Which Filler for Marionette Lines and is One Syringe Sufficient? Can a Nurse Inject?

My face is gaunt with loss of volume and several marionette lines when I smile. Would juvederm work for this area? I've had restylane in past and it made my skin appear blue and didn't work that well. I'm hoping Juvederm will give a better result. Is one syringe enough (hat is all I can afford at this time.) When I made the appt, I was informed my PS has a nurse do the injections. I trust my PS, but is this ok? Would one syringe be enough for marionette and a little in my lips?

Doctor Answers 12

Which is the best filler for Marionette Lines? Can a nurse inject?

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  I find that Juvederm and Restylane are more alike than they are dissimilar and both will work well for the Marionette lines you show.  Personally, I do not delegate filler injections to my R.N. and although many R.N.s will do a fine job, my patients prefer me to do this for them and it is a service that I am happy to provide.  After viewing your photos, it looks like you may benefit  more from 2 syringes of these fillers than trying to get by with just one.   In such cases, I usually advise my patients to consider Radiesse which comes in a 1.5 cc size, is wonderful for Marionette Lines, and which probably lasts twice as long as the HA fillers.  It costs less than two syringes of the HA filler and I think it is a better value for the money.  hope that this helps!  

Saint Petersburg Oculoplastic Surgeon
4.8 out of 5 stars 140 reviews


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Your lines at rest and those that are superficial, may be helped with fillers.  They dynamic lines which are increased with animation can only be softened with fillers.  My suggestion would be to start with one syringe and see how you like the result.  It is always easier to add more filler then to try and remove it.  Also, I would suggest starting with an HA like Juvederm or Restylane since these can be melted away with another injection.  Who injects you would have to be based on experience as every plastic surgeon does not do fillers and some injectors treat thousands of patients a year with fillers while others do it a few times a week.  


Good Luck.

Sculptra is best

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I would suggest Sculptra as it seems you have lost a lot of fat in your cheeks, which is the underlying cause of the smile lines.  I would suggest only letting an MD do your injections, especially if you move to a filler like Sculptra.

Mitchel P. Goldman, MD
San Diego Dermatologic Surgeon
4.9 out of 5 stars 26 reviews

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Marionette lines are different from cheek lines

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It depends on the injector's skill and some nurses are better than the doctor, and, vice versa.

You don't really have marionette lines. You have nasolabial lines and cheek lines and they are noticable when you animate your face. Fillers will only 'help' because you have a strong dynamic smile which causes these lines. I'd suggest Sculptura for the cheek and Juvederm ultra plus or Voluma or Radiesse for the nasolabial lines. You may need 2 syringes for the nasolabial lines and 2 syringes for the cheeks.

Harlow Hollis, MD
Victoria Plastic Surgeon

Injections of marioneet lines

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Personally, I like to inject my patients myself.  Although I am sure there are many nurses qualified to do it. The marioneet lines can certainly be filled out with hyaluronic acid.  The depressions behind your marionette lines can be treated as well.

Steven Wallach, MD
New York Plastic Surgeon
4.2 out of 5 stars 30 reviews


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Many nurses under a doctors oversight are excellent injectors. Stay away for medical spas nd Botox/filer parties. If you want a lip fill that must be done first in order to have enough to make sure they are equal.  The remainder goes into marionette lines. One syringe should do it but, be prepared for two.

David A. Bray, Sr., MD
Los Angeles Facial Plastic Surgeon


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The best solution to loss of volume in the face is fat transfer.

You can use juvederm, if it is well placed it will not have a blue hue. Although there are good injectors, I believe if your plastic surgeon does not have the time for you to inject your FACE with fillers, I would not allow any nurse injector. Find a plastic surgeon that can give you the time you deserve.


Samir Shureih, MD
Baltimore Plastic Surgeon

I generally recommend staying away from nurse injectors

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I generally recommend staying away from nurse injectors unless the nurse has tremendous injecting experience.  You also want somebody who can inject all the different products, not just Juvederm.  In this case, it doesn’t look like the marionette lines are so much an issue as the fact that you need more lifting.  Sculptra will thicken the skin and minimize the lines.  I think it’s very important to go to someone who can do injections for all products such as Radiesse, Sculptra, and Juvederm because in this photograph it looks like Sculptra would be more appropriate.  But, I cannot be sure without looking at you in person. 

Joseph A. Eviatar, MD, FACS
New York Oculoplastic Surgeon
4.7 out of 5 stars 68 reviews

Filler might help some

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A filler  like restylane or juvederm might help soften the marionette lines but I'm not sure that that will make you happy. It will improve what you see when you are still, not smiling. It will not improve the lines lateral to that that occur with motion. Sculptra or Radiesse would be better to add volume. If you are on a budget and want to take the edge off things and add some volume to lips I would choose Restylane as one syringe will get you started well. You should see no blue if injected properly. If you are paying for this service, why would you have a nurse do it when a physician with years of experience can do your treatment. 

Jo Herzog, MD
Birmingham Dermatologist
4.8 out of 5 stars 20 reviews

The Best Fillers for marionette Lines and Cheeks

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Your photos clearly demonstrate that these are not "marionette lines" but are caused by "deflation of the cheeks" due to volume loss. Juvederm is used to treat superficial wrinkles and is not effective for volume loss so I believe you will be disappointed if you rely on Juvederm for your treatment. Volume correction can best be done using either Radiesse or Sculptra. Neither of these should be injected by the nurse instead of the doctor. In fact, Sculptra is restricted for use only by physicians who have been trained how to properly inject the aging face. Please do not have your treatment done by someone to whom this treatment has been "delegated". It is important to understand the difference between "stimulatory" fillers and "wrinkle" fillers. When treating problems due to volume loss such as cheek hollows and sagging skin beside the mouth, I will almost always use stimulatory fillers such as Radiesse and/or Sculptra. They are injected deeper, beneath the skin, and will generate more volume to create a much better lifting effect for sagging skin. They work by stimulating your skin to produce more collagen, which is why they are so effective for problems due to volume loss. The pictures below show a very effective treatment for this area.


Mitchell Schwartz, MD
South Burlington Dermatologic Surgeon
4.4 out of 5 stars 13 reviews

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