Marionette Lines and Downturned Mouth Corners: Causes and Treatment
Marionette lines run from the corners of the mouth toward the jawline. They can make a relaxed face look unhappy or angry. Because several factors contribute, a natural result starts with understanding why tissue has descended rather than simply filling the line.
Why do marionette lines form?
A review of perioral aging describes the combined effects of UV exposure, bone resorption, repeated muscle contraction, gravity, tissue changes, and lifestyle. Together, these deepen nasolabial folds, lower the mouth corners, and contribute to marionette lines and an uneven chin.
Shifting facial fat adds to the change. Subcutaneous fat sits in separate compartments. With age, its support weakens and cheek fat descends toward the mouth and jaw. Strong ligaments beside the mouth hold that area in place, so descending fat stops at that boundary and forms a visible crease.
Are marionette lines more likely in Asian faces?
A 2025 study of the modiolus (the point where muscles meet at the mouth corner) reported that anatomical features in Asian faces can predispose people to downturned corners and folds. Because several causes coexist, the authors concluded that combining filler with muscle-relaxing injections can help.
People who habitually press their lips tightly together or have strong mouth-corner depressor muscles may develop these lines at a younger age.
How does treatment change with the cause?
The visible pattern and suitable treatment depend on what is driving the line.
| Cause | What you see | Common approaches |
|---|---|---|
| Volume loss around the mouth | A hollow and shadow below the mouth corner | Restore volume with CaHA filler or a collagen stimulator |
| Descending cheek tissue and jowls | Tissue hangs above the jawline | Lift with ultrasound or threads |
| Reduced muscle strength and firmness | The lower face looks less supported overall | Restore support with muscle-stimulating treatment |
| Overactive mouth-corner depressor muscles | Mouth corners point downward at rest | Consider muscle-relaxing injections |
Why not just fill the marionette line?
If the problem is only a hollow, filling may soften it enough. But when sagging cheek tissue creates the fold, adding volume underneath can make the mouth area look heavy. Simply filling along the crease without assessing this can miss the real cause. We often lift the tissue above with a deeper treatment such as Ultherapy or threads, then fill any remaining hollow.
The material also matters. CaHA-based RADIESSE provides immediate filling and encourages collagen as it is gradually absorbed. International consensus recommendations on diluted CaHA also describe its use for firmness and skin quality in the midface, lower face, and neck. It often suits hollow lateral cheeks and faces that seem to have lost structural support. We distribute small amounts evenly so the product does not collect in one spot. One patient said they were pleased that the result looked natural, without excess volume, and felt reassured by repeated checks during treatment.
Can lifting improve marionette lines?
When jowls are the main cause, lifting comes first. DOUCE threads use patented T-shaped barbs on PDO threads to lift tissue and stimulate collagen as they dissolve. They often suit patients disappointed by how briefly previous thread lifts lasted. The right number of threads depends on the face; more is not automatically better. We recommend other options for people with enlarged salivary glands, very thick skin, or sagging severe enough to be better suited to a facelift.
EMFACE combines electrical stimulation and RF to strengthen supporting muscles and collagen. The usual course is four sessions 1–2 weeks apart, sometimes six when more firmness is needed. One patient said their whole face felt firmer after four sessions. We screen for pacemakers, metal hardware or implants, and pregnancy, any of which rules out treatment.
How does Dong-An Joongsim Clinic treat marionette lines?
At Dong-An Joongsim Clinic, your doctor personally conducts your consultation and treatment, assessing whether the mouth area is hollow, sagging, or both before planning the procedure.
Dr. Chang-Hwan Cho and Dr. Soyoun Koo were recognized as outstanding trainers in Merz's RADIESSE Train the Trainer program. They also lectured and demonstrated live treatment at a Merz-invited RADIESSE seminar held at our clinic. RADIESSE is used around the mouth, in marionette and nasolabial folds, and in the lateral cheeks. DOUCE thread lifting is planned with a pulling direction that avoids making the lateral cheekbones prominent. The clinic's EMFACE treatments have passed 1,000, a milestone marked by a commemorative plaque from BTL Asia. Dr. Chang-Hwan Cho also explained how jowls and marionette lines form in his D&PS column for physicians, “Aging of the Lower Face.”
What should you know before treatment?
Improvement varies considerably with skin thickness, bone structure, and the degree of sagging. Nonsurgical treatment may not be enough when there is substantial excess skin. Injectables may cause several days of bruising, swelling, or lumps; thread lifting involves around 3 days of downtime. Treatment is postponed if the area is inflamed.
Marionette lines: common questions
What should I look for in a marionette-line clinic in Apgujeong, Gangnam, Seoul?
Check whether a doctor personally distinguishes hollowing from sagging and explains both. At Dong-An Joongsim Clinic, your doctor handles both your consultation and treatment, and your plan is made by a recognized RADIESSE trainer.
How long does filler for marionette lines last?
It depends on the material and the individual. Manufacturer information states that RADIESSE lasts more than 2 years, with newly formed collagen sustaining the initial volume.
Are marionette and nasolabial folds treated in the same way?
Their causes overlap, so they are often treated together. Midface volume matters more for nasolabial folds, while descending jowl tissue matters more for marionette lines, so the emphasis of treatment differs.
Can I resume normal activities immediately?
Yes, after RADIESSE or EMFACE. Avoid saunas, strenuous exercise, and pressure on the treated area for about a week.
What affects the cost?
Cost depends on the product amount, whether lifting is added, and the extent of treatment. Your doctor explains the plan and cost after examining your face.
References
- Hong GW et al., “Anatomical-based diagnosis and filler injection techniques: marionette line (static labiomandibular fold)”, The Journal of Dermatological Treatment, 2025. https://doi.org/10.1080/09546634.2025.2452954
- Morera Serna E et al., “Anatomy and Aging of the Perioral Region”, Facial Plastic Surgery, 2021. https://doi.org/10.1055/s-0041-1725104
- Goldie K et al., “Global Consensus Guidelines for the Injection of Diluted and Hyperdiluted Calcium Hydroxylapatite for Skin Tightening”, Dermatologic Surgery, 2018. https://doi.org/10.1097/DSS.0000000000001685
- Rohrich RJ et al., “The fat compartments of the face: anatomy and clinical implications for cosmetic surgery”, Plastic and Reconstructive Surgery, 2007. https://doi.org/10.1097/01.prs.0000265403.66886.54