Marionette lines why they form, and which treatment fits

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What marionette lines are

Marionette lines run from each corner of the mouth down towards the jawline. Doctors may call them labiomandibular folds; in Chinese they are often called 木偶纹. When they deepen, the mouth corners can look turned down even when you are relaxed, which people often describe as looking tired, sad or annoyed in photos.

They are different from nasolabial folds, or smile lines, which run from the sides of the nose to the mouth corners, and from jowls, the soft bulge that forms along the jawline beside the chin. In practice the three are linked: as the cheek and jowl settle lower, all three tend to deepen together, which is why treatment usually looks at the whole lower face rather than one crease.

Causes

Why marionette lines form

Several changes happen at once, and one usually leads. Facial fat sits in separate compartments that age at different rates; jowl fat is the lowest of them, so it is where descending tissue tends to gather.

• Volume loss: the fat pads beside the mouth and chin thin out with age, so the skin between the mouth corner and jaw has less underneath it and folds more easily.
• Jowl descent: the ligaments that hold the cheek and jowl in place loosen, so tissue slides down and forward and gathers beside the chin, deepening the line in front of it.
• Muscle pull: the depressor anguli oris (DAO), a small fan-shaped muscle running from the jaw to the mouth corner, pulls the corners down. When it is strong or overactive, the corners turn down and the line is etched with every expression.
• Bone resorption: the jawbone just in front of the jowl, the prejowl area, slowly resorbs with age. With less bony support, a hollow forms there and the jowl looks heavier beside it.
• Skin quality: sun exposure and the steady loss of collagen and elastin leave skin thinner and less springy, so creases form sooner and stay after expression. Smoking speeds this up.
• Anatomy: a review of Asian faces noted that the position of the modiolus, the point where several muscles meet at the mouth corner, may make drooping mouth corners and marionette lines more common in Asian populations.

Self-check

Volume, sagging, muscle or skin: a mirror check

In good daylight, a few simple checks give a useful first idea of what is driving your lines. They are not a diagnosis, and most people find more than one cause.

• Look straight on, then at an angle. A hollow just below and to the side of the mouth corner, or a dip in the jawline in front of the jowl, suggests volume and bone loss.
• Place your fingertips on the cheek near the ear and lift gently upwards and backwards. If the line softens a lot, sagging of the jowl is a large part of the problem.
• Relax your face, then pull the corners of the mouth down as if grimacing. If the corners drop sharply and the line deepens a lot, the DAO muscle is contributing.
• Look closely along the line. Fine crisscross creases and thin, crepey skin point to skin quality, which needs a different approach from volume or lifting.

Matching the cause

Cause, what you see, and the usual route

SkinRev Lab prices are per session, before GST. Medical treatments at IN Eternity Clinic are performed by Dr Sin Yong and priced at consultation by the clinic.

SkinRev Lab · Non-invasive

SKINLIFT and SKINTIGHT for mild lines, and their limits

SKINLIFT is a needle-free lifting session using N Pulse-Ultrasound, a multi-sequential focused ultrasound aimed at the deeper support layers beneath the skin. SKINLIFT Face covers the jowls, nasolabial folds and jawline in about 30 minutes, without numbing, and most people go straight back to work. Change builds gradually over a planned course as collagen remodels. It is S$888 per session, before GST.

SKINTIGHT is a microplasma resurfacing session on the Alma PrimeX. A pin-tip applicator forms tiny channels in the skin surface while warming the dermis, prompting collagen renewal over the following weeks. Around the mouth and jaw it is used for crepey texture and fine laxity. Tightening settings usually leave mild redness for a few hours. It is S$588 per zone, before GST.

Both suit mild lines where early laxity and skin quality are the main problems. They do not replace lost fat or bone, and they do not change how strongly the DAO pulls the mouth corners down. If your line is deep mainly because of a hollow or a strong muscle pull, your Aesthetic Specialist will say so and can pass your enquiry to IN Eternity Clinic.

IN Eternity Clinic

Doctor-led options for deeper marionette lines

When lines are deep, or the mouth corners are clearly turned down, the realistic options are medical. They are performed by Dr Sin Yong at IN Eternity Clinic, 9 Scotts Road, #12-01 Pacific Plaza, beside Orchard MRT, after an assessment, and priced at consultation by the clinic. SkinRev Lab does not inject anything.

