Marionette lines: what helps and what doesn't

What are marionette lines, and why do they form?

Marionette lines are the vertical creases that run downward from the corners of your mouth towards the chin and jawline. They're named after puppet mouths, which is fairly accurate: they give the impression of a downturned or sad expression, even when you're smiling or at rest.

They form because of three overlapping factors. First, the depressor anguli oris muscle, which pulls the mouth corners downward, becomes more active or dominant over time. Second, volume loss in the lower face and chin causes the skin to sag, which deepens any existing fold. Third, skin elasticity declines with age, so the tissues don't rebound the way they did in your twenties. The result is a crease that looks permanent even when you try to lift it with a smile.

Why direct filler into the line often makes things worse

Many people assume the answer is to inject filler directly into the marionette line itself, the same way you might plump a lip. This is where the first mistake happens. When you fill only the line without addressing the surrounding volume loss, you create a ridge effect. The skin on either side of that line casts a shadow, making the line appear deeper and more pronounced rather than softer.

Think of it like highlighting a wrinkle with a shadow: if you only fill the bottom of a fold, the edges stand out more. The solution is to work in layers and address the deeper structures first. In my clinic, we focus on restoring volume in the supramuscular and submuscular layers, particularly in the prejowl sulcus and chin projection area. This lifts the skin naturally and softens the line as a consequence, rather than drawing attention to it.

Using a cannula for deeper placement allows precise distribution of filler where it actually addresses the anatomical problem: volume loss below the marionette line, not the line itself.

DAO Botox: lifting the mouth corners

The depressor anguli oris (DAO) is the small muscle at the corner of the mouth that pulls it downward. When injected with Botox, this muscle is temporarily weakened, which allows the natural upward-pulling muscles of the mouth to take over. The result is a subtle lift at the mouth corners and a reduction in the downturned appearance.

The dose is small: typically 2-4 units per side of the mouth. This is one of those treatments where less is always better. Too much Botox in the DAO can create an odd, overly-wide grin or an asymmetrical appearance. The goal is a gentle lift that looks like you've had a good night's sleep, not a surgical surprise.

You'll see results within 3-5 days, though the full effect takes about two weeks. The lift lasts between 3 and 6 months, depending on how quickly you metabolise the product. DAO Botox is most effective when marionette lines are primarily driven by dynamic muscle pull rather than deep volume loss, though in reality, most people benefit from combining it with filler for the best outcome.

Strategic filler placement: volume, support, and lift

Dermal fillers work for marionette lines by restoring the lost volume that allows gravity and muscle pull to deepen the fold in the first place. The key is placement: we're not filling the line, we're supporting it by lifting the tissues around it.

The best results come from a technique that addresses three areas: the chin projection, the prejowl sulcus (the shadow between the chin and jawline), and the lower cheek just above the marionette line itself. By restoring volume in these zones, the skin naturally sits higher and the marionette line softens as a side effect. It's a much more natural-looking result than trying to fill the line directly.

Hyaluronic acid fillers are the standard choice. Results are visible immediately and typically last between 6 and 18 months. Because hyaluronic acid fillers are reversible with an enzyme called hyaluronidase, there's a safety margin: if the result isn't right, we can adjust it.

Biostimulators: skin quality and longer-term improvement

For some clients, particularly those with more significant skin laxity or loss of elasticity, adding a biostimulator like HarmonyCa or Sculptra can make a real difference. These products work differently from traditional fillers: instead of adding immediate volume, they stimulate your own collagen production over weeks and months.

The advantage is that you're improving the quality and thickness of the skin itself, not just filling a space. This is particularly useful in the lower face where skin tends to become crepey and thin. Results build gradually and last considerably longer than hyaluronic acid.

The combined approach: why it works

Marionette lines are a multifactorial problem, which means they benefit from a multimodal treatment. Botox alone won't lift the corner of your mouth if there's significant volume loss. Filler alone won't address the dynamic downward pull of the DAO muscle. Combining the two gives you both lift and support.

• · DAO Botox addresses the dynamic component: the muscle that pulls the mouth down.
• · Strategic filler addresses the static component: the volume loss and skin descent that deepen the line.
• · Together, they soften the line, lift the mouth corner, and restore the definition of the jawline.
• · Biostimulators can be added if skin quality is poor, for a longer-lasting and more fundamental improvement.

In my clinic, we usually start with Botox and filler in the same appointment. This allows time for the Botox to take effect (which it does gradually over two weeks) while the filler provides immediate support. By the time the Botox is at full strength, the combined result is a naturally lifted, softened lower face.

A short safety note

Botox and dermal fillers are prescription-only medicines in the UK and must be administered by a trained, qualified practitioner. Marionette line treatment requires a thorough understanding of lower facial anatomy, particularly the position of the DAO muscle and the blood supply to the lower face. Injecting in the wrong plane or with too much product can cause asymmetry, nerve compression, or vascular complications.

If you're considering treatment, book a consultation with a practitioner who has relevant training and experience, and who will talk you through the risks and realistic outcomes before you commit. A good consultation should take at least 30 minutes.