Your questions - our answers

    What are marionette lines?

    Colloquially, marionette wrinkles are also called Merkel wrinkles. The anatomical name for marionette wrinkles is mentolabial fold. The wrinkles extend from the downward corner of the mouth to the edge of the lower jaw. There are different degrees of expression of marionette folds (Carruthers A, et al., 2008, Dermatol Surg). Discreet initial signs of a marionette fold include a depression below the corner of the mouth and a slightly drooping corner of the mouth. Drooping corners of the mouth are among the first signs of aging. Over time, the furrow becomes longer and deeper. Accompanying this, a narrowing of the lips and the development of drooping cheeks can be observed. These are natural signs of aging, but they give the impression of sadness or dissatisfaction and are therefore perceived as unpleasant by those affected.

    How are marionette folds formed?

    The corner of the mouth depressor (Musculus depressor anguli oris) is a muscle that pulls the corner of the mouth downward. The corner of the mouth is connected to the skin by a connective tissue ligament (ligamentum labiomandibulare) (Pessa JE, et al, 1988, Plast Reconstr Surg). This connective tissue ligament extends from the so-called modiolus to the mandibular rim. The modiolus is a common junction of six muscles that move the mouth. The modiolus is located about one centimeter to the side of the corner of the mouth. On the mandible, the skin is connected to the bone by another ligament (ligamentum mandibularis). These connections of the skin with the nearby muscle and bone form a solid framework and form the anatomical boundary between the mouth area and the cheeks. Relative to the cheeks, there is little subcutaneous fat tissue at the mouth area. Therefore, changes in aging affect the face differently. There are four reasons for the development of marionette wrinkles:

    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?

    Google provides millions of answers to the question of what helps against wrinkles 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. The most effective ingredients of anti-aging creams include vitamin C (ascorbic acid) and vitamin A (retinol). The anti-inflammatory effect of Aloe Vera is also scientifically well proven (Budai M.M., et al, 2013, Mol Immunol). Anti-aging creams are highly recommended for prevention, but not for the treatment of drooping corners of the mouth. Hyaluronic acid or autologous fat injections add fullness to the lips and can correct sagging corners of the mouth (Carruthers J., et al, 2005, Dermatol Surg). The position of the corners of the mouth can also be corrected with a muscle relaxant (Qiang W., et al., 2016, Aesthetic Plast Surg). The most effective way to correct drooping corners of the mouth is with a mouth corner 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. Sagging fat pads of the cheeks. Sagging cheeks interrupt the youthful jawline contour, emphasizing marionette lines. For a youthful contour and softening of marionette lines, the volume on the cheeks must be restored with hyaluronic acid 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 raise 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 in combination with autologous blood treatment, improves skin elasticity and thickness. In 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.

    Effect of hyaluronic acid is scientifically proven. After hyaluronic acid treatment by qualified doctors, patients look more youthful, sympathetic, attractive and trustworthy. The symmetry of the face can be significantly improved (Othman S, et al., 2020, Aesthetic Plast Surg).

    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 treatment with hyaluronic acid or a muscle relaxant can be useful even 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 clarification, we can offer you a filler treatment of marionette wrinkles on the same day. An occasional tension usually dissolves after the expert consultation with Dr. Santos Stahl. The treatment itself takes about 30 minutes. For your comfort, a numbing cream is applied beforehand. A pleasant atmosphere and light background music not only contribute to your relaxation, but have been proven to reduce the sensation of pain. Under the highest hygienic standards, make-up is removed and the skin is carefully disinfected. Marionette lines are usually eliminated using the dot technique or the linear technique. 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 milliliters (0.3 to 1.2 milliliters) is used to get rid of marionette wrinkles. A gentle massage helps to distribute the hyaluronic acid better. Before you leave the practice, we will tell you what to look for and how to reach Dr. Santos Stahl in case of 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 relaxant against marionette wrinkles

    In patients who have excessive tension in the muscles that lower the corners of the mouth, a supplementary injection of a muscle relaxant may be useful. To correct the excessive muscle tone, two to four units of the muscle relaxant are injected into the corner of the mouth (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 slightly. There is no need to fear paralysis or a mask-like, rigid facial expression. The treatment is painless to painless and takes only a few minutes. You can learn more about the muscle relaxant here.

    Fat way syringe against marionette wrinkles

    The fat way injection is suitable for the elimination or reduction of the smallest fat pads, such as sagging cheeks. The result is visible one month after the injection. In most cases, a second injection is necessary to eliminate the excess fatty tissue of the sagging cheeks. After the injection, you may experience temporary mild swelling, pain to the touch or a bruise. In four to five percent will come a temporary muscle weakness (irritation of the ramus marginalis mandibulae) or growth disturbance of the whiskers. These symptoms resolve on their own (Jones DH, et al, 2016, Dermatol Surg; Shridharani S., 2020, Plast Reconstr Surg). Learn more about fat removal injections here.

    Thread lift against marionette wrinkles

    A PDO thread lift can correct the sagging of the fat pads of the cheeks. Thread lifting is a useful component of marionette wrinkle treatment in certain cases. Marionette lines are also the result of sagging skin and loss of volume of the lips as well as the mouth area. A beautiful result requires targeted treatment of the causes. Therefore, for visible sustainable and harmonious results, softlifting should be combined with other treatments. Hyaluronic acid injections of the lips and cheeks provide balanced and more youthful facial contours. A microneedling and autologous blood treatment for skin rejuvenation.

    Facelift 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, a disturbing sagging of the skin can occur. During a facelift, the structures between the skin and the facial muscles in particular are shaped and tightened. The main goals of a facelift are to lift the fat pads and tighten the connective tissue under the skin. After the framework is rejuvenated, only the excess skin is removed. Contrary to common preconceptions, it is not the skin that is tightened, but the connective tissue under the skin (SMAS). The scars disappear in the hairline or are hidden in the natural contours of the ear. Therefore, the elasticity of the skin does not change with a facelift. However, a facelift can also be combined with microneedling and nanofat treatment. The latter have been shown to improve skin properties. You can learn more about a facelift here.

    Risks of injecting marionette wrinkles

    Hyaluronic acid injections are, after neurotoxin injections, the second most common aesthetic treatment performed by plastic surgeons worldwide. Hyaluronic acid treatment of marionette lines is considered a very safe treatment, provided you are in the right hands and appropriate high quality hyaluronic acid is used. The pinpoint 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 may be palpable, which quickly disappear under a light massage. Impaired skin circulation may occur if the hyaluronic acid enters a skin vessel and impedes blood flow. The risk of impaired blood flow is rare and can heal without consequences if acted upon quickly. Therefore, it should always be remembered that this is a medical aesthetic treatment that should be performed by qualified doctors who are also prepared for emergencies.

    Author’s statement

    Author: Stéphane Stahl, MD, PhD. There are no financial relationships with the pharmaceutical or medical device industries that could have influenced the above text. Any reproduction, even partial, is permitted for personal use only. All texts used on this website are protected by copyright.

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