How to Treat Marionette Lines
What Causes Marionette Lines?
One of the primary contributors to marionette lines is the depressor anguli oris (DAO) muscle. This muscle connects the corner of the mouth to the lower border of the mandible, just to the side of the chin. Over time, the DAO muscle can become overactive, pulling the corners of the mouth downward and creating a visible crease extending toward the chin. This can result in an expression that appears sad or fatigued, making us look visibly older.
At the same time, facial fat pads begin to diminish with age. In youth, these fat pads provide structural support and create a naturally rounded, full appearance. As they shrink, the overlying skin loses support, contributing to a hollowed or sunken look around the mouth and jawline.
Genetics, significant weight loss, and natural aging all play a role in the rate and extent of this volume depletion. In many patients, the combination of volume loss and muscle tension amplifies the appearance of marionette lines.
Another anatomical factor is the activity of the mentalis muscle, located in the chin. This muscle often becomes more active as we age, pulling the soft tissue of the chin upward. The result is a tug-of-war effect, with the DAO pulling down and the mentalis pulling up—both of which contribute to deepening lines around the mouth.
While the development of marionette lines cannot be entirely prevented, they can be effectively managed with both non-surgical and surgical interventions.
Treatment Options for Marionette Lines
Neuromodulators (BTA, Xeomin, etc.)
If the primary issue is overactivity of the DAO muscle, neuromodulators such as botulinum toxin (BTA, Xeomin) can be injected in small doses to relax this muscle. This reduces its downward pull on the corners of the mouth, softening the line and subtly lifting the area. The procedure is quick, with minimal discomfort and no downtime, though the effects are temporary and generally last three to four months.
Dermal Fillers
In cases where volume loss is a significant factor, hyaluronic acid-based dermal fillers are commonly used. These are injected beneath the skin to restore lost volume and reduce the appearance of folds and creases.
Product selection and injection technique are important in this area. The filler must be soft enough to blend naturally with the surrounding tissue but firm enough to provide support. Careful placement allows for a slight lifting effect and reduces the shadowing that exaggerates the marionette lines.
It’s important to avoid using too much filler in this area. Overfilling can sometimes lead to a less natural look or affect facial movement. A careful, conservative approach usually provides the most balanced and natural-looking result.
Combined Approach: Neuromodulator and Filler
Many patients benefit from a combination of neuromodulator and dermal filler. By addressing both muscle activity and volume loss, we can achieve a more comprehensive and balanced improvement. This approach is commonly used in clinical practice and is often well tolerated.
It is important to note that these treatments are not permanent.
Neuromodulators must be repeated every few months, while the effects of dermal fillers typically last six to twelve months, depending on the product used and individual factors.
Radiofrequency (RF) Microneedling
Microfocused Ultrasound (Ultherapy)
Ultherapy uses focused ultrasound energy to target the deeper layers of the skin, particularly the superficial musculoaponeurotic system (SMAS). This is the same tissue layer addressed during a surgical facelift. During treatment, ultrasound is used to see the different layers of tissue in real time, which helps ensure the energy is delivered to the exact depth where it will be most effective.
The heat generated by the ultrasound causes a controlled thermal injury, which then triggers the body’s repair process. This leads to the formation of new collagen and elastin, gradually lifting and tightening the treated area. Ultherapy is FDA-approved and is often used for non-surgical facial rejuvenation.
Fat Transfer
For patients with more significant volume loss who prefer a more natural or longer-lasting alternative to fillers, autologous fat transfer may be an option. Also known as microlipoinjection, this procedure involves harvesting a small amount of fat from another part of the body, such as the abdomen or thighs. The fat is then processed and reinjected into the face to restore volume.
Fat transfer addresses volume loss very much the same way that fillers do but uses the patient’s own body fat. While some of the fat may be reabsorbed over time, the portion that survives can offer long-lasting results.
Facelift Surgery
Where fat transfer with liposuction might not be enough, we can also consider a facelift. A facelift is a great option because it directly addresses all of the laxity caused by time and gravity that pull the soft tissues of your face downward and forward against fixed ligamented attachments. This will help minimise marionette lines while maintaining a natural appearance.
Although a facelift is more invasive than other treatments, the key advantage is that the results are much longer lasting. Unlike fillers or neuromodulators, which need to be repeated every 6-12 months to maintain the effect, a facelift typically provides results that last around 10 years. However, it does take longer for patients to recover. There will be some downtime following surgery, and sun exposure, and exercise will need to be avoided for six weeks post-surgery.
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