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 91

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.

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 105 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 78 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

Jowls - Look at many facelift before and after images

Loss of skin elasticity with age (and sun exposure) allows the lateral and lower cheeks, which aren't tightly attached to facial bones, to 'sag'. On either side of the chin are ligaments which hold the skin more tightly against the jawbone (mandible). This is where, and why, 'jowls' develop. I have also observed that many people develop both atrophy of soft tissues and slight recession of the mandible between the chin and the jowl area, which serves to exaggerate the appearance of jowls.

The surgical procedure that has traditionally been referred to as a' facelift' involves mobilizing the skin and soft tissues of the lower face and jawline (and in most cases, the neck), and advancing them upward and laterally to eliminate sagging (jowls) and provide the appearance of improved skin tone. The excess skin is removed.
What is currently referred to as a facelift usually means some combination of surgical lower face rejuvenation with procedures that are designed to improve other facial aesthetic areas: the brow and eyelids, the midface, and the neck. The combination of procedures I perform on any patient are customized for that individual's specific needs and desires, and thus no two 'facelifts' are exactly alike.
The facelift procedure involves incisions that skirt the contour of the ears, using the anatomy of the ear to help conceal them. For a full facelift, the incision starts in the sideburn area, follows the contours of the junction of the ear with the face, curves behind the earlobe into the recess between the posterior ear and the neck/scalp, and then extends into the hairline posteriorly at the top of the ear. When I make these incisions, I design them so that, once fully healed, they may be difficult for even a hairdresser to detect. That goal can often be achieved, and it requires meticulous attention to every centimeter of the closure.
So what about this "Weekend Facelift"?
A standard facelift involves incisions as described in the paragraph above. That pattern of incisions is generally required for patients with prominent jowls and very loose neck skin, who require significant skin advancement and removal. A shorter incision which does not extend into the scalp at either end, but is made only in front of the ear and immediately behind the earlobe, can be used to improve jowls and to tighten the neck somewhat in selected patients with lesser degrees of lower face and neck aging changes.
This latter facelift procedure involves shorter incisions, less dissection, and quicker recovery than a conventional facelift, and has been dubbed by some as "the weekend facelift". This, in my mind, is a marketing strategy designed to make the procedure attractive to those who might shy away from a 'full' facelift. I have seen marketing materials which actually suggest that a patient might "go shopping" immediately after this surgery, or drive themselves home!
I think that "weekend facelift" is a misleading term, as it suggests dramatic surgical improvements are possible with minimal surgery. As with most things which sound too good to be true, so it is with the "weekend facelift". As you might expect, the degree of improvement one obtains from surgery is, in general, directly proportional to the surgeon's effort. An hour of surgery through a shorter incision can not be expected to produce a result approaching that of a conventional facelift.
Patients with relatively small 'jowls' and minimal neck skin laxity, however, can obtain a very nice improvement using the technique described above. A better term, however, might be "Mini-facelift", as no surgeon can guarantee a two-day recovery, and patients' expectations may be inappropriately heightened by the promise of a big improvement by a minimal surgery.
Aesthetic improvement of the neck
The majority of patients having a facelift surgery also have aging changes in the neck, which can be corrected and improved through a variety of surgical procedures. To improve the neck contours, the facelift can be extended over the jawline and onto the anterior and lateral aspect of the neck. In other patients without major aging changes at or above the jawline, neck rejuvenation alone may be performed.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 118 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 129 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 55 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

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.