Marionette lines and folds

Marionette lines are facial wrinkles that run vertically between the mouth and chin, they can also create sagging in the lower half of your face. They are caused by loss of collagen that occurs with ageing. Gravity also plays a role in sagging skin around the chin, making marionette lines more noticeable.

What are marionette lines?

Unfortunately during the natural ageing process a downturned mouth with lines and folds that make you look sad can appear. This can be especially annoying as it can make you look older than you are. Similar to a marionette puppet’s face these lines look like you are able to open and close your mouth without the rest of your face moving.

As time goes on the down and inward movement of the face can result in marionette folds and nasolabial lines. Volume loss is also a big factor that contributes to the development of lines and folds.

Loss of skin elasticity and collagen depletion is the underlying cause. Where soft tissue is lost and where the bone of the mandible becomes thinner and reabsorbs (especially if the patient is missing teeth) it can become more evident. Finally, when the depressor muscles at the corner of the mouth are constantly activated these can contribute to the development of marionette lines and folds.

As with any other sign of skin ageing, lifestyle factors can also have a negative impact. A good skincare routine, adequate sleep (preferably on your back) optimal nutrition, staying away from the sun or using SPFs daily and curbing weight fluctuations will have a preventative effect.

How to treat marionette lines and folds?

Hyaluronic acid fillers such as Juvéderm can be injected below the corners of the mouth to lift the smile and fill out small creases. Mr Ferrando is an expert at treating lines with Juvéderm as well as other fillers too. If there are very deep lines either a thread lifts or even face lift or lower lift surgery may be an option to pull the skin taut.

Marionette lines typically appear with the natural ageing process, it’s however possible to reduce their appearance. There are several options available to treat this problem, usually injections and dermal fillers are the first step to consider, however, when the jawline is totally compromised, a lower face lift surgery would be the only option to eliminate them permanently.

Botox for marionette lines


Botox (Botulinum toxin type A) injections are a very popular solutions for facial wrinkles around the eyes and the mouth. They work by relaxing the facial muscles, causing the skin to become smoother, which consequently eliminates the wrinkles in the areas treated.

Botox may occasionally cause minor bruising and irritation at the injection site which willl quickly subside. To successfully treat marionettes lines with Botox injections, one will need to repeat the treatment every three to four months. This treatment method is ideal if one is just starting to develop these wrinkles.

Chemical peels

Chemical peels are a treatment used to remove the outer layer of skin (epidermis)in addition to parts of the middle layer (dermis). This process reduces considerably the appearance of age spots and facial wrinkles, and the new skin cells that are generated are much stronger.

Before getting a chemical peel, one should inform Dr. Ferrando if using retinoids or face acids, as these could cause your skin to be too sensitive for this treatment option. To maintain results with the treatment of marionettes lines, one will likely need a chemical peel once a month for a period of 4 to 6 months.


Dermal Fillers


Similarly to Botox, dermal fillers are temporary injectables that can be used to treat marionette lines in their earlier stages. Fillers don’t relax muscles, they plump your skin with either poly-L-lactic or hyaluronic acid. This is designed to act like the effects of collagen and elastin to smooth wrinkles and fine lines.

Hyaluronic acid filler produces an instant result, while poly-L-lactic takes several months to show results, as it acts as a stimulatory filler which promotes the production of collagen over time.

Dermal fillers can also help to address sagging caused by marionette lines.

Laser resurfacing

Despite being considered an invasive treatment for wrinkles, laser treatments, unlike facelifts don’t require any incisions. Laser resurfacing, works by removing the top layers of one’s skin with lasers.

While it can be a very effective treatment for some, laser resurfacing could potentially cause hyperpigmentation and scarring. The results of this therapy are long lasting, however, not permanent and treatments may be repeated every few months.

When the jawline is completely compromised, the only treatment available to permanently eliminate marionette lines is surgery. For significant wrinkles, Mr. Ferrando might recommend a rhytidectomy (facelift). With performing this type of surgery, incisions are made to transfer or remove fat, while underlying tissue is lifted upward to tighten one’s face.

Given the fact that facelift is a major surgery, it’s usually only recommended once other wrinkle treatments have failed. If wanting to eliminate marionette lines only, Dr. Ferrando might recommend a partial rhytidectomy (mini facelift).



Retinoids are a class of compounds that are chemically related to vitamin A. They have been used for many years in the field of plastic surgery due to their ability to improve skin texture, reduce the appearance of fine lines and wrinkles, and even out skin tone.

Retinoids work by increasing cell turnover, which means that they help to speed up the natural process of skin cell renewal. This results in a smoother, more youthful-looking complexion. Retinoids can also help to stimulate the production of collagen, which is a key structural component of the skin that provides firmness and elasticity.


Microneedling, also known as collagen induction therapy, is a treatment that helps to generate stronger skin cells, by creating very small holes in the skin. A derma roller or microneedling pen, is used to create these small holes in the target area of the skin.

When used to treat to deep marionette lines, microneedling may be helpful to generate more collagen production, which will fill in these deeper facial wrinkles. Depending on the depth of marionettes and results one is looking to achieve, it will be necessary to repeat microneedling several times.


Hyaluronic acid


Hyaluronic acid is a substance that occurs naturally in skin tissues. Like collagen, hyaluronic acid production is effected by the natural ageing process. This substance is found in several dermal fillers, skin care products and serums. When applied to wrinkles, it helps to plump and to smooth the skin.


Your consultation for plastic surgery with Mr Ferrando is an important step in the process of considering and undergoing cosmetic or reconstructive procedures.

This initial meeting allows the patient and surgeon to discuss goals, expectations, and potential outcomes, as well as evaluate the patient’s eligibility for the desired procedure. It will be an opportunity to ask questions or clarify any concerns that you may have. You will look at the “before and after” images of previous patients and get further information you need to make a decision.

Mr Ferrando will review your medical history and conduct a physical exam. He will then discuss all options suitable for you and explain each stage of the procedure or treatment. The exact procedure depends on the anatomy of the patient.

Our team believes that a well-informed, comfortable patient is one of the most important elements of the process. Whether you move forward with surgery or simply learn more, Dr Ferrando is looking forward to meeting you!

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This initial contact allows the patient and surgeon to discuss goals, expectations, and potential outcomes, as well as evaluate the patient’s eligibility for the desired procedure.

It will be an opportunity to ask questions or clarify any concerns that you may have and get further information you need to make a decision.

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