Here Are my Jowls/marrionette Lines. What Should I Do? and Which First? (photo)

I would use a filler like Perlane to soften the jowls and maybe Juvederm or Restalyne for the marionette lines. Sculptra is another option, a longer lasting product that seems to work nicely in jowly area. This product can last 24 plus months in that area.

Morpheus 8 is a non-invasive skin and soft tissue tightening treatment that is consistently amazing in our patients. We use the Morpheus to exact fractional induced RF into the skin or tissue in order to tighten collagen and stimulate contraction of the tissue. For acne scars, it is quite useful to build collagen in patients who have atrophic scars but is not very productive for ice-pick scars which require TCA Cross. For tissue tightening, Morpheus is ideal for the face and neck and we often combine it with CO2 laser or Ultherapy to further enhance results