Marionette Lines and Nasolabial Folds Are Not the Same—Here’s How to Treat Both

Perhaps to soften the blow of seeing them in the mirror, wrinkles have gotten rebranded, earning cutesy names like elevens, bunny lines, and crow’s-feet. But be honest: Do you actually know what all these terms are referring to? The lines of the lower face, in particular, can be especially confusing, with many people describing creases around the mouth using two terms that may seem similar but are not interchangeable.

The first set of wrinkles here is the nasolabial folds, which are often referred to as laugh lines or smile lines because that’s when they’re most prominent. “Nasolabial folds are the creases in the skin that start at the outer base of the nose, where the nostrils connect to the cheek, and travel in an outward diagonal line down toward the corners of the mouth,” explains Dr. Steven Dayan, a board-certified plastic surgeon in Chicago. The other pair of wrinkles are marionette lines, which get their apt name from puppets’ unique facial structure. “Marionette lines run vertically from the corners of the mouth to the chin, often giving a downturned appearance,” says Dr. David Shafer, a board-certified plastic surgeon in New York City. (You’ll almost never hear the formal name of these wrinkles, but it’s “melomental folds,” FYI.)

Like all wrinkles, nasolabial folds and marionette lines get more noticeable as you age. “They’re generally caused by repeated facial expressions, loss of collagen and elastin, sun damage, and age-related fat reduction in the cheeks,” says Dr. Gabriel Chiu, a double board-certified plastic surgeon in Beverly Hills. Dr. Dayan notes that this area is especially susceptible to profound creasing due to bone loss. “As we age, we all know that we may shrink in height from vertebral bone loss,” he says. “Similarly, we lose bone in our skull, our teeth and jawbone resorb slightly, and our face involutes somewhat, which is a significant factor in the deepening of the facial folds.”

While you have your pick of procedures, from noninvasive to surgical, it’s key to have your nasolabial folds and marionette lines treated by a skilled provider. Because this area of your face moves so much, overzealous or inferior treatment could make you look unnatural or even inhuman. Keep reading to discover the best options for treating marionette lines and nasolabial folds.

At-Home devices

Treats nasolabial folds: Yes

Treats marionette lines: Yes

Listen, you’re going to need to have reasonable expectations here—if you have seriously deep creases and skin laxity, no amount of at-home tech is going to give you the results that you want. But if you’re just starting to see shadows and folds starting to form, you could help fend them off (to a degree) by incorporating a microcurrent device into your routine. The NuFace Trinity+ Complete Set ($595) includes the original larger attachment (best for marionette lines) as well as a more precise one (great for nasolabial folds) that helps stimulate your facial muscles to create a more lifted look.

“It has to be used consistently, to maintain tonicity,” points out Dr. Chiu. It’s best to use this device at least five days a week and pair it with pro treatments and skin care; don’t expect to look smooth and sculpted if you use your NuFace only once in a blue moon and think of SPF as “special-occasion skin care” rather than a daily must-have. Annoying, we know, but using it is only a five-minute, once-daily commitment—or you could just skip ahead to in-office procedures. 

Botox 

Treats nasolabial folds: Sometimes

Treats marionette lines: Sometimes

Treating these areas with neurotoxins like Daxxify or Botox depends entirely on your injector’s skill and your facial anatomy. Dr. Dayan notes that he occasionally treats around the nasolabial folds and nose with high doses of neurotoxins, which will relax the fold and lift the tip of the nose. “Unfortunately, if the toxin spreads to the wrong muscles, a person can look like a Bell’s Palsy patient for weeks to months, so this must be done well,” he warns. 

The safer and simpler area to inject with neurotoxins is the DAO, or depressor anguli oris, muscle. “By relaxing the DAO, which pulls down the corners of the mouth, contributing to marionette lines, neurotoxins can help soften them,” explains Dr. Shafer. However, you’ll still need to see a skilled provider with a deep understanding of facial anatomy for this treatment. They’re less likely to give you a crooked smile (which can happen if done incorrectly) and more likely to tell you if you’re not a candidate for treatment of the DAO. “Depending on the anatomical relationships, it can actually make marionette lines look deeper, with the corner of the mouth pushing up and out, into the lines,” Dr. Chiu says. Remember, if you have volume loss or skin laxity, neurotoxins won’t be the solution, so they’re best used in conjunction with other options.

Injectable filler

Treats nasolabial folds: Yes

Treats marionette lines: Yes

Filler can be used to smooth out both the nasolabial folds and the marionette lines, but who you see for your aesthetic treatments matters a lot, and you’ll want to do your due diligence when finding a provider to fill your nasolabial folds, in particular. “Getting a good result is not intuitive or easy if you don’t understand the anatomy or how they are formed,” says Dr. Dayan. “The commonly taught and approved methods for treating folds with filler often worsen them!” He notes that the key to addressing nasolabial folds is treating them in multiple layers, starting deep on the bone, at the pyriform aperture in Ristow’s space (feel around on your face—it’s an indentation at the edge of your nostril, where the cheekbone ends and the upper jaw begins). Injecting here can also improve the projection of the nose and upper lip sans surgery. 

