Marionette lines are deep folds in the skin that run vertically from the corners of the mouth to the chin. Their name originates from the marionette puppets as the lines from the mouth down to the chin resemble that of a puppet. These line/folds can contribute to a sad, tired, or angry look.
Marionette lines are caused by three separate factors: volume loss (age related changes or weight loss), gravity, and the pull of the depressor muscle at the corner of the mouth. Volume loss due to decrease in collagen and elastin leaves the tissue unable to resist the pull of gravity therefore the skin becomes saggy along the jawline and wrinkled around the mouth and chin. Furthermore, some individuals have a strong depressor muscle called the depressor anguli oris (DAO) that creates a constant downward pull on the corners of the mouth.
Treatment is often a combination of dermal filler, neurotoxin (Botox) and microneedling. Replacing lost volume in the upper (temple) or mid-face (cheek) first may improve the appearance of folds/jowling in the lower face. If more correction is needed, placement of dermal filler in the marionette lines themselves is next. This includes not only a deeper injection of filler but the addition of a soft, flexible filler in the surface of the skin to help soften the etched in lines and give support to the skin. Neurotoxin injections every 3-4 months will prevent the DAO (depressor anguli oris) muscle from pulling down on the corners of the mouth creating a be slightly lifted, more relaxed, happy appearance. Lastly, a series of three microneedling with PRP/PRF to generate more collagen to essentially plump the skin decreasing the appearance of the etched in lines and prevent further wrinkling of the skin.
We were able to achieve these results over two treatment sessions of dermal filler and neurotoxin. These sessions involved both deep injections of a dynamic filler that has both stretch and strength, as well as surface injections using the “fern pattern” to the top layer of the skin to soften the etched in lines, give support to the skin, and increase collagen production. A series of 3 microneedling sessions are next on his customized treatment plan. This client has voiced how pleased he is with the results and we both agree that it took a good decade off the age of his lower face!