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Marionette lines are a common sign of aging, making the face appear saggy or downturned. According to board-certified plastic surgeon Dr. Christopher Costa, "These are those lines that extend from the corners of your mouth to your chin. Sometimes, making the face look more 'pulled down' or saggy. These are a part of the aging process because with aging comes a loss of collagen and elasticity in the skin, which causes it to sag and wrinkle. The muscles beneath the skin also weaken over time, contributing to the formation of these lines."
Aging is the primary cause of marionette lines, but other contributing factors exacerbate their development. Dr. Costa emphasizes that "It's not just about aging or genetics. Sun exposure is one of the biggest causes because it breaks down collagen and elastin faster. Smoking nicotine is another big one because it constricts blood vessels, reducing oxygen flow to your skin and accelerating aging. Even repetitive facial movements, like frowning or pursing your lips, can deepen these lines over time. It's like folding a piece of paper repeatedly—the more you do it, the more permanent the crease becomes," he told HOLA! USA.
Common Risk Factors
Certain individuals are more susceptible to developing marionette lines. Dr. Costa notes, "I find that patients with heavier-set cheeks and a lot of skin laxity are more likely to see marionettes. To put it frankly, no one is immune to aging, so it's just a question of when and how these lines appear."
Non-Surgical Treatment Options
Several non-invasive treatments offer effective solutions for individuals looking to reduce marionette lines without surgery. Dr. Costa highlights that "Dermal fillers are one of the most effective ways to address marionette lines without surgery. They help put back some volume and smooth out the lines immediately." He adds, "Fillers, like Juvederm or Restylane, are injected into areas where the skin has lost volume, essentially propping it up and smoothing the lines. They're like spackle for your skin but more sophisticated. The effects are instant and can last anywhere from 9 to 18 months."
Dr. Viktoryia Kazlosukaya, a board-certified dermatologist, shared additional treatments with HOLA! USA: "Additional laser resurfacing and tightening procedures such as Sofwave, as well as Botox for specific muscles on the lower face and jawline, may also benefit. And be consistent with skincare, especially sun protection and retinol—this is a must!"
Botox and Neurotoxins
Both Dr. Costa and Dr. Kazlosukaya agree that Botox can be an effective treatment for marionette lines. Dr. Kazlosukaya explains, "Botox can be injected into the depressor angular muscle to elevate the corners of the mouth slightly. Injection along the jawline and lower neck can also additionally relax the skin in this area. The results are less long-lived compared to dermal fillers, and one would need to maintain the results every 3-6 months."
Preventative Measures and Lifestyle Adjustments
Experts stress the importance of preventive care. Dr. Costa advises, "Prevention is key when it comes to marionette lines. A good skincare routine with daily sunscreen is essential to protect the skin from sun damage, accelerating aging. Incorporating retinol into your routine can help boost collagen production, and collagen supplements may support skin elasticity. Avoiding smoking and managing facial expressions can also help minimize the development of these lines. Also, Japanese face tape can help to prevent these from forming, or getting worse if they're already there."
According to Dr. Arnold Breitbart, MD, a board-certified facial plastic surgeon based in New York, "daily sunscreen use helps protect against UV damage that weakens skin structure over time, and retinol stimulates collagen production and enhances skin cell turnover. Although more controversial, Collagen supplements may benefit some people by supporting the skin's natural building blocks."
Potential Risks and Side Effects
While non-surgical treatments are generally safe, they do carry some risks. Dr. Costa notes, "Like any procedure, there are some risks involved with fillers or surgery. Common side effects include bruising, swelling, or redness at the injection site, which usually resolves within a few days. In rare cases, infection or allergic reactions may occur. Working with a qualified professional is important to minimize risks and ensure the best results."
Dr. Kazlosukaya adds, "With surgical treatments, scarring is a potential side effect, as well as less desirable results."
Dr. Breitbart adds, "Risks associated with dermal fillers include bruising, swelling, and temporary lumps at the injection site, though these typically resolve quickly. Rare complications include vascular occlusion or infection, which is why it's important to get treatment from an experienced injector. "For surgical treatments like a facelift, risks include scarring, anesthesia-related complications, and temporary numbness or swelling. Always seek treatment from a board-certified plastic surgeon or injector who understands facial anatomy and can tailor the treatment appropriately."
Choosing the Right Treatment Plan
Determining the best approach to treating marionette lines depends on the individual's facial anatomy and desired outcomes. Dr. Costa explains, "It all starts with a conversation. I look at the patient's skin, facial anatomy, and ask about their goals. Are they looking for a quick fix, or ready to invest in something longer-term? Based on that, we tailor a plan that might include fillers, Botox, or even a combination of treatments like skin tightening. Every face is different, and my job is to bring out your best features in the most natural way possible."
Dr. Kazlosukaya echoes this sentiment: "Usually, I thoroughly evaluate the patient and perform standardized photography in all face positions to evaluate the extent of skin changes and laxity. Based on this, I develop a plan that would be the most beneficial for the patient."
Emerging Treatments and Future Innovations
The field of aesthetic medicine continues to evolve, offering new possibilities for treating marionette lines. Dr. Costa expresses excitement about "advances in non-surgical options like bio-stimulatory fillers, which help stimulate collagen production for longer-lasting results. I'm also excited to see how new technologies in skin tightening can complement filler treatments for even better outcomes, especially with the current GLP-1 boom that has led to a lot of saggy skin."
Dr. Kazlosukaya adds, "I know that more dermal filler companies are entering the market, which will expand the plethora of treatments already available. Additionally, we now have more devices—lasers, ultrasound, and radiofrequency-based technologies—that can also be used in this area with predictable results."
Alan Matarasso, MD, FACS, president of The Plastic Surgery Foundation, an organization that supports the research and international activities of the American Society of Plastic Surgeons (ASPS) and ASPS Member Surgeon, told HOLA! USA that "There are continually emerging treatments, both surgical and non-surgical. That's why you want to go to a qualified board-certified professional and a member of the American Society of Plastic Surgeons."
According to Dr. Matarasso, qualified experts "can explain the different options based on your unique anatomy and whether you want a non-invasive or invasive treatment. Whereas if you go to someone who just has one type of treatment or owns one machine, they're necessarily going to give you what they have available to them. So it's important to know the full range of options by seeing a qualified, board-certified plastic surgeon."
While marionette lines are a natural part of aging, several preventative and corrective treatments can help maintain a fuller appearance. With continued advancements in aesthetic medicine, patients now have more tools than ever to achieve natural, long-lasting results.