• Dermal fillers: hyaluronic acid gel placed in the deeper fat layers below and beside the mouth corner, and sometimes along the prejowl or chin, to replace support rather than simply filling the crease. Hyaluronic acid filler can be dissolved with an enzyme if needed.
• Wrinkle-relaxing injections: small doses placed into the DAO muscle reduce its downward pull, so the mouth corners sit a little higher. The effect wears off over months. The muscle sits close to the one that lowers the lower lip, so precise placement matters.
• Collagen biostimulators: injectables such as PLLA or PCL that prompt the skin to build collagen gradually over months, used for broader support of the lower face rather than a single line.
• Lifting devices: energy-based treatments such as HIFU or VF Lift for moderate jowl sagging, which reduce the weight pulling down on the line.
• Threads: absorbable threads placed under the skin to reposition the jowl and stimulate collagen, for selected people with moderate sagging.

Combinations

Why combinations often work better than one treatment

Marionette lines rarely have a single cause, so a single treatment rarely addresses all of them. A recent anatomical review concluded that they are complex, multifactorial lines that benefit from a multimodal approach, with filler for volume loss and wrinkle-relaxing injections to the DAO to reduce the downward force on the mouth corner.

A common sequence is to lift or support first and fill last: reduce jowl descent with energy-based lifting or threads, restore support in front of the jowl and below the mouth corner with filler, then relax the DAO if the corners still pull down. Skin quality care, such as SKINTIGHT, collagen stimulation and daily sunscreen, supports the result. Filling the line alone, without addressing the jowl above it, can make the lower face look heavy.

The order, timing and amount depend on your face. A doctor plans this after examining you at rest and in motion, and some people only need one step.

Safety

Risks and side effects to know about

Non-invasive SKINLIFT and SKINTIGHT usually cause only mild redness or warmth for a few hours. In Asian skin, any treatment that heats or resurfaces the skin can occasionally leave temporary darkening, called post-inflammatory hyperpigmentation (PIH), so settings are chosen cautiously and daily sunscreen matters.

Fillers commonly cause swelling, bruising and tenderness for a few days, and can cause lumps, asymmetry or delayed nodules. Rarely, filler can block a blood vessel and damage the overlying skin or, very rarely, affect vision; a 2019 review of published cases found that most involved hyaluronic acid filler. This is why filler should only be placed by a trained doctor who can recognise and treat a complication immediately.

Wrinkle-relaxing injections to the DAO can, if they spread to the neighbouring muscle, make the lower lip or smile look uneven until the effect wears off. Threads commonly cause swelling and can cause skin dimpling, visible threads or infection; a meta-analysis found satisfaction was lower over the long term than straight after treatment. Tell the doctor about pregnancy, bleeding disorders, blood thinners, active skin infection or previous filler in the area.

Prevention

What helps at home, and what does not

Daily broad-spectrum sunscreen on the face, jaw and neck slows the collagen loss that lets creases form, which matters in Singapore's year-round high UV. A retinoid at night can improve fine lines and skin quality over months, though it will not lift a jowl or fill a hollow. Not smoking and keeping your weight steady also help.

Creams and face exercises cannot replace lost bone or reposition a descending jowl. If you are unhappy with deep lines, an assessment is more useful than a new product.

Sources

References & sources

1. Mendelson B, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36(4):753-760.
2. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-2227.
3. Hong GW, Wong S, Yoon SE, Wan J, Yi KH. Anatomical-based diagnosis and filler injection techniques: marionette line (static labiomandibular fold). J Dermatolog Treat. 2025;36(1):2452954.
4. Choi YJ, Kim JS, Gil YC, et al. Anatomical considerations regarding the location and boundary of the depressor anguli oris muscle with reference to botulinum toxin injection. Plast Reconstr Surg. 2014;134(5):917-921.
5. Beleznay K, Carruthers JDA, Humphrey S, Carruthers A, Jones D. Update on avoiding and treating blindness from fillers: a recent review of the world literature. Aesthet Surg J. 2019;39(6):662-674.
6. Niu Z, Zhang K, Yao W, et al. A meta-analysis and systematic review of the incidences of complications following facial thread-lifting. Aesthetic Plast Surg. 2021;45(5):2148-2158.
7. Ayatollahi A, Gholami J, Saberi M, Hosseini H, Firooz A. Systematic review and meta-analysis of safety and efficacy of high-intensity focused ultrasound (HIFU) for face and neck rejuvenation. Lasers Med Sci. 2020;35(5):1007-1024.

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