Dermal Filler Pouches?

I have a first consult coming up to discuss a dermal filler for puppet lines and , if possible sagging lower jaw.. My concern is with the pouches sometimes seen when gals have the fillers. It looks like they have 2 acorns or chestnuts tucked inside each cheek! That I don't want. Is that common, and what would cause that?

Doctor Answers 10

You may need a gradual approach.

Treating marionette creases and what we call pre-jowl depressions often requires more than one treatment.  Often I use Radiesse deep and a hyaluronic acid like Juvederm or Belotero more superficially.  The challenge in treating to de-emphasize the jowls is that you are adding volume to raise the skin of the jawline above its normal level to the level of the jowls.  Too much filler in trying to do this can lead to the acorn look.  It should be placed carefully and perhaps in two sessions.  In my opinion, the best way to deal with jowls is a combination of liposuction and at least a mini facelift (ie cheek lift).  Without seeing you, I cannot really tell what you need.  Happy to see you in our Stoneham or Worcester offices.    

Boston Facial Plastic Surgeon
4.5 out of 5 stars 25 reviews

Natural looks

You have valid concerns.  When fillers are done properly, they look completely natural.  In fact, one is capable of receiving high volume fillers (up to 8 syringes at a time) while still looking 100 percent natural.  People are "done" looking when procedures are performed incorrectly usually by inexperienced doctors who are not trained in aesthetics.

Tim Neavin, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 42 reviews

Juvederm for marionette lines

For any tye of injections, always have a mirror in your hand and take a look as the physician is injecting and stop him/her when you think he/she has placed enough product. Remember, it is best to return for more product as opposed to having all done in one setting It may cost a little more, but this is a good practice philosophy.

Hratch Karamanoukian, MD, FACS
Buffalo Phlebologist
4.8 out of 5 stars 41 reviews

Juvederm for Lips

Juvederm for the jowls can be very tricky to administer so its very important to find an experienced physician to provide your treatment. Juvederm is excellent at absorbing water and retaining volume over time, so it's important not to inject too much during the initial treatment otherwise you end up with the "acorn" effect that you described. Hope this helps.

Michael A. Zadeh, MD, FACS
Sherman Oaks General Surgeon
5.0 out of 5 stars 10 reviews

Dermal filler pouches

Improper placement of filler, poor technique, and using too much filler are issues that may lead to a poor result following treatment. When looking to have treatment with filler, it is important to choose a board certified physician who has a great deal of experience. A plastic surgeon, facial plastic surgeon, or dermatologist are all great choices. For the marionette lines, Perlane and Restylane both work very well. I hope this helps, and I wish you the best of luck. 

Paul S. Nassif, MD
Beverly Hills Facial Plastic Surgeon
4.7 out of 5 stars 47 reviews

Fillers for jowl area and marionette lines

I assume you mean marionette lines and jowl area. Yes, when you try to use too much filler to camouflage the jowls, they can look a bit chipmunky.  You may need a facelift?

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Problems from Filler Injection


The "acorns" and "pouches" you speak of are from someone doing the injection who does not appreciate facial anatomy and the pathophysiology of aging. There are an exceptional number of people doing injections without the proper training. Ask the people you have observed with the changes you do not care for who did their procedure. Then find someone else. Make sure the person you do find is well trained in injection procedures and has done it for a long time. One good source is


Robert T. Buchanan, MD
Highlands Plastic Surgeon
5.0 out of 5 stars 6 reviews

Radiesse is really great for the marionette lines on the sides of the mouth

The puppet lines are also called marionette lines in the U.S., and apparently in France they are called bitterness lines, wow!  Here are my thoughts on treating this area:

  • The skin of the lower face is very heavy and it helps to have a structural filler like with Radiesse to support this skin.
  • To avoid the problem you described it's key to only inject in front of these lines
  • It's also helpful to augment the chin somewhat
  • Probably most important, is to find an experienced injector who injects a lot and has before and after images you like.

I am attaching a link to an example patient of mine. 


David C. Mabrie, MD
Bay Area Facial Plastic Surgeon
4.7 out of 5 stars 105 reviews

Filler pouches - unlikely

Filler pouches are highly unlikely in experienced and trained hands (e.g. dermatologist). That said, in the worst case scenario, hyaluronidase can be injected to clear up this problem by your physician. Benjamin Barankin, Toronto Dermatology Centre.

Benjamin Barankin, MD, FRCPC
Toronto Dermatologic Surgeon
4.8 out of 5 stars 50 reviews

Dermal filler pouches?

First of all you need to have a consult with a very qualified, experienced cosmetic injector and express your concerns during the appointment.  Juvederm is a great product but placement is everything! It's hard to know if what you have seen on others is misplaced product or sagging jowls.  

Sam Naficy, MD, FACS
Seattle Facial Plastic Surgeon
4.7 out of 5 stars 221 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.