What are marionette lines?

Colloquially, the so-called marionette folds are often also called Merkel folds. The anatomical name of the Merkel fold is mentolabial fold. These oral folds extend from the downward corners of the mouth to the edge of the lower jaw. There are different degrees of expression of these wrinkles [1]. Discreet initial visual hints of a marionette crease are a depression below the corner of the mouth and a slightly drooping corner of the mouth. Pronounced marionette wrinkles are one of the first signs of aging and can sometimes begin to appear at a young age. As we age, the collagen in the skin decreases and so the furrow becomes longer and deeper over time.

Accompanying this, a narrowing of the lips and the development of drooping cheeks can be observed. These are signs of the natural aging process, but they convey a sad expression on the face or a dissatisfaction in the facial expressions. For this reason, they are often perceived as unpleasant by those affected, which is why patients want to have them removed. Of course, external factors such as UV rays also have an effect on skin aging. In addition to UV radiation, an unhealthy diet and cigarette smoking, among other things, have a negative impact on the skin and accelerate aging and thus the appearance of wrinkles.

Facts about the treatment of marionette wrinkles

Treatment duration 30 min
Anesthesia Anesthetic cream / local anesthesia / vibration anesthesia / laughing gas
Clinic stay Outpatient
Costs To the price calculator
Socially acceptable Immediately
Additions or alternatives Jawline

How are marionette folds formed?

This is one of the most frequently asked questions. The angle of the mouth (Musculus depressor anguli oris) is a muscle that pulls down the corner of the mouth. The angle of the mouth is connected to the skin by a connective tissue ligament (Ligamentum labiomandibulare) [2]. This connective tissue ligament extends from the so-called modiolus to the edge of the lower jaw. The modiolus is a common connecting point of six muscles that move the mouth. The modiolus is located about one centimeter to the side of the corner of the mouth. At the lower jaw up to the chin the tissue of the skin is connected with the bone by another ligament (Ligamentum mandibularis). These connections of the skin with the nearby muscle and bone form a solid framework and the anatomical boundary between the mouth area and the cheeks. In relation to the cheeks, there is little subcutaneous fat around the mouth. Therefore, changes in aging affect the entire face differently. There are four reasons for the development of mentolabial folds:

  1. Sagging of the fat pads of the cheeks with the formation of drooping jowls.
  2. sagging of the skin due to decrease in skin thickness, collagen, elastin and hyaluronic acid content
  3. Loss of subcutaneous fatty tissue and thinner lips
  4. Increased muscle activity of the corner of the mouth

What are the causes of marionette folds?

In young people, increased contraction of the corner of the mouth is the cause of drooping corners of the mouth (Qiang W., et al, 2016, Aesth Plast Surg). Depending on lifestyle habits and predisposition, the first signs of aging, such as drooping corners of the mouth, can be seen as early as age 30. The lips become thinner, marionette lines and sagging cheeks appear. Aging of the skin in particular, and of tissues in general, is accelerated by the following factors:

  1. Ultraviolet light
  2. Cigarette smoking
  3. Common pollutants of air pollution such as ozone, carbon monoxide, nitrogen oxides and particulate matter (Ferrara F, et al, 2021. Plast Reconstr Surg).
  4. Genetic characteristics (The ends of chromosomes called telomeres).

Aging cells are characterized by impaired energy metabolism (mitochondria) and damage to genetic material (DNA). UV light, cigarette smoke and air pollution lead to the activation of messenger substances (interleukins), which cause a response from the immune system. Over time, inflammatory messengers damage the cells of the skin. Oxygen radicals from bad air or cigarette smoke lead to the breakdown of collagen and elastin. Solarium use and tobacco smoking can significantly accelerate the aging process.

What helps against drooping corners of the mouth?

When asked what helps against wrinkles, Google delivers millions of answers in a fraction of a second. Unfortunately, very few sources are based on scientific facts. Physical applications such as facial exercises, massage or ultrasound are not able to influence the development of wrinkles. Anti-aging creams are highly recommended for prevention, but not for treating drooping corners of the mouth. Hyaluronic or autologous fat injections add fullness to the lips and can correct sunken corners of the mouth [3]. The position of the corners of the mouth can also be corrected with a muscle relaxant [4]. The most effective way to correct drooping corners of the mouth is with a corner of the mouth lift.

What to do about marionette wrinkles?

A meaningful and holistic treatment must take into account all the factors that contribute to the development of marionette wrinkles to achieve natural harmonious results.

