss any future episodes.

Until next time. Bye for now.

Bye.