Marionette Lines: Not Just Mouth Wrinkles, But a ‘Downward Pulling Structural Issue’

The long wrinkles extending from the corners of the mouth down to the chin,

are commonly referred to as marionette lines.

When these lines appear,

they can make you look tired,

cause the corners of your mouth to look downturned,

and easily give off an angry impression.

However, marionette lines are not simply wrinkles around the mouth.

The Essence of Marionette Lines According to International Studies

International anatomy and aging studies

explain marionette lines as

👉 the result of structural collapse around the mouth + muscle traction + fat repositioning.

In other words,

**they are not ‘lines formed around the mouth,’

but rather ‘traces of facial structures being pulled downward.’**

Dividing Marionette Lines into 3 Causes

① Type 1 – Perioral volume deficiency

This is when volume loss next to the mouth, specifically in the pre-jowl area,

serves as the starting point for marionette lines.

As the anterior mandibular volume decreases

and the structure supporting the mouth weakens,

the lines begin to form downward.

👉 In this case, the core issue is the ‘loss of support’ rather than the wrinkle itself.

② Type 2 – Sagging of lower facial fat (occurring with jowls)

As we age,

the weight difference between the fat above and below the mouth increases,

and as fat is pushed down along the jawline,

marionette lines deepen.

The characteristic here is that

✔ marionette lines +

✔ a collapsed jawline +

✔ downturned mouth corners all appear simultaneously.

👉 If you only fill the mouth area in this type, the jowls may look even more pronounced.

③ Type 3 – Muscle-driven marionette lines

This is a highly emphasized aspect in international studies.

The muscle that pulls the corners of the mouth downward,

namely the *depressor anguli oris (DAO)*, is deeply involved in marionette lines.

This muscle is directly attached to the skin around the mouth,

constantly exerting downward tension even when not smiling,

and fixing the wrinkles in place over time.

👉 While they may only be visible during facial expressions when young,

👉 they become permanent wrinkles even when expressionless as you age.

This is why we ‘do not directly fill’ marionette lines either.

Problems that can arise if fillers are injected directly into marionette lines:

The mouth area looks heavy

Facial expressions become dull

A more saggy downward impression

This is because most marionette lines are

👉 not an issue of the line itself,

👉 but a problem with the upper and lower structures creating the line.

The Core of Marionette Line Treatment: Structural Volume Restoration

The main approach I use for treating marionette lines is

lower facial structural realignment using **Radiesse**.

✔ Rather than directly filling the mouth area,

✔ by first rebuilding the pre-jowl, jawline, and lower facial support structures,

✔ and restoring skin elasticity through collagen regeneration,

marionette lines are naturally alleviated.

This approach is particularly effective in these cases:

When the corners of the mouth appear pulled downward

When marionette lines are accompanied by a collapsed jawline

When you are worried about unnatural results after mouth fillers

When you want natural and long-lasting changes

Key Summary of Marionette Line Treatment

✔ It is a structural issue, not just a wrinkle

✔ Consider the influence of downward-pulling muscles

✔ Minimize direct filler injection into the mouth area

✔ Treatment focused on lower facial support & collagen regeneration

In Conclusion

Marionette lines are

❌ not just a single wrinkle problem around the mouth,

⭕ but a sign of lower facial aging.

Therefore, rather than asking ‘Where should we inject?,’

it is much more important to ask, **‘Where should we rebuild first?’**

Accurate cause analysis creates the most natural and pleasant-looking results.

📚 Referenced International Studies/Academic Materials

✅ 1. Anatomical-based diagnosis and filler injection techniques: marionette line (static labiomandibular fold)

Title: Anatomical-based diagnosis and filler injection techniques: marionette line (static labiomandibular fold)

Journal: Journal of Dermatological Treatment (Review Article)

DOI / Link: https://doi.org/10.1080/09546634.2025.2452954

✏️ This paper covers the anatomical mechanisms of marionette lines (modiolus position, muscle, and subcutaneous fat structure) as well as filler injection and muscle inhibition strategies.

✅ 2. Why do marionette lines appear? Exploring the anatomical perspectives and role of thread-based interventions

Title: Why do marionette lines appear? Exploring the anatomical perspectives and role of thread-based interventions

Journal: Skin Research & Technology

DOI / Link: https://doi.org/10.1111/srt.13676

✏️ It explains that marionette lines are caused by a complex interaction of anatomical and physiological factors, and analyzes the role of thread interventions.

✅ 3. Efficacy evaluation of endolift laser for treatment of nasolabial folds and marionette lines

Title: Efficacy evaluation of endolift laser for treatment of nasolabial folds and marionette lines

Journal: Skin Research & Technology

DOI / Link: https://doi.org/10.1111/srt.13480

✏️ A clinical study evaluating the efficacy of lasers in treating marionette lines and nasolabial folds.

✅ 4. Marionette lines correction with volumizing threads

Title: Marionette lines correction with volumizing threads

Journal: Journal of Cosmetic Dermatology

DOI / Link: 10.1111/jocd.16490 (PubMed)

✏️ Shows through case reports how marionette lines are corrected in thread-based treatments.

✅ 5. Instrumental analysis of retaining ligaments and soft tissue descent…

Title: Instrumental analysis of retaining ligaments and soft tissue descent…

Journal: Journal of Craniofacial Surgery Open

✏️ Provides an anatomical analysis showing that the loss of support in midface structures is associated with the formation of nasolabial folds and marionette lines.