Marionette and cheek hollows. Any suggestions?

I have "puppet lines" and lower face droop.cheek hollows. Have tried juvaderm ultra and radiesse in upper cheekbones and apples to pull up lower face. Have tried this about 25 times with no luck. I am 41

Doctor Answers 7

Marionette and cheek hollow

From your photos,it appears that a modified mini facelift along with fat/stem cell transfer may be the most effective solution.This combination should correct both the loose skin and the hollowness.Best of luck with your decision.

Orange County Plastic Surgeon
4.6 out of 5 stars 22 reviews

How can I get facial improvement without fillers?

Once a person has excess skin, fillers will probably not be the answer and it may be time to consider at least a mini facelift. I can perform many of my facial lifts under local anesthesia in my certified operating facility. This would improve the excess skin and should soften the lines around the mouth. Additional procedures like fat transfer can be used to decrease the hollowness. 

Edward J. Domanskis, MD
Newport Beach Plastic Surgeon
4.4 out of 5 stars 27 reviews

Facial Sculpting Using Fillers Like Voluma, Radiesse, Lyft, Juvederm and Sculptra and Fat

Fillers, implants and fat can all be used to sculpt the face. Fillers like Radiesse, Voluma, Perlane work great for cheek volumization which helps improve nasolabial and marionette lines as well indirectly. Fat can also be used which is something I do frequently in my practice. I suggest consulting with a facial contouring expert. Best, Dr. Emer

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.9 out of 5 stars 159 reviews

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Have tried juvaderm ultra and radiesse in upper cheekbones and apples to pull up lower face about 25 times with no luck.

Hi, I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts on women. From the photos your cheeks are flat anteriorly (in the front), jowls are present and the chin is weak. These factors combine to create a rectangular shaped face.

Following the beauty principles outlined in my book on face and body beauty, women look the most feminine, youthful and attractive with heart shaped faces. Heart shaped faces have cheeks that are full and round in the front. Cheek augmentation with a dermal filler or using cheek implants for a permanent enhancement will create full, round cheeks that will feminize the entire face.

A weak chin creates an imbalance making the nose appear larger, the mid face top heavy and the lower face look short that de-emphasizes the lips and allows early formation of a double chin. Chin augmentation using a chin implant will add projection to the chin creating harmony and balance to the lower face. I have found that placement of a silastic chin implant, through a small curved incision under the chin (also allows excess skin removal) to be very safe, quick and highly effective.

If you have "jowls” these are sagging facial tissues and an indication for some form of a SMAS facelift. The underlying SMAS layer, of the face, must be dissected, lifted, trimmed and re-sutured (not merely folded or suspended with threads or sutures that will not last). The excess skin is then removed and the facelift incisions closed. Marionette lines are the lines formed by "Jowls".

My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face, deep plane, cheek lift and subperiosteal facelifts) but with these added benefits:

  • very small incisions
  • minimal tissue dissection = less bruising and swelling = rapid recovery
  • can be performed in 90 minutes or less, with or without general anesthesia
  • no incisions within the hair = no hair loss
  • excess fat can be removed
  • excess skin removed
  • cheeks, chin and jaw line can be augmented with dermal fillers (I prefer Restylane Lyft) or facial implants
  • most patients fly back home to parts all over the world in as little as 3 days post-op
I combine facial shaping with every facelift procedure. When jowls are present, these should be done in concert and not alone or separately in order to create a naturally, more attractive face. In my opinion,fillers to the cheeks will "not" lift adjacent sagging tissues.

Hope this helps.

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.6 out of 5 stars 24 reviews

Laxity and aging around the mouth and jawline, jowls

Some of the areas to address during your consultation are the jawline, the mouth and the facial appearance overall.

You will obtain your best result by a facelift and neck lift and judicious (not excessive) use of filler.

The face is a package so it must be balanced.

Brent Moelleken, MD
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 134 reviews

Lower facelift

Your issues of concern may resolve with a proper lower facelift.  You have adequate filling done already.  It would be best to have a personal consultation to assess your face in person.

Afshin Farzadmehr, MD
Los Angeles Dermatologic Surgeon
5.0 out of 5 stars 33 reviews

Addressing marionette lines and cheek hollows.

Facial aging used to be about lax, loose skin. More modern thinking blames volume loss as the culprit, which has made facial fillers a popular treatment. It actuality it likely both contributing to signs of aging.

Using a combination of treatments conservatively is a better solution than blasting away with one treatment. Restylane Lyft or Voluma in the midface can project the cheek and recruit skin in the lower face. Restylane and Juvederm used directly under nasolabial folds and marionette lines improve contours focally. Skin care and resurfacing improves the quality and tone of the overlying skin. 

There is a limit of what injectables can do. Surgical rejuvenation options, including fat transfer, should be discussed with your surgeon at your next consultation. Don't get overwhelmed by all of the options. Take your time, move forward conservatively. Safety is the priority. 

Victor Chung, MD
San Diego Facial Plastic Surgeon
5.0 out of 5 stars 10 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.