Marionette lines

Marionette lines are vertical grooves running from the corners of the mouth down towards the chin. Their name refers to marionette puppets, in which the movable lower part of the face is separated by a distinct line from the rest of the face. In aesthetic medicine, these changes are referred to as nasolabial folds. They are part of the aging process of the lower third of the face and often give the face a sad, tired, or stern expression, even with a neutral facial expression. Their formation is the result of complex anatomical changes involving the skin, fat tissue, facial ligaments, and bone structures.

Marionette lines – what are they

Marionette lines are:

static creases – visible even at rest,
located between the corners of the mouth and the lower part of the face,
often associated with sagging contours and loss of cheek firmness.

Anatomically, they form in the area of:

facial ligaments (e.g., mandibular ligament),
fat tissue of the lower cheek,
muscles that depress the corners of the mouth (depressor anguli oris muscle),
dermis with a loss of collagen and elastin.

These wrinkles should be distinguished from:

nasolabial folds,
"sad lines" resulting solely from muscle overactivity,
scars or post-traumatic deformations.

Proper qualification requires a three-dimensional assessment of the face, not just an analysis of the crease itself.

Unlike nasolabial folds, which run from the wings of the nose to the corners of the mouth, marionette lines start below the corners of the mouth and extend downward. They are often part of the so-called lower facial aging syndrome, which also includes:

cheek volume loss,
tissue sagging (ptosis),
deepening of the jawline,
formation of "jowls."

Marionette lines - where do they come from

The etiology is multifactorial and involves both biological and mechanical processes.

1. Skin aging:

decreased synthesis of type I and III collagen,
degradation of elastin fibers,
reduced amount of hyaluronic acid,
thinning of the dermis.

2. Tissue volume loss:

atrophy of subcutaneous fat tissue,
downward displacement of fat compartments,
resorption of the mandible and maxilla bones.

3. Overactivity of muscles lowering the corners of the mouth:

depressor anguli oris muscle,
depressor labii inferioris muscle.

4. Environmental factors:

photoaging (UV radiation),
tobacco smoking,
chronic oxidative stress.

5. Genetic predisposition and facial structure

Individuals with thin skin, a narrow jaw, and a tendency for tissue sagging experience this problem earlier. In some patients, marionette lines appear as early as around the age of 30-35, especially with pronounced facial expressions and weight loss.

Marionette lines - how to remove

Treatment requires a layered approach and causal analysis.

Key principles of therapy:

Do not correct the furrow exclusively.
Evaluate cheek volume and jawline.
Consider muscle tension.
Improve skin quality.

Depending on the dominant mechanism, the following are used:

1. Volumetric correction

Filling tissue deficits in the area of:

marionette lines,
corners of the mouth,
lateral cheeks,
jawline.

2. Muscle tension modulation Weakening of the overactivity of muscles that depress the corners of the mouth.

3. Skin stimulation

Improving skin quality and density by stimulating neocollagenesis (formation of new collagen).

In clinical practice, the best results are achieved with combined treatment, which includes several techniques simultaneously, rather than focusing solely on the furrow itself.

Marionette lines – treatments

In modern aesthetic medicine, minimally invasive methods with documented effectiveness are used.

1. Hyaluronic acid-based fillers

volume restoration,
lifting the corners of the mouth,
improving the jawline contour.

The effect usually lasts 9–18 months (depending on the preparation and the patient's metabolism).

2. Tissue stimulators

Preparations such as calcium hydroxyapatite, polynucleotides or polylactic acid:

thicken the skin,
improve its firmness,
work long-term by stimulating collagen.

3. Microneedle radiofrequency

Induces controlled micro-injuries and thermal effects in the dermis, leading to:

skin thickening,
improving firmness,
reduction of sagging in the lower face area.

4. Monopolar radiofrequency and deep biostimulation

The therapy utilizes, among others:

INDIBA® (448 kHz),
technologies that improve firmness and microcirculation.

5. Lifting threads

PDO threads, barbed threads, or autologous threads:

lift sagging tissues,
improve facial contour,
act mechanically and biostimulatively.

6. Mesotherapy and regenerative therapies

Needle mesotherapy is an auxiliary method in treating marionette lines, especially in cases of significant skin laxity and quality loss. It is not a volumetric or lifting technique, but it improves the biological environment of the dermis.

Therapy includes, among others:

platelet-rich plasma (PRP) – an autologous preparation containing concentrated platelets that release growth factors (PDGF, TGF-β, VEGF), stimulating fibroblast proliferation and collagen synthesis,
collagen preparations – providing substrates for the extracellular matrix,
growth factors and biomimetic peptides – modulating skin cell activity,
amino acid complexes and non-crosslinked hyaluronic acid – improving hydration and tissue metabolism.

The mechanism of action is based on the induction of repair processes and stimulation of neocollagenesis (formation of new collagen). The effect develops gradually, usually after a series of 3–4 treatments performed at intervals of 3–4 weeks. The procedure is particularly useful for younger patients with early signs of aging or as part of combined therapy with fillers or stimulators.

At Ambasad Urody Warszawa, comprehensive combined therapies are used, including fillers, tissue stimulators, microneedle radiofrequency, and INDIBA treatments, tailored individually to the patient's facial structure.

Marionette lines – Botox

Botulinum toxin type A (commonly "botox") is used when there is a predominant muscular component.

Its action involves:

blocking neuromuscular transmission,
temporarily weakening the muscles that lower the corners of the mouth.

Indications:

pronounced drooping of the mouth corners,
excessive activity of the depressor anguli oris muscle,
significant muscle asymmetry,
persistent "sad" expression.

Limitations:

does not fill volume deficits,
does not correct advanced ptosis,
the effect lasts 3–6 months.

In many cases, botox is only part of a combined therapy—its use without volume supplementation does not provide a satisfactory aesthetic result.