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How to Get Rid of Marionette Lines

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Marionette lines are the vertical creases that run downward from the corners of the mouth toward the jawline. They’re named after the lines on a puppet’s mouth — and they’re one of the most commonly cited reasons patients say their face looks "sad" or "tired" even when they’re not.

What’s important: marionette lines are a volume problem, not a wrinkle problem. The line itself is real, but the cause sits above and around it — in the descended cheek tissue, the loss of jawline structure, and the downturned corner of the mouth that gravity and age together.

This guide explains the anatomy, what drives the change, and the realistic treatment options at each stage — from filler through to when descent is significant.

The anatomy

Several factors contribute to marionette line formation:

Descended mid-face tissue. As the cheek fat compartments thin and descend with age, weight accumulates above the jawline. This tissue forms what we call jowls. The line where descended cheek tissue meets the relatively immobile chin and lower lip area is the marionette line.

Loss of the depressor anguli oris support. The depressor anguli oris (DAO) is a small muscle that runs from the side of the chin upward to the corner of the mouth. Its job is to pull the corner of the mouth down — when it more strongly than the muscles lifting the mouth corner, the result is a permanently mouth.

Loss of bone support. The mandible (jawbone) changes shape with age — it becomes slightly narrower and less projected. The skin and soft tissue that previously sat on a fuller bony framework now sit on a smaller one, to descent.

Skin laxity. The skin itself loses elasticity, can no longer recoil over the changing structure, and develops static creases along the natural lines of tension.

The implication: treating just the line itself, in isolation, often doesn’t produce the result want. The cause of the line involves several different structures, and the treatment that works best addresses the structural context rather than just masking the appearance.

For broader context on how facial ageing progresses, see our guide on .

What makes marionette lines worse

Volume loss is the primary driver. fat thinning starts in the mid-30s and progresses over decades. Patients who lose weight rapidly often notice marionette lines becoming more obvious because the volume loss is concentrated.

Sun exposure degrades dermal collagen and elastin, reducing the skin’s ability to bounce back over the changing underlying structure.

Smoking compounds the problem in multiple ways: direct collagen damage, vascular impairment, and the repetitive lip-pursing action of smoking adding mechanical wear.

Genetics set how prominent the lines become and how early. Some patients see marionette lines in their early 40s; others develop them only in their 60s.

facial expressions — particularly chronic downturning of the mouth (frowning, sadness, concentration) — etch the lines deeper over time.

Sleep position. Consistent side-sleeping contributes to asymmetric marionette line development on the side that presses into the pillow.

Treatment options — by stage

Skincare doesn’t established marionette lines but slows their progression and supports any other treatment you have:

Daily broad-spectrum SPF is the highest-impact single intervention.

Topical retinoids build dermal and skin quality over time.

Vitamin C provides antioxidant protection.

Stopping smoking matters substantially if you’re a current smoker.

Maintaining stable weight prevents the rapid volume changes that marionette lines.

For most patients, is the most effective treatment. As with nasolabial folds, the most natural-looking results come from a structural approach rather than just filling the line itself.

Cheek and jawline restoration first. Restoring volume to the mid-face and supporting the jawline structurally lifts the descended tissue that’s contributing to the marionette line. placed in the lateral and zygomatic cheek areas creates the architectural support that’s been lost.

Mouth corner support. A small amount of filler placed at the corner of the mouth lifts the downturned corner and reduces the "sad" appearance.

Direct line filling — as a secondary step. After the structural work, any residual visible marionette line can be addressed with a small amount of filler placed within the line itself. Often, addressing the cheek and mouth corner first reduces how much direct line filling is needed.

Why the structural approach is preferred. Filling marionette lines without addressing the descended tissue above them can produce a heavy, sausage-like appearance below the mouth — the line is filled but the face still looks aged. Restoring the structural context produces a far more natural-looking result.

Filler longevity in this area is typically 9 to 18 months, depending on the product and patient. The treatment is reversible with if needed.

The combined approach is the same one used for — the principle being that the lower face works as an integrated unit, and treating it that way produces the most natural results.

have a small but useful role for marionette lines. A small dose into the depressor anguli oris (the muscle pulling the mouth corner down) its activity. With the DAO weakened, the mouth corner returns to a more neutral or slightly lifted position, which improves the appearance of the marionette line indirectly.

This is a technically demanding injection — the dose must be small and the location precise. Too much, and the lower lip function is affected; the wrong placement, and the smile becomes asymmetric. The technique should only be performed by injectors familiar with this specific anatomical area.

AWI for the DAO is combined with filler treatment rather than used alone.

For patients whose skin quality is also a concern, energy-based treatments stimulate collagen and improve overall texture:

— radiofrequency microneedling reaches deep into the dermis. Particularly useful for the lower face where skin laxity is starting to appear.

