Is a Facelift the Only Answer for Marionette Lines and Jowls?

I'm 66 and a happy person. But I look sad because of the lines going down from the corners of my mouth to each side of my chin. I also have little pockets of fat on each side along my jaw line. Guess this is all normal, but I'm tired of hiding behind my long hair. I'm afraid of a face lift, and have read that a lower face lift does not take care of the Marionette lines anyway. What to do? Thank you

Doctor Answers 92

Solution for Marionette (Puppet or Drool) lines and Jowls

A successful solution and treatment are always based on proper diagnosis. For this reason, a picture would have made answering your question much easier and applicable to your situation.

Young people do NOT have nose to mouth (Nasolabial) lines or corner of mouth to jaw (Marionette, Puppet or Drool) lines, these come on with age.

As we age, our facial bones become smaller resulting in the scenario of the same table cloth (IE skin) covering an ever shrinking table - as a result, less of the teeth are showing and the skin sags. But the sagging is not uniform. Instead, it is seen most where there is active sagging of the skin AROUND the points of fixation of the skin to the skull which happen to be just central to these lines. The result of this tectonic plate like skin movement is that the saggin stops at these points with heaping of the skin over them causing the folds.

Solutions:
1. FILL the valleys (Fat,Restylane, Perlane, Juverderm etc)
2. Fill the face with fat to make up for the bone resorption to "take up the slack"
3. EXCISE the valleys (leaving permanent scars where the valleys were (rarely done)
4. Correct the sagging by lifting and replacing the skin where it belongs (Facelift with vector pulling of the areas just in front of the folds

Which is THE treatment for you? It would depend on YOUR presentation and your willingness to accept a less than perfect result but with a lot lower risks and vice versa.


Memphis Plastic Surgeon
4.9 out of 5 stars 108 reviews

Facelift only answer for marionette lines and jowls

A well performed facelift is the best procedure to treat sagging and puffy jowls as well as the associated sagging skin and soft tissues of the neck. At your age,
most people have, to a greater or lesser degree, the findings of laxity of the skin
and soft tissues of the face and neck.

These findings are amenable to a facelift that will provide redraping with significantly improved contours. Unfortunately, surgery to treat the marionette lines is often far from successful. In some cases, there may be some degree of improvement but I would not recommend having a facelift specifically to treat these marionette lines. The best treatment for these depressions is the use of appropriate fillers.

Sigmund L. Sattenspiel, MD
Freehold Facial Plastic Surgeon

Options for jowls and marionette lines.

A lower face lift with either a chin implant or fat injections and perhaps precise jowl liposuction are a reasonable and relatively low risk approach to managing jowls and marionette lines. Your other options are fillers. I generally am not impressed by the results of skin tightening lasers and believe they achieve only a subtle change.

Otto Joseph Placik, MD
Chicago Plastic Surgeon
4.9 out of 5 stars 81 reviews

Jowls and facelift procedures

For deep marionettes and sagging of the face, I still consider a facelift to be a prudent. Facial fat grafting can be added for a more permenant rejuvenation.

Jose E. Barrera, MD, FACS
San Antonio Facial Plastic Surgeon
5.0 out of 5 stars 46 reviews

Marionette line solutions

The simplest answer is for injections of filler, either hyaluronic acid products like restylane or juvederm, or calcium based products like radiesse. these are temporary though, so some patients then consider fat transfer as a more permanent solution. But in many cases that just leaves patients with a full, jowly chipmunk appearance. So that is why a facelift of some type is a better solution.

Facelifts have lots of names, and mean different things in different offices. So whether its a minifacelift, lower facelift, neck lift, or facelift is hard to distinguish. The main thing to keep in mind is that more release means more improvement and longevity to the surgical result. With that in mind, you would need to talk to your surgeon about what is the best facelift in his or her hands to improve your situation.

And I would also agree with some of the other surgeons that the best solution may also include some form of volume in the fold as well. Chin implant, prejowl chin implant, fat, portions of tissue normally discarded from the facelift (fat, SMAS) , or post op fillers all have merit.

