Marionette Line Treatments: How to Choose the Most Effective Treatment by Type

Hello. I’m Jo Wonjin, the chief director of Chai Clinic, where I have been providing dermatology care in Hongdae for 10 years.

The grooves on both sides of the corners of my mouth are deeply sunken,

and people keep telling me I look angry.

Ulthera, thread lifting, Thermage…

There are many types, but which one is right for me?

When I consult about marionette lines, many people have already had one or two treatments,

but they come in without having been told what type of cause their marionette lines fall under.

Today, under the topic of Marionette Line Treatments: How to Choose the Most Effective Treatment by Type,

I’ll explain the causes of marionette lines, which of the four types your own marionette lines are closest to,

and which treatment should be considered first.

Key Summary of Marionette Line Treatments

• Cause of marionette lines: a complex form of aging involving the skin, fat, volume, and muscle
• The starting point for choosing a treatment is identifying your own cause type, not the device
• Four non-surgical options (laser lifting, thread lifting, filler, Botox) come first; surgical options (such as liposuction) are last

Table of Contents

• Why marionette lines form
• A 3-move self-check
• Treatment principles by cause type
• Which treatment to use and when
• Side effects and precautions for marionette line treatments
• Frequently Asked Questions (FAQ)

Why marionette lines form

Marionette lines refer to the two long vertical grooves that run downward from the corners of the mouth toward the chin.

Unlike expression lines, they are noticeable even when the face is at rest.

Rather than being just wrinkles, they are closer to a phenomenon in which the entire tissue under the mouth area collapses all at once.

The following four factors act at the same time.

• Dermal thinning: the dermis (the thick inner layer of the skin) becomes thinner, reducing elasticity
• Fat sagging: the fat under the cheeks (bulldog jowls) flows downward with gravity
• Volume loss: the deep-layer fat and volume that supported the area beside the corners of the mouth shrink
• Muscle overactivity: the depressor anguli oris muscle (a small muscle that pulls the corners of the mouth downward) becomes overactive

One more thing to know is that the tissue above and below the wrinkle line differs in nature.

The area beside the mouth has more fat, while the area beside the tip of the chin is held up by firm fibrous tissue that supports the structure.

The upper fat sags downward, while the lower area stays in place,

so that difference in height makes the groove look deeper than it actually is.

In other words, marionette lines are not the result of a single cause

but the result of four types of aging combined with a structural difference in height.

A 3-move self-check

Before a consultation, I recommend trying these three movements in front of a mirror.

The treatment priority changes depending on which direction your case leans.

Movement	Result	Estimated type
Gently lift the cheeks upward with your fingers	The groove almost disappears	Skin / fascial sagging type
The groove remains deeply sunken	Volume loss type
Look straight ahead with a neutral expression	The skin beside the corners of the mouth hangs noticeably	Fat sagging type
Tense the corners of the mouth and say “ee”	The corners of the mouth do not rise and feel pulled down more	Muscle activity type

The appropriate treatment differs depending on which signal is strongest in these three movements, or whether the signs are mixed.

Treatment principles by cause type

Below are the four types we distinguish in clinic and the layer and mechanism involved in each.

Type 1. Skin sagging type

This is a case in which the dermis and fascia (SMAS, the deep layer covering the facial muscles) have stretched.

Thread lifting is used to create a physical support line and reposition the tissue,

or ultrasound devices such as Ulthera are used to apply heat to the fascia to induce contraction and rearrangement.

Thermage, which tightens the skin overall and increases collagen production, can also be used as a complementary treatment.

Type 2. Fat sagging type

This is a case in which the fat under the cheeks has flowed down toward the corners of the mouth, creating bulldog jowls.

In such cases, thread lifting is also effective,

and reducing the fat volume in the marionette area with contour injections is also recommended.

Type 3. Volume loss type

This is a case in which the deep-layer fat beside the corners of the mouth has shrunk, leaving no support.

Filler or collagen-stimulating injections (such as Juvelook and Rejuran, which are in the dermal remodeling category) are used to support the empty space.

The idea is not to fill it in, but to provide support.