— four laser modes including an intra-oral pass that delivers heat to the deeper tissues from inside the mouth. Useful for the lower face and jawline.

These don’t replace filler or surgery for marionette lines but improve the overall context — better skin quality and modest tightening complement the structural work.

and treatments improve dermal quality from within. Useful as preparation before filler work in patients with poor skin quality, or as maintenance between filler sessions.

For patients with significant tissue descent — jowling, sagging along the jawline, advanced mid-face flattening — surgical treatment is more effective than continuing non-surgical maintenance.

repositions the SMAS (the deeper structural layer of the face) and overlying tissue. The repositioning lifts the descended cheek tissue off the jawline, restores jaw definition, and dramatically reduces marionette line prominence. The result is long-lasting — typically 7 to 12 years before recurrence.

focuses on the lower cheek and . Useful for with moderate jowling and softening of the marionette area but not yet enough descent to warrant a full facelift.

is often combined with facelift because the neck and lower face age together. Treating one without the other can leave a visible mismatch.

— the patient’s own fat is harvested from another body area, processed, and into the and mouth corner area. Unlike HA filler, the result is permanent for the fraction that survives transfer (typically 50-70%). Often combined with facelift for a more complete result.

A consultation with our specialist team — including — establishes which approach matches your anatomy.

How to decide which treatment fits

Mild marionette lines, descent: filler with cheek and mouth corner . Add daily SPF and good skincare.

Moderate lines with early jowling: filler combined with AWI to the DAO, plus energy-based skin treatment. Sometimes this is enough; sometimes it’s the stage at which patients start thinking about surgery.

Established lines with visible jowling and mid-face descent: surgical consultation becomes appropriate. Continued non-surgical work at this stage produces diminishing returns and increasingly heavy appearance from accumulated filler. The honest answer is that a facelift produces what filler can’t.

Significant lower-face and neck descent: facelift with neck lift, often combined with fat transfer.

For most patients in their 40s and 50s, combination treatment over time produces the best result — moving through the stages as the underlying anatomy changes.

Cost

Filler treatment is priced per syringe. Most patients need 1 to 2 syringes for cheek/mouth corner work plus a smaller amount for the line itself if required after that. Surgical options vary substantially. , including 0% APR, are available.

What we don’t recommend

PDO thread lifts. The Centre for Surgery does not offer thread lifts. The evidence for sustained benefit is weak, the complication rate (visible threads, palpable threads, thread extrusion, infection) is higher than alternatives, and the cost is comparable to filler treatment that has more reliable outcomes. Patients seeking a non-surgical lift typically get better, more results from comprehensive filler treatment.

Filling marionette lines without addressing the cheek. For the reasons discussed above, isolated line treatment often produces an unnatural-looking result. Comprehensive treatment is more expensive in the short term but produces a more appearance and tends to last longer.

Continued filler treatment when surgery is the right answer. Patients who have advanced to the point where surgical lifting would address their concerns more effectively sometimes continue layering filler year after year, with diminishing returns and a progressively unnatural appearance. An honest consultation should identify this point and recommend when appropriate.

Common questions

The combination of descended mouth corners and visible marionette lines produces a face at rest that reads as sad to others — even when the person isn’t feeling that way. The goal is usually to restore a more neutral expression at rest, not to make the face look perpetually happy. Subtle improvement in mouth corner position is enough to change the impression.

The volumetric change is visible immediately. Mild swelling for 2 to 5 days settles. The "final" result is what you see at the 2-week mark.

No — the face returns to state it was in before . Hyalase dissolves only the filler, not your underlying tissue.

It improves them but doesn’t eliminate them entirely — some line is anatomical rather than purely age-related, and complete erasure would produce an unnatural look. The aim is restoring a youthful balance, not making the face flat.

A useful self-test: lift the skin in front of your ears upward and slightly back with your fingertips. If the result is what you’re hoping for, surgery is likely to give you something close. If the result is too dramatic for what you want, filler-based maintenance is probably the right next step. A consultation provides a more definitive assessment.

Centre for Surgery · CQC-regulated · GMC specialist-registered surgeons · · · ·

Medically reviewed by , GMC .

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Centre for Surgery is a CQC-regulated private hospital on London’s Baker Street, delivering plastic and cosmetic surgery through GMC-registered specialist surgeons. Our expertise spans facial procedures including and , , for men, and body contouring procedures such as and . Patient safety, surgical excellence and natural-looking results sit at the heart of everything we do.

Centre for Surgery is a CQC-regulated private on London’s iconic , offering plastic and cosmetic surgery led by GMC-registered consultant surgeons.

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