  1. Sinking of the fat pads of the cheeks. Drooping jaws interrupt the youthful jawline, emphasizing creases at the corners of the mouth. For a youthful contour and reduction of marionette wrinkles, the volume on the cheeks must be restored with a hyaluronic filler or autologous fat. The fat pad above the lower jawline (prejowls) can be reduced with a fat removal injection. A thread lift is able to lift the sunken fat pads again. During a face lift, the fat pads are returned to their original position.
  2. Sagging of the skin. Microneedling, especially when combined with a treatment using processed autologous blood, improves skin elasticity and thickness. If the therapy is applied to the face with the patient’s own blood, this is also referred to as a vampire lift. In the case of thin skin, the body’s own formation of collagen can also be stimulated with Sculptra® (Poli-L-lactic acid). Lost hyaluron can also be injected. Excess skin is most effectively treated by a facelift.
  3. Attrition of subcutaneous fat tissue. Replacing the volume of the lips and mouth area smoothes the contours, corrects sunken corners of the mouth and helps to achieve fuller lips. Autologous fat is used for volume correction and supports skin regeneration.
  4. Increased muscle activity of the corner of the mouth. A large and hyperactive muscle is relaxed by a muscle relaxant.

The effect of hyaluronic acid is scientifically proven. It occurs in a very short time. After a hyaluron treatment by qualified doctors of aesthetic medicine, patients appear more youthful, sympathetic, attractive and trustworthy. The symmetry of the face can be significantly improved [5].

Prevent marionette wrinkles at 30

Skin care is like physical fitness. If you have not done any sports for years, you will only achieve the endurance and strength of an athlete to a limited extent and after years of training. The longer wrinkles exist, the deeper and longer they become. You cannot start early enough with a mindful approach to your health. This includes sun protection, a healthy diet and exercise. Good skin care protects the skin from premature aging. Skin moisture, skin elasticity, skin thickness decrease more slowly and even pigmentation is preserved longer. In the case of hereditary strong tension of the corner of the mouth, a wrinkle treatment with a hyaluron gel or a muscle relaxing preparation can also be useful before the age of 30. Of course, this does not stop aging. However, a youthful and fresher appearance is preserved for longer.

How are marionette lines injected?

Immediately following an examination and explanation, we can offer you a filler treatment of the corner of the mouth on the same day. An occasional tension usually dissipates after the expert consultation with Dr. Santos Stahl. The wrinkle treatment itself takes about 30 minutes. For your comfort, a topical anesthetic cream will be applied beforehand. A pleasant atmosphere and light background music not only contributes to your relaxation, but has been proven to reduce the sensation of pain. Make-up is removed and the skin is carefully disinfected under the highest hygienic standards. The wrinkles at the corners of the mouth are usually eliminated with the point technique or the linear technique with fine needles. Therefore, of course, no visible scars remain. The corners of the mouth are usually lifted using the criss-cross technique. Depending on the hyaluronic acid and the extent of the wrinkles, an average of 0.8 millilitres (0.3 to 1.2 millilitres) is used to get rid of marionette wrinkles. A gentle massage helps to distribute the hyaluronic acid better. This allows the full effect of the treatment to unfold. Before you leave the practice, we will inform you what to look out for and how to reach Dr. Santos Stahl in an emergency. One to two weeks after the filler treatment we offer you an examination appointment. On this occasion, a follow-up injection (also called touch-up) can be performed if it is necessary to improve a natural result.

Muscle relaxants for marionette wrinkles

In patients with an excessive tension of the muscles of the mouth, a supplementary injection with muscle-relaxing substances can be useful. To correct excessive muscle tone, two to four units of the active ingredient are injected into the depressor anguli oris muscle. The injection points are located 10 millimeters to the side and 10 to 15 millimeters below the corner of the mouth. This raises the corners of the mouth a little. There is no need to fear paralysis or a mask-like, rigid facial expression. The wrinkle treatment is painless to painless and takes only a few minutes.

Vermehrte Muskelaktivität des Mundwinkelsenkers. Ein großer und hyperaktiver Muskel wird durch ein muskelentspannenden Mittel entspannt.

Fat way injection against marionette wrinkles

A PDO thread lift can correct the sagging of the fat pads of the cheeks. In certain cases, this method with thread is a useful component of a marionette wrinkle treatment. The drooping corners of the mouth, popularly known as Angela Merkel wrinkles, are also the result of sagging skin and loss of volume in the lower and upper lips and mouth area. Good results require targeted treatment of the causes in the region. Therefore, for a visible, harmonious and lasting result, softlifting should be combined with other wrinkle treatments. Hyaluronic acid injections of the lips and cheeks provide balanced and more youthful facial contours. Microneedling treatment and therapy with the patient’s own blood lead to skin rejuvenation.

