Marionette Line Filler

What is marionette line filler?

Marionette line filler is the injection of hyaluronic acid gel to treat the lines that run from the corners of the mouth down to the chin and volume loss around the corners of the mouth. These lines appear with age and are visible even when your face is at rest, which is why they are described as static lines around the mouth. The filler targets the volume loss seen in the fat layers above and below the muscle in this area.

These lines form when several factors combine, so a multi-pronged approach that considers filler and muscle treatments together is favoured. According to published sources, a low-viscosity hyaluronic acid is injected superficially for the fine line on the skin surface; where muscle movement is involved, filler may be combined with botulinum toxin, which has a muscle-relaxing effect.

Hyaluronic acid fillers are not permanent and can be dissolved with the enzyme hyaluronidase. Research on complications from permanent fillers shows that hyaluronic acid continues to be preferred because of this reversibility. When the clinic assesses a product, approval by the US Food and Drug Administration (FDA) is not the deciding criterion on its own; the assessment is based on the product’s CE marking, its registration and conformity status in Türkiye, and the manufacturer’s intended purpose.

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What does ‘marionette’ mean?

A marionette is a puppet worked by strings; in Turkish it is also spelt ‘marionet’. The two lines running from the corners of the mouth down to the chin got their name because they resemble the mouth lines of puppets whose jaw moves as a separate piece.

In medicine, other names are also used for the same area: the labiomandibular fold or the mouth-corner line. A marionette line is also described as a static labiomandibular fold: a fold that is visible not only when you speak or your expression changes, but also when your face is at rest. This distinction matters, because a line that shows only with movement and a line that is also visible at rest may not have the same solution.

According to published sources, the fine line running down from the corner of the mouth (the commissural line) and the fold between the cheek and the lip (the melolabial fold) are also part of this picture. So what is described in everyday language as a single ‘marionette’ concern is often the sum of several separate findings.

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Why do marionette lines form?

Marionette lines have no single cause. Bone loss, gravity, changes in the fat compartments, muscle pressure, the ligaments that hold tissue in place and skin ageing all play a part together. It has also been reported that people of Asian descent have a tendency towards sagging in this area because of the structure and position of the point where the muscles around the corner of the mouth meet (the modiolus); in other words, this tendency varies from person to person and between populations.

The fold itself forms at the border between two different tissues. In a cadaver study, the fold was described as the boundary between a fat-rich zone on the outer side and a zone with little fat on the inner side. The same study showed that fibres of the muscle that pulls the corner of the mouth down (depressor anguli oris), the neck muscle (platysma) and a cheek muscle form a network that extends into the skin, and that with age the downward pull of these muscles makes the fold more pronounced.

Fat tissue also shifts. A study comparing MRI scans of the same people taken at least four years apart reported that lengthening and descent of the fat pad in the cheek (buccal fat) made this fold worse. The bone underneath changes too. Research shows marked bone loss (bone resorption) in the facial skeleton, especially in the bones that hold the teeth: reduced bone support creates the impression that the tissues have moved down, and reduced ligament support loosens the tissue above.

A joint assessment by doctors from different specialties also describes lower-face ageing as a process driven by a combination of changes in bone structure, descent of the soft tissues and increased muscle activity. Filler addresses the volume-related part of these processes. Which of these is most prominent in your case is assessed at a consultation.

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Down-turned mouth corners and the role of muscle

When the corners of the mouth look turned down, the pull of the muscle that draws them down (depressor anguli oris) plays a part, as well as volume loss. It has been reported that botulinum toxin injected into this muscle can support the result of filler by reducing the downward force on the corner of the mouth. Botulinum toxin is often called Botox®, a brand name that has passed into everyday use.

The position of this muscle is not the same in everyone. In an ultrasound study of 41 patients, the muscle’s depth below the skin and its width varied along the fold; in about one third of patients, no fibres of this muscle were found in some parts of the fold. According to a consensus panel of 14 experts, the strongest reason for treating this muscle is to correct down-turned corners of the mouth. Because the muscles of the lower face have important functions, the same panel points out that treatments in this area carry a higher risk of side effects.

When looking at study results, what they do not show matters as much as what they do show. In a randomised, double-blind trial (in which participants are randomly assigned to groups), injection into the lower part of the muscle was found to be more effective than injection into the upper part; no serious side effects were reported. In another study that followed 34 volunteers, the position of the corner of the mouth improved on measurement, but there was no significant change in the global aesthetic improvement score; the researchers noted that this improvement may not make a meaningful difference for patients. In a study of 51 people, the effect had returned to baseline by the end of follow-up, and no satisfactory result was achieved in the most severe cases.

