Advice/Treatment Options for Sunken Cheeks/Marionette Lines? (photo)

In my lower cheek I've lost volume and developed ‘pouches’/marionette lines. I've had Juvederm in nose-to-mouth lines twice since the age of 30 (last time 1 yr ago) and was pleased with that area. Also in my marionette lines twice in the last 3 years, but less pleased, as it gave a ‘hamster’ look. 9 months ago I had Juvederm Voluma but it was put into my high cheek bone area and hasn't helped my area of concern. Fraxel /Thermage were suggested but I've read frightening stories that have put me off.

Doctor Answers 11

Treatment options for sunken cheeks

Deeper stimulatory fillers such as Sculptra or Radiesse, when strategically injected high along the cheekbones and lateral face, will create a much better lifting effect for sagging skin. Sculptra or Radiesse is not injected directly into the wrinkle lines and folds, but rather into other areas of the face to treat the subtle volume loss that leads to their appearance. This leads to the natural-looking results that are so often desired. Patients don’t want to look “done” but also don’t want to look “tired”. Seemingly small changes in shape, proportions, balance, and symmetry can have a surprisingly large effect on our perception of the aging face. Please remember, the effectiveness of your treatment depends on your physician’s ability to visualize the desired changes and to select and skillfully administer the best treatments alone or in combination. Since every face is different, the experience and technique of your physician injector is the most critical part to your achieving a beautiful, natural result.

South Burlington Dermatologic Surgeon
4.7 out of 5 stars 12 reviews

Options for facial volumization

The main issue is volume loss, but you also have a chin structure that predisposes you to looseness in the jowl area.  These areas can be helped with volumization, not just in the creases or folds, but also in the areas that have lost volume and contruibuted to structural descent.  My fillers of choice for deep volumization are your own fat and sculptra.

It is great to see so many doctors catching on the the importance of facial volumization, but a word of caution.  Like any good idea, volumization can be carried to extremes, in which case some very strange results occur.  Seek a physician who is highly experienced with a refined artistic vision

John Q. Cook, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 12 reviews

Volumization is needed to improve sunken cheeks and marionette lines

Volume, volume, volume is needed to improve you issue.  You must go to a surgeon familiar with fillers and not just the cheapest or closest place to you.  I would put more in the cheek area, buccal area, marionette jawline and fill the face out somewhat.  Just attacking the marionette or nasolabial will look funny and won't completely improve your problem.

Steven F. Weiner, MD
Panama City Facial Plastic Surgeon
4.7 out of 5 stars 41 reviews

Advice/Treatment Options for Sunken Cheeks/Marionette Lines?

 From the photos provided, there are evidence of facial sagging and "jowls".  A minimal incision facelift to tighten the face, remove excess skin...combined with Perlane to shape the anterior cheeks and fill out the Marrionette lines would address these issues.  

Francis R. Palmer, III, MD
Beverly Hills Facial Plastic Surgeon
4.6 out of 5 stars 25 reviews

Fillers for face

Fillers placed selectively in the face can provide great results to faces that appear deflated.  Good luck.

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

Advice/Treatment Options for Sunken Cheeks/Marionette Lines?

You can continue to try the non invasive therapies as mentioned- Fraxel, Thermage. Plus yearly fillers. But either think about a mini lift plus fat grafts/PRP injections at this time or keep looking at these short term fixes. 

Darryl J. Blinski, MD
Miami Plastic Surgeon
4.6 out of 5 stars 174 reviews

General volume loss

The problem I see in your photos is that you have generalized loss of volume. You submitted very good photos that prove this, but I suspect it would be even more apparent with 3/4 or side view photos as well. In particular your temples are very sunken, in a way that is disproportionate to the rest of your thin face. If you agree with my assessment I have some suggestions for you:

  • find a skilled physician who will tell you that you have generalized volume loss and not try to put filler in your smile/marionette lines; that will only make you look like a 'hamster' as you put it
  • the most natural appearing remedy for generalized volume loss is Sculptra
  • I'm not a fan of fat transfer for very thin faces; Sculptra is more predictable
  • the very volume depleted temples can be instantly improved with hyaluronic acid filler
  • treat the whole face, not just parts and you will have more balance

Kimberly Finder, MD
San Antonio Dermatologic Surgeon
4.7 out of 5 stars 63 reviews


You have an overall deficiency of facial volume. Have you lost a lot of weight recently? This can potentially accentuate facial volume loss. If you have a bit of excess body fat [inner thighs or knees in ladies] then fat grafting would be a great long term solution.

If not, then other fillers can be helpful. Sculptra is a more long term filler than Juvederm or Restylane, but its results are more gradual over a period of 6 weeks or so.

A.J. Amadi, MD
Seattle Oculoplastic Surgeon
5.0 out of 5 stars 41 reviews

Don't chase the lines, focus on volume

My headline pretty much sums it up.  Be sure to see a physician who can offer you the choice of the full spectrum of fillers voilumizers and collagen stimulators.  Don't simply chase the lines around the mouth.  In my office we would be looking at deep volume replacement over the cheek bones, collagen stimulating and creating more volume replacement in the soft part of the cheek below the cheekbones and in front of the ears as well as some collagen stimulation in the lines around the mouth.  Don't attempt to approach this in one quick 'fix'.  Focus on each area as a work in progress to get you to the fullness you deserve.

Steven Swengel, MD
Los Gatos Dermatologic Surgeon
5.0 out of 5 stars 11 reviews

Sunken Cheeks/Marionette Lines

Long term fillers or fat, which I prefer, can be used to add volume to your face. Marionette lines can be improved but it is almost impossible to achieve the ideal result.

Richard W. Fleming, MD
Beverly Hills Facial Plastic Surgeon
4.9 out of 5 stars 39 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.