Fat way syringe against marionette wrinkles

Modern minimally invasive facelift techniques preserve the natural facial expression and rejuvenate the facial expression in a harmonious way. After the age of 50 to 60, the skin can start to sag and deep wrinkles can appear. During a minor surgical procedure for facelift, mainly the structures between the skin and the facial muscles are shaped and tightened. The main goals of a facelift are to lift the fat deposits and tighten the connective tissue under the skin. After the framework is rejuvenated, only the excess skin is removed. Contrary to frequent prejudices, the procedure does not tighten the skin, but the connective tissue under the skin (SMAS). The scars of the surgical procedure disappear in the hairline or are hidden in the natural contours of the ear. The elasticity of the skin is therefore not changed by the surgical method of facelift. However, the plastic surgery procedure can also be combined with micro needling and nanofat treatment. The latter have been shown to improve skin properties. You can learn more about a facelift under facelift / facelift.

Thread lift against marionette wrinkles

Hyaluronic acid injections are, after neurotoxin injections, the second most common aesthetic treatment performed by plastic surgeons worldwide. Hyaluronic acid treatment for wrinkles at the corners of the mouth is considered a very safe treatment, provided. You are in the right hands at Centerplast for lifting the corners of your mouth. We always use a suitable and very high quality hyaluronic acid from renowned manufacturers for your needs and the optimal result.

The precise injection is not trivial and requires precise anatomical knowledge. A slight swelling and small bruises are unavoidable with an injection treatment and will disappear after one or two days.

In the case of a superficial injection, small irregularities can be felt, which quickly disappear under a light massage. Impaired skin circulation can occur if the hyaluronic acid enters a skin vessel and obstructs blood flow. The risk of circulatory problems is rare and can heal without consequences if acted upon quickly. It should therefore always be borne in mind that this is a medical, aesthetic treatment which should be carried out by qualified doctors who are also prepared for emergencies. Therefore, to be on the safe side, you should always seek treatment from plastic aesthetic surgeons who have a thorough knowledge of anatomy. Always make sure that the doctor has years of experience in the aesthetic plastic field.

Facelift against marionette wrinkles

With the help of our price calculator you already have the possibility to get an overview of the costs. If these are within your price range, it is best to first make an individual appointment with the cosmetic surgery specialist to discuss your desired result and any unanswered questions you may have. Before a first hyaluronic injections is an examination, the education and the creation of a treatment plan essential. Frequently asked questions will be answered during the personal meeting and you will receive an individual offer. The costs of wrinkle injections are calculated on the basis of the effort and the amount of hyaluronic acid used. This in turn depends on how pronounced the wrinkles are and what result is desired.

You will find further information and, in addition, answers to other questions relating to a personal consultation under Information on your consultation.

Risks of injecting marionette wrinkles

Before patients decide on a non-surgical treatment of deep marionette wrinkles and thus to lift the corners of the mouth, they want to take the opportunity to view corresponding before-and-after pictures of a wrinkle injection that the selected practice has performed. Since it is not allowed by law to publish such results online, Centerplast offers you the possibility to view such pictures of a marionette wrinkle treatment during the preliminary consultation. The patients have of course given their consent for this. You can find more information about this topic on our information page about before and after pictures under the menu item “About us”.

Testimonials on the injection of marionette wrinkles

Before patients opt for sagging skin injections for a friendly facial expression and choose a suitable experienced expert for the treatment, they usually search the internet for testimonials. People who have already used the treatment at the respective practice explain in such reports whether they were satisfied with the service, the consultation and of course with the treatment and the result of their appearance. Patient testimonials can be quite helpful. Ratings additionally provide an average overall picture of patient satisfaction. Therefore, visit our corresponding page on testimonials, which bundles all this.

Google Rating
Based on 98 reviews

The author

Unsere Fachärzte für Plastische Chirurgie Saarbrücken
Dr. Adelana Santos Stahl

“Our goal is to provide the best, most discreet and precise treatment based on our extensive expertise in plastic surgery. „

Dr. Adelana Santos Stahl is distinguished by a unique international perspective with a feminine view of plastic surgery. Her personalized and detailed approach is key to the beautiful and natural results she achieves. Having trained in Brazil, one of the largest and most well-known countries for aesthetic and reconstructive plastic surgery, she understands her patients’ desire to look and feel their best. She completed her medical studies and her training as a specialist for plastic and aesthetic surgery in Brazil. In 2009, she also successfully passed the German equivalence examinations for the medical state examination. Two years later, in 2011 she received the German and in 2012 the EU specialist recognition (EBOPRAS) for plastic surgery. From 2009 to 2013, she deepened her knowledge of aesthetic and reconstructive facial surgery with world-renowned representatives of plastic surgery such as Professor Gubisch at the Marienhospital and Madame Firmin in Paris. A VDÄPC Fellowship (continuing fellowship for graduate students) in Switzerland, France and the USA has further enriched her professional experience. Dr. Santos Stahl is active in several prestigious professional societies. Besides the DGPRÄC and DGBT, she is also a member of the Brazilian Society of Plastic Surgery – SBCP. She is also the author of several scientific articles and, together with her husband, is dedicated to research and clinical studies in the field of plastic surgery.


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