Treating marionette
lines Saarland

Remove marionette lines in Saarbrücken

Colloquially, the so-called marionette lines are often referred to as Merkel lines. The anatomical name of the Merkel fold is mentolabial fold. These mouth folds extend from the downward-facing corners of the mouth to the edge of the lower jaw. There are different degrees of these wrinkles 1 . Discreet first visual hints of a marionette fold are a depression below the corner of the mouth and a slightly falling corner of the mouth. Pronounced marionette lines are one of the first signs of ageing and can sometimes appear at a young age. With increasing age, the collagen in the skin decreases and the furrow becomes longer and deeper over time.

This can be accompanied by a narrowing of the lips and the development of sagging cheeks. These are signs of the natural aging process, but they convey a sad expression on the face or 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 ageing. In addition to UV radiation, an unhealthy diet and cigarette smoking also have a negative impact on the skin and accelerate ageing and thus the appearance of wrinkles.

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Information at a glance

Duration of treatment - Icon

Duration of treatment

30 minutes

Aftercare - Icon



Anesthesia - Icon


Anesthetic cream / vibration anesthesia / local anesthesia

Thread tension - Icon

Thread tension


Hospitalization - Icon



Socially acceptable - Icon

Socially acceptable


Additions or alternatives - Icon

Additions or alternatives


Treatment consultation for the treatment of marionette lines

How do marionette lines develop?

This is one of the most frequently asked questions. The angular depressor muscle (Musculus depressor anguli oris) is a muscle that pulls the corner of the mouth downwards. The corner of the mouth is connected to the skin via a connective tissue ligament (labiomandibular ligament) 2 . This connective tissue ligament extends from the so-called modiolus to the edge of the lower jaw. The modiolus is a common connection point 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 lower jaw up to the chin, the tissue of the skin is connected to the bone by another ligament (mandibular ligament). These connections between the skin and the nearby muscle and bone form a firm framework and the anatomical boundary between the mouth area and the cheeks. In relation to the cheeks, there is very little subcutaneous fatty tissue around the mouth. This is why ageing has different effects on the entire face. There are four reasons for the development of mentolabial folds:

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

In young people, increased contraction of the corner of the mouth is the cause of drooping corners of the mouth 3 . Depending on lifestyle habits and predisposition, the first signs of ageing, such as drooping corners of the mouth, can already be seen from the age of 30. The lips become thinner, mentolabial folds and sagging cheeks appear. The ageing of the skin in particular and of the tissue in general is accelerated by the following factors:

  1. Ultraviolet light
  2. Cigarette smoking
  3. Common air pollution pollutants such as ozone, carbon monoxide, nitrogen oxides and particulate matter 4
  4. Genetic characteristics (the ends of the chromosomes called telomeres)

Ageing cells are characterized by a disturbed energy metabolism (mitochondria) and damage to the genetic material (DNA). UV light, cigarette smoke and air pollution lead to the activation of messenger substances (interleukins), which trigger a response from the immune system. Over time, inflammatory messenger substances 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 ageing process.

Treatment of marionette lines

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 treatments such as facial exercises, massage or ultrasound are not able to influence the formation of wrinkles. Anti-ageing creams are highly recommended for prevention, but not for treating drooping corners of the mouth. Hyaluronic acid or autologous fat injections add fullness to the lips and can correct sunken corners of the mouth 5 . The position of the corners of the mouth can also be corrected with a muscle-relaxing agent 6 . The most effective way to correct drooping corners of the mouth is with a corner of the mouth lift.

What to do about marionette lines?

A sensible and holistic treatment must take into account all factors that contribute to the development of marionette lines in order to achieve natural harmonious results.

  1. Sinking of the fat pads of the cheeks. Sagging cheeks interrupt the youthful jawline and emphasize the folds at the corners of the mouth. For a youthful contour and reduction of marionette lines, the volume of 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 sagging fat deposits again. During a facelift, the fat pads are returned to their original position.
  2. Sagging of the skin. Microneedling, especially in combination with a treatment using the body’s own blood, improves skin elasticity and thickness. If the therapy is applied to the face using the patient’s own blood, this is also referred to as a vampire lift. If the skin is thin, the body’s own collagen formation can also be stimulated with Sculptra® (Poli-L-lactic acid). Hyaluronic acid that has been lost can also be injected. Excess skin is most effectively treated with a facelift.
  3. Atrophy of the subcutaneous fatty tissue. Replacing the volume of the lips and the mouth area smoothes the contours, corrects sunken corners of the mouth and helps to create 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 has been scientifically proven. It occurs in a very short time. After a hyaluronic acid treatment by qualified doctors of aesthetic medicine, patients appear more youthful, likeable, attractive and trustworthy. The symmetry of the face can be significantly improved 7 .

Preventing marionette lines at 30

Skin care is like physical fitness. Anyone who has not done any sport for years will only achieve the endurance and strength of an athlete to a limited extent and after years of training. The longer wrinkles persist, the deeper and longer they become. You can’t start paying attention to your health early enough. This includes sun protection, a healthy diet and exercise. Good skin care protects the skin from premature ageing. Skin moisture, skin elasticity and skin thickness decrease more slowly and even pigmentation is maintained for longer. If the corners of the mouth are severely strained due to hereditary factors, wrinkle treatment with a hyaluronic gel or a muscle-relaxing preparation can be useful even before the age of 30. Of course, this does not stop ageing. However, a youthful and fresher appearance is retained for longer.

Procedure of a marionette wrinkle treatment


Immediately following an examination and consultation, we can offer you a filler treatment for the corner of the mouth on the same day. Occasional tension usually dissipates after a professional consultation with Dr. Santos Stahl.