Type 4. Muscle activity type

This is a case in which the depressor anguli oris muscle is too strong and overactive.

Botox (botulinum toxin) is used to selectively reduce the strength of this muscle and restore the position of the corners of the mouth.

[Marionette Line Treatments at a Glance]

Treatment	Key point	Strengths	Cautions
Laser lifting	Applies heat to the deep skin layer to lift it / skin sagging type	Lifts the structure itself	Effects appear after 2–3 months
Thread lifting	Uses dissolvable threads to reposition sagging tissue / fat sagging type	Immediate repositioning	Pulling sensation, indentation
Filler	Fills sunken areas to provide support / volume loss type	Immediate support effect	Too much can worsen sagging
Collagen-stimulating injection	Promotes collagen regeneration in the skin / volume loss type	Short recovery and natural result	Gradual effect
Botox	Relaxes the muscle that pulls the corners of the mouth downward / muscle activity type	Corrects corner-of-mouth position	Re-treatment every 3–4 months
Liposuction (surgery)	Directly removes sagging subcutaneous fat / for selected cases with a very large amount of fat	Directly removes the cause of sagging	Recovery time and side-effect burden

The four options above (Ulthera, thread lifting, filler/injection, and Botox) are the non-surgical first-line options,

and facial liposuction is considered only when the amount of sagging fat is very large.

Because it is a surgical procedure and the burden is greater, it is kept as the last option in the clinic.

Rather than asking, “What is the best treatment?” the question should be changed to, “Which tool is right for my type?” That is when the answer appears.

Which treatment to use and when

In consultations, I make decisions in this order.

1. First, look at the muscle.

If the depressor anguli oris muscle is highly active, Botox is considered first.

If the muscle keeps pulling, other treatments will wear off more quickly.

2. Then look at volume loss.

If the area beside the corners of the mouth is hollow and the support has disappeared, filler or collagen-stimulating treatment is used first.

3. Then look at skin and fascia sagging.

If the entire dermis and fascia have stretched, HIFU or radiofrequency is added to lift the tissue at the structural level.

4. Is it already deeply sagging?

If fat has sagged downward to a degree that cannot be corrected by the three steps above, thread lifting is added last to reposition the tissue physically.

People in their early to mid-30s can often improve with Botox alone or Botox plus laser,

and people in their late 40s and 50s often have a more natural result with a combination of filler, Ulthera, and thread lifting.

This varies greatly depending on the cause of the wrinkles, so it is important to analyze this properly.

Side effects and precautions for marionette line treatments

There is no treatment that can be claimed to have “no side effects at all.”

It is important to identify possible symptoms in advance and plan carefully.

In particular, thread lifting, which shows the most direct improvement, can cause thread protrusion or skin indentations.

To prevent this, it is important to place it in a layer that is not too shallow.

I have written more detail in the post below.

If too much filler is injected into an inappropriate layer,

the weight can make the area around the mouth look more bulging.

Since marionette lines require more detailed technique than other areas,

it is best to find medical staff with extensive treatment experience and reliable know-how.

Frequently Asked Questions (FAQ)

Q. What is the average duration of each treatment?

A. The duration varies depending on the principle and material of each treatment.

Treatment	Average duration
Botox	3–4 months
Laser lifting	6–12 months
Thread lifting	6 months–2 years
Filler	6 months–1 year

Q. Will marionette lines disappear permanently after one treatment?

A. No. No treatment can permanently eliminate marionette lines.

Because aging continues, it is realistic to approach this through step-by-step, periodic management rather than a one-time procedure.

To conclude

Marionette lines are a four-layer form of aging in which the skin, fat, volume, and muscle all collapse together.

So before choosing a treatment, the first step is to determine which type your marionette lines are closest to.

If it is muscle type, start with the muscle; if it is volume loss type, start with support; if it is sagging type, start with the fascia; if it is fat type, start with the position.

When the order is right, the result is more natural and there is less regret.

I hope today’s post was helpful in solving your concerns about choosing a treatment for marionette lines.

Thank you. This was Jo Wonjin.