2026-07-03
Marionette Lines
Discover the true causes of marionette lines, from anatomical changes to aging and muscle action, and learn effective, balanced treatment strategies for a natural look.
The reason behind a sagging mouth: The true causes of marionette lines
As we age, the wrinkles that extend from the corners of the mouth down to the jawline,
commonly known as marionette lines,
are one of the main factors that make a face look depressed and tired.
Rather than simply saying ‘wrinkles have formed,’
it is the result of a complex combination of anatomical structural changes, aging, and muscle action,
a fact clearly proven by international medical journals.
What are marionette lines?
Marionette lines
are medically referred to as static labiomandibular folds,
and are characterized by being constantly present even without any facial expression (static folds).
Starting from the corners of the mouth (oral commissure)
and extending towards the jawline,
they usually appear alongside the prejowl sulcus.
The name is known to have originated from the way the corners of the mouth are pulled down,
resembling a marionette puppet in European puppetry.
Why they are more common in Asians
In clinical practice,
many Asian patients, including Koreans,
feel that their expression looks depressed
even when the corners of their mouth are not particularly sagging.
This is related to the position of the modiolus,
the structure where the muscles around the mouth converge.
Anatomically, if this area is located relatively outward and downward,
it can create an impression of downturned mouth corners even when the face is at rest.
Therefore, as one ages, sagging or wrinkles around the mouth
can appear more pronounced than their actual age.
The gradual changes of perioral wrinkles
Medical papers explain perioral wrinkles as follows:
1️⃣ Early lines next to the mouth corners
Difference in thickness between the fat next to the lips and the fat above the chin
Decrease in fat on the outer side of the lower lip
This creates a thin, groove-like line
2️⃣ Melolabial fold
Fat below the mouth decreases,
while the upper cheek and jowl fat becomes relatively thicker,
making the boundary line more distinct
3️⃣ Marionette lines
Mandibular bone resorption due to aging
Tissue descent caused by gravity
Atrophy of the deep fat layer
Loss of skin elasticity
Eventually, the wrinkles connect to the jawline and become permanent
Summary of the core causes of marionette lines
The main causes summarized in international papers are as follows:
Bone resorption of the maxilla and mandible
Atrophy of the deep fat layer (especially under the DAO muscle)
Sagging of the cheek and jowl fat
Loss of elasticity in the skin and connective tissues
Pulling effect of the mandibular ligament
Action of muscles pulling the mouth corners downward
👉 In other words, these are wrinkles that cannot be resolved simply by filling a single spot.
How should marionette lines be treated?
1️⃣ Volume restoration is the most fundamental
Medical papers
suggest volume replenishment considering both the fat layers above and below the muscle as a core treatment.
For shallow cases → Soft volume replenishment in the fat layer above the muscle
For deep cases → Volume restoration in the submuscular layer using a cannula → Simultaneous correction up to the pre-jowl sulcus
This approach allows for the simultaneous improvement of perioral wrinkles and jawline disruption.
2️⃣ Controlling the muscles that pull the mouth corners
When the Depressor Anguli Oris (DAO) muscle,
which pulls the mouth corners down, is overactive,
👉 using botulinum toxin in combination can:
Increase the longevity of filler effects
Improve the impression of the mouth corners
Soften the overall facial expression
3️⃣ Why shouldn't you inject ‘a lot at once’?
Marionette lines
are not wrinkles caused simply by a lack of volume.
This area is
✔ The pulling direction of the perioral muscles
✔ Sagging of the lower facial soft tissues
✔ The weight of the jowl
✔ The influence of the mouth corner structure and facial expression muscles
affected by a complex combination of these various factors.
Therefore, just because marionette lines look deep,
if you inject a large amount of filler at once,
you may end up just pushing the surface up
while leaving the root causes unaddressed.
As a result,
✔ The mouth area may look bulky
✔ Facial expressions may become unnatural
✔ Over time, it can create an even more sagging impression.
For marionette line correction,
rather than trying to solve it with fillers alone,
it is most important to first determine the cause of why this area looks deep.
So, when necessary,
✔ Radiesse + lifting procedures as the main treatment
Adding a small amount of volumizing threads or fillers as needed
✔ Botox to control muscle tension
✔ Balancing surrounding structures (jawline, mouth corners)
taking a divided approach like this creates more natural results.
The core of marionette line treatment is ‘balance’
Marionette line treatment is not simply a wrinkle treatment, but a process of restoring facial balance.
If you do not look at the entire structure together, including volume, muscles, skin elasticity, and the jawline,
it is difficult to achieve natural results.
In conclusion
The more you worry about perioral wrinkles,
rather than taking the approach of ‘I just need to fill this spot,’
it is important to first understand why these lines have formed.
Because marionette lines are wrinkles directly linked to
✔ An older-looking impression
✔ A depressed-looking expression
✔ A blurred jawline,
an accurate anatomical approach is more important than anything else.
📚 International medical papers referenced for this article
Anatomical Considerations and Treatment Strategies for Marionette Lines and Labiomandibular Folds
Ethnic Differences in Modiolus Position and Perioral Aging
Superficial and Deep Fat Compartments of the Lower Face and Their Role in Aging
Injection Techniques and Vascular Safety in Perioral Filler Treatment
(All summarized based on papers published in international academic journals)