Kevin Robertson, MD
Madison Facial Plastic Surgeon
4.7 out of 5 stars 14 reviews

Title: Combination of a Lower Face Lift with Facial Fillers

Marionette lines and jowls are essentially two different forms of aging: the marionette lines are caused by thinning of the skin combined with repeated facial expressions, while the jowls are caused by sagging skin. A lower facelift is typically the most effective and satisfying way to resolve jowls, and while it can also reduce marionette lines, you wouldn’t want your facelift to fully remove every fine line and wrinkle, because your results would look overly “tight” and unnatural. Because every patient is unique, I would need to see you in person to make a true recommendation, but based on your description, in order to address both of your concerns while maintaining a natural look, your best option is probably a lower face lift (ideally a minimally invasive one like my Band Aid Mini Facelift) paired with facial filler injections (like Restylane®, Juvéderm®, or Radiesse®) to further minimize your marionette lines.

John L. LeRoy, MD, FACS
Atlanta Plastic Surgeon
5.0 out of 5 stars 1 review

Jowls and Marionette lines, do they require a facelift?

  • Marionette lines and early jowls can often by improved with non-surgical treatments including fillers and volume augmentation. The advantage of non-surgical treatments is a fast recovery and minimal downtime. However there is a point at which jowls will be accompanied with lose skin and sagging and this will require more than fillers along. The downside of fillers is that they have a relatively short lived effect of 6-12months, some care is required to avoid over-filling the face that can look unnatural. 
  • Significant jowls with loose skin will require a facelift to achieve the best possible result. The time frame most often provided when patients ask how long the results of a SMAS or deep plane facelift will last is 8 to 10 years. This number can, however, is just a generalization and can vary significantly from patient to patient. Factors that can affect the results of your facelift surgery include skin elasticity, genetics, sun exposure, and the experience/expertise of the surgeon who performed your surgery. It is common for facelift patients to consider additional surgery to touch-up and maintain the results of their original facelift once it is appropriate. 

Julian De Silva, MD
London Facial Plastic Surgeon
5.0 out of 5 stars 141 reviews

Marionette lines are best treated with filler. A facelift can help too.

It's hard to be 66 and not have jowls!  The only effective treatment is a well-done facelift, not a skin-only lift or minilift.  This way those bags of fat can be lifted back into the face and not hang down over your jawline.  At the same time, the crease in front of the jowl can be treated with a filler.  The best filler is your own fat, so it is very common for me to perform fat injection the same time I do a facelift.  I have attached a link in case you want to look at some before-and-after photos.  Fear of surgery is normal and common.  The only antidote is being well prepared and going to a surgeon you trust.  The fewer surprises, the less nervous you will be.

Eric Swanson, MD
Kansas City Plastic Surgeon
4.7 out of 5 stars 56 reviews

Marionette Lines and Jowls Options?

There are a number of surgical and non-surgical options that can improve one's cosmetic appearance: fillers, skin-tightening procedures, lasers, fat contouring, and face lifts. Each
has benefits and drawbacks. Mini procedures do not produce the long lasting maximum improvement that is achieved with a natural appearing artistically performed lift performed by an expert experienced plastic surgeon. That is achieved by a combination of elevating the sagging tissues, removing the excess skin, contouring the fat, and adding micro-fat grafts or fillers where there is a deficiency.

Keep in mind, that following the exact advice from a surgeon on this or any other website who proposes to tell you what to do without examining you, physically feeling the tissue, assessing your desired outcome, taking a full medical history, and discussing the pros and cons of the proposed operative procedure may not be in your best interest. I would suggest you find a plastic surgeon certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAPS) that you trust and are comfortable with. You should discuss your concerns with that surgeon in person.

Robert Singer, MD FACS

La Jolla, California

Robert Singer, MD
La Jolla Plastic Surgeon
4.6 out of 5 stars 19 reviews

Mini Face Lift and Face Lifting best option for Marionette lines and Jowls

The short answer is that Mini Face Lift (e.g. Lite Lift, MACS lift, Quick lift and others) and Face Lifting are the  best options for Marionette lines and Jowls. Placement of filler at the same time in the pre- jowl area (depression between chin and jowl) is also helpful in the right person

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 154 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.