These findings show that marionette lines are not only a volume problem; they do not put one method ahead of the other. How prominent the muscle’s effect is in your case, and whether a separate treatment should be considered for it, is assessed at a consultation; the decision is still yours.

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The link with jowls (sagging along the jawline)

Right next to the marionette line, there is often some sagging along the jawline. This sagging, known as jowls, is a different process from the volume loss that filler targets. An anatomical study of 49 cadavers showed that jowls form in the layer under the skin, over the rear part of the ligament of the lower jaw (mandibular ligament). According to the same study, the fold below the corner of the mouth marks the rear edge of the area where the muscle that pulls the corner of the mouth down is firmly attached to the skin.

According to this study, the connective tissue under the skin is short and elastic in youth: it allows the mouth to open wide but does not cause laxity. With age, this tissue lengthens and loosens, and an excess forms under the skin and in the skin. The jowl is this excess itself. Another study, which used a computer model of the face, also showed that changes in the skin, the tissue under the skin and the retaining structures that anchor the skin to deeper structures are needed for jowls to form, but that none of these is enough on its own.

In short, jowls are not a lack of volume but excess tissue and laxity. Supporting the hollow beside the corner of the mouth with filler does not remove the sagging above it. A review of non-surgical methods for the jaw and chin area stresses that these methods are not a substitute for surgery and offer temporary solutions. Thread lifts and surgery are also listed as separate options for this area; which of these is considered is a separate decision.

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How strong is the evidence?

The data supporting hyaluronic acid in the marionette area are more limited than those for the nose-to-mouth lines (nasolabial folds) and the lips. In a systematic review of 53 clinical reports on hyaluronic acid fillers, the highest-quality evidence related to the nasolabial folds. For the corners of the mouth and marionette lines, the evidence is at a lower level; it comes from non-randomised, open-label (where both patient and doctor know which product is used) or retrospective studies.

In the sources reviewed, no controlled study was found that directly targeted marionette lines and compared the results with an untreated group or with another method. In a prospective, open-label study of marionette lines, carried out after the product had come onto the market, 69.9% of the 83 participants who completed the study showed an improvement of at least one point on a validated scale at one month. The researchers cited the lack of published data on the product’s effectiveness in this area as the reason for the study. This study had no control group.

In a randomised trial of 280 people assessing filler for the lips and the area around the lips, the corners of the mouth were tracked with a separate scale; in the researchers’ assessment, a difference was reported between two hyaluronic acid products in this area. However, the main aim of this study was lip fullness. In an analysis combining data from two studies in people with olive or dark skin (Fitzpatrick skin types IV–VI), 46.4% of the 56 people treated for the corners of the mouth were classed as responders; in the same group, the figure for lip fullness was 85.0%.

These figures are not a promise of results; they were obtained with different products, different techniques and different scales, and they are not results from this clinic. A five-point photographic scale specific to marionette lines has also been developed and validated so that studies can be compared objectively and reproducibly.

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Limits of this treatment

Marionette line filler supports areas of volume loss around the corners of the mouth; on its own, it does not correct the other factors that contribute to the line. These lines are a multifactorial picture created by bone loss, changes in the fat compartments, muscle pull, the ligaments that hold tissue in place and skin ageing together. Filler addresses the volume-related part of this.

In practical terms, this means:

• Jowls (sagging along the jawline) result from excess and laxity in the skin and the tissue under the skin; filler does not remove this excess.
• Filler does not eliminate the movement of the muscle that pulls the corners of the mouth down.
• Fine lines on the skin surface and skin quality are a separate matter.
• Hyaluronic acid fillers are not permanent; the treatment may need to be repeated to maintain the effect.
• Non-surgical methods are not a substitute for surgery and offer temporary solutions.

Trying to make up for sagging with volume also carries a risk. The condition known as facial overfilled syndrome is linked to excessive or inappropriate use of fillers; it shows up as a distorted shape of the face at rest and unnatural facial movements. According to a review on this subject, the problem cannot be explained by excess volume alone; placement that does not suit the anatomy and the build-up of repeated treatments also play a part. For this reason, the priority is to reduce the risk of this condition developing.