Be aware that nasolabial folds are often best treated by injecting multiple areas of the face, as the midface is all interconnected. “We have to think about overall harmony when injecting a patient,” says Dr. Michelle Henry, a board-certified dermatologist in New York City. “If we micromanage the patient’s face and look only at the area in question, not looking at the interplay of that area with other areas of volume loss and skin laxity, we’re not going to correct that deficit in a way that is both natural and aesthetically well functioning.“ 

When treating these areas, your provider should use not only multiple layers of filler but multiple viscosities as well. “If we’re putting in a firm, stiff, static filler that doesn’t integrate well and moves with the tissue, we often get a very unnatural look,” warns Dr. Henry. See if your provider offers a dynamic filler, like those of the RHA Collection, which are engineered to work with your facial tissues’ movements and are imperceptible, especially when administered well. Stiffer fillers can be quite visible, particularly when injected superficially and when the face is in motion. Dr. Dayan notes that this can create a chimp-like look or even a line of filler that looks like a worm under the skin. Too much filler in the marionette lines can make for a heavy lower face, like a bulldog’s, says Dr. Chiu. 

There’s a chance you’ve noticed more pronounced facial folds after years of achieving juicier lips and cheeks courtesy of filler—this is a sign that you’ve overdone it. “If an area is really overfilled and exaggerated in such a way that it’s making the tissue heavy and pendulous, it can definitely contribute to a fold,” says Dr. Henry. “Think of it as if you are pulling a belt tight, and your waist falls over the belt,” adds Dr. Dayan. 

Radiofrequency devices

Treats nasolabial folds: Yes

Treats marionette lines: Yes

Radiofrequency energy can be administered in a variety of different ways, ranging from fully noninvasive (like NuEra and Emface) to treatments that require incisions (such as FaceTite). Dr. Chiu likes radiofrequency microneedling, specifically Sylfirm X, which offers minimal downtime. “It has excellent results, especially after three or four treatments performed four to six weeks apart,” he says. “Since the results happen over a few months, the improvements appear to transition gradually.” These treatments are best for those who don’t have seriously pronounced lines and folds, because “all of these treatments help improve but do not eliminate the lines,” says Dr. Shafer.

Renuvion

Treats nasolabial folds: No

Treats marionette lines: Yes

Both Dr. Chiu and Dr. Shafer are fans of Renuvion, a treatment that combines both helium plasma and radiofrequency energy to contract the collagen fibers, lifting and tightening the skin. According to Dr. Shafer, it’s best reserved for the lower face, where skin needs to be treated with intense energy to address laxity. Keep in mind that by tightening the skin, this treatment will help reduce the depth of folds but may not fully eliminate them, especially if they’re quite deeply etched into the skin. It’s also not for everyone: Renuvion is FDA-cleared only for treatment of patients with Fitzpatrick skin types I-III. If you are a candidate, be prepared for some downtime. “The recovery is similar to with a laser ablation, taking a couple of weeks and specific care,” says Dr. Chiu.

Threads

Treats nasolabial folds: Yes

Treats marionette lines: Yes

Thread lifts are touted as a minimally invasive alternative to plastic surgery, using targeted placement of dissolvable sutures to pull certain areas of the face (including the nasolabial folds and marionette lines) up and back for a tauter look. However, they’re not a lasting solution. 

“Threads are very temporary and not as effective as Instagram or social media makes them seem,” says Dr. Shafer. According to Dr. Chiu, a thread lift is often a painful procedure, with highly provider-dependent results that often don’t even make it to the one-month mark, despite being marketed as a six- to nine-month solve. “To top it off, they leave behind scar tissue that may make it nearly impossible to properly perform a facelift when the time comes and compromise the healing of facial surgeries,” he warns. 

This is not to say that threads can’t be done well—and you may still be intrigued if you’re confident you’ll never seek out surgery. A lot of people pursue this option because they’re hoping to avoid the steep bill of a facelift but when done correctly, thread lifts are pricey. “To get optimal results, we should do multiple threads and vectors,” says Dr. Dayan. “Our colleagues in Asia use a lot of threads, up to 5 to 10 times the number we use, and the price might be cost prohibitive in the U.S. for most—it’s approaching the cost of a facelift if we use that many threads.” He notes that permanent threads are used abroad, which can produce excellent and lasting results—but this technology is not FDA approved. “In the coming years, there will be more interest, more research, better results, and greater longevity with threads,” he adds. In the meantime, you can still consider the final option—surgery.

Plastic surgery

Treats nasolabial folds: Yes

Treats marionette lines: Yes

If skin laxity is to blame for the severity of your nasolabial folds and marionette lines, noninvasive procedures alone are likely not going to give you the results you’re looking for. “A rule of thumb is that if you can point to the area of concern, then fillers may be a good option, but if you have to push your skin back toward your ears to create the effect you desire, then surgery may be a better option,” offers Dr. Shafer. 

Dr. Chiu recommends sitting down for a frank conversation and thorough consultation with a board-certified plastic surgeon about your concerns and goals—from there, your doctor should be able to make recommendations and explain the rationale behind your suggested treatment plan. Keep in mind that to get the most natural-looking outcome, a lot of providers will take a hybrid approach, combining surgery with energy-based treatments, neurotoxins, and dermal fillers. “It’s okay to have an expectation of what you may need, but keep an open mind until you finalize a plan with your surgeon,” he adds.