The treatment

The wrinkle treatment itself takes about 30 minutes. For your comfort, a local anesthetic cream is applied in advance. A pleasant atmosphere and light background music not only contribute to your relaxation, but have also been proven to reduce the sensation of pain. Make-up is removed and the skin is carefully disinfected to the highest hygienic standards. The wrinkles at the corners of the mouth are usually removed using 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 severity of the wrinkles, an average of 0.8 milliliters (0.3 to 1.2 milliliters) is used to get rid of the marionette lines. Gentle massaging helps to distribute the hyaluronic acid better. This allows the full effect of the treatment to unfold.

After the treatment

Before you leave the practice, we will inform you what to look out for and how to contact Dr. Santos Stahl in an emergency. One to two weeks after the filler treatment, we offer you an examination appointment. On this occasion, a touch-up injection can be performed if necessary to improve the natural result.

Your experts for filler treatment

Dr. Adelana Santos Stahl
Dr. Adelana Santos Stahl
Dr. Stephane Stahl
PD. Dr. Stéphane Stahl

In patients with excessive tension in the muscles that lower the corners of the mouth, additional injections with muscle-relaxing active ingredients can be useful. To correct the excessive muscle tone, two to four units of the active substance 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 slightly. There is no need to worry about paralysis or a mask-like, rigid facial expression. The wrinkle treatment is painless to painless and only takes a few minutes.

Increased muscle activity of the corner of the mouth. A large and hyperactive muscle is relaxed by a muscle relaxant.

Sketch of a woman with the corners of her mouth pulled down

A PDO thread lift can correct the sagging of the fat pads in 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 a loss of volume in the lower and upper lips as well as the mouth area. Good results require targeted treatment of the causes in the region. For a visible, harmonious and long-lasting result, soft lifting should therefore be combined with other wrinkle treatments. Hyaluronic acid injections of the lips and cheeks ensure balanced and more youthful facial contours. A microneedling treatment and therapy with the patient’s own blood lead to skin rejuvenation.

Modern minimally invasive face-lifting techniques preserve natural facial expressions and rejuvenate the facial appearance in a harmonious way. After the age of 50 to 60, skin sagging and deep wrinkles can become disturbing. During a minor surgical procedure to lift the face, the structures between the skin and the facial muscles are shaped and tightened. The main aims of a facelift are to lift fat deposits and tighten the connective tissue under the skin. Once the scaffold has been rejuvenated, only the excess skin is removed. Contrary to common preconceptions, the procedure does not tighten the skin, but the connective tissue under the skin (SMAS). The scars from the surgical procedure disappear into 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 the facelift. However, the plastic surgery procedure can also be combined with micro needling and nanofat treatment. The latter have been proven to improve the skin’s properties. You can find out more about a facelift under Facelift.

Risks of injecting marionette lines

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

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

With a superficial injection, small irregularities can be felt, which quickly disappear with a light massage. Impairment of the skin’s circulation can occur if the hyaluronic acid enters a skin vessel and impedes blood flow. The risk of circulatory disorders is rare and can heal without consequences if action is taken quickly. It should therefore always be borne in mind that this is a medical, aesthetic treatment that must be carried out by qualified doctors who are also prepared for emergencies. To be on the safe side, you should therefore always be treated by plastic and aesthetic surgeons who have a comprehensive knowledge of anatomy. Always make sure that the doctor has years of experience in the aesthetic plastic surgery field.

Treating marionette lines

Consultation with a patient

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

Before and after pictures of marionette lines injections

Before patients decide on a non-surgical treatment for deep marionette lines and thus for lifting the corners of the mouth, they would like to take the opportunity to view corresponding before and after pictures of a wrinkle injection performed by the selected practice. Since it is not legally permitted to publish such results online, Centerplast offers you the opportunity to view such images of a marionette wrinkle treatment during the preliminary consultation. The patients have of course given their consent for this.

Testimonials on the injection of marionette lines

Before patients decide to undergo 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 undergone treatment at the practice in question 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 voices can be very helpful. Ratings also provide an average overall picture of patient satisfaction.

Dr. Adelana Santos Stahl has a unique international perspective with a female view of plastic surgery. Your individual and detailed approach is the key to the beautiful and natural results. Having trained in Brazil, one of the largest and best-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 training as a specialist in plastic and aesthetic surgery in Brazil. In 2009, she also successfully passed the German equivalence examinations for the state medical examination.

Two years later, in 2011, she received the German and in 2012 the EU specialist certification (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 scholarship for graduate students) in Switzerland, France and the USA has further enriched her professional experience. Dr. Santos Stahl is active in various renowned professional associations. In addition to 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.

She has been based in Saarbrücken since 2019.

  1. Carruthers A, et al., 2008, Dermatol Surg ↩︎
  2. Pessa JE, et al., 1988, Plast Reconstr Surg ↩︎
  3. Qiang W., et al, 2016, Aesth Plast Surg ↩︎
  4. Ferrara F, et al, 2021. Plast Reconstr Surg ↩︎
  5. Carruthers J., et al., 2005, Dermatol Surg ↩︎
  6. Qiang W., et al., 2016, Aesthetic Plast Surg ↩︎
  7. Othman S, et al., 2020, Aesthetic Plast Surg ↩︎

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The CenterPlast

CenterPlast GmbH
Bahnhofstraße 36
66111 Saarbrücken

Telefon +49 681 30140055

Opening hours

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08.00 Uhr – 12.00 Uhr 13.00 Uhr – 16.00 Uhr
08.00 Uhr – 13.00 Uhr
08.00 Uhr – 12.00 Uhr 13.00 Uhr – 16.00 Uhr
09.00 Uhr – 12.00 Uhr 13.00 Uhr – 18.00 Uhr
Centerplast in Saarbrücken