The aim is not to put you off but to help you compare the options. Which path makes sense for you — filler, another method or none at all — is decided through the assessment at your consultation and by your own decision. Having no treatment at all is also a valid outcome.

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Blood vessels and nerves in this area

The facial artery and its branches run through the corner of the mouth and the area around it, so knowledge of anatomy is the foundation of safety in marionette line filler. In procedures in this area, the entry points and the technique must be chosen carefully to reduce the risk of damage to blood vessels such as the facial artery and to the nerve that carries sensation from the skin of the chin (the mental nerve).

The depth of the artery is not the same in everyone. In an analysis combining 12 studies (a meta-analysis), the average depth of the facial artery at the level of the corner of the mouth was 9.72 mm, based on 794 vessels; however, the confidence interval covers a wide range, from 6.50 to 12.94 mm. The artery that runs horizontally between the lip and the chin and the superficial branches of the facial artery are also structures that need care. Because the course of blood vessels can vary from person to person and unusual courses can occur, an individual approach is favoured.

According to a review of complications from permanent fillers, the injection site, the technique and the permanence of the filler play a greater role in severe and permanent outcomes than the amount injected. It has also been reported that deep layers in this area can be treated with a cannula (a fine, flexible tube with a blunt tip). At the clinic, the doctor chooses a needle or a cannula for each person, based on the treatment area and the anatomy.

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Known risks

With hyaluronic acid fillers in the face, the most commonly reported side effects are swelling, bruising, pain, redness and firmness you can feel; these are mostly temporary. An analysis combining randomised controlled trials also reported lumps or bumps you can feel, tenderness, itching and discolouration.

Reports of side effects are not rare. In an analysis of 42 studies looking at non-surgical facial treatments together, hyaluronic acid fillers in the lower face and nasolabial folds were the group with the most frequently reported side effects among the treatments examined; the most commonly reported were swelling and pain. The researchers also stress that side effects should be reported in more detail, including when they start and how long they take to resolve. Another analysis combining treatments around the mouth found that injection-site reactions generally remained mild or moderate.

Delayed-onset inflammatory reactions are rare, but they can appear months or even years later. An analysis of facial treatments calculated the frequency of these reactions as about one event for every 2,000 patients followed for one year. The median time to onset was 3 months; the shortest was two weeks and the longest was 12 years. Common presentations are nodules (lumps under the skin), redness, swelling and hardening.

The most serious risk, though rare, is vascular occlusion (a blocked blood vessel); this is covered in the Vascular occlusion and hyaluronidase section. The findings here are based on averages from studies and are not results from this clinic. What the risks mean for you is discussed at your consultation, together with your medical history.

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Vascular occlusion and hyaluronidase

If filler blocks an artery, it can disrupt the blood supply to the tissue. This occurs rarely, but early recognition determines the outcome. In an analysis of vascular occlusions after filler, the most commonly affected areas were those with complex blood vessel anatomy: between the brows, the nose and the nasolabial folds. Timely recognition and treatment were associated with better recovery, and delays of more than five days were associated with permanent damage.

In the same study, using hyaluronidase for occlusions caused by hyaluronic acid was associated with a high rate of partial or complete recovery, and its role as first-line treatment was confirmed once again. Emergencies such as vascular occlusion and vision loss need treatment without delay.

Non-urgent situations are assessed separately: non-inflammatory nodules you can feel, a bluish discolouration under the skin (the Tyndall effect) and hypersensitivity reactions. Controlled study data on these situations are limited. Hyaluronidase is kept at the clinic. How to contact the clinic if you notice symptoms is explained to you at your consultation, before the treatment.

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If you have had filler before

If you have had filler in the marionette area before, the first question is not a new treatment but what the existing filler is. Research shows that permanent fillers increase the risk of complications in the long term; hyaluronic acid continues to be preferred because it can be reversed. The permanence of a filler is also counted among the factors that determine severe outcomes.

For filler done elsewhere, you are first asked about the type of filler, when it was injected and in which area; filler of unknown type, or filler that cannot be confirmed to be hyaluronic acid, is not dissolved straight away. If you have a record of your previous treatment, this information is useful at your consultation.

When previous treatments were done, in which area and with what type of filler are also part of the question of whether a new treatment is needed. It has been reported that the cumulative load of repeated treatments also plays a part in facial overfilled syndrome. So past treatments matter not only for safety but also for the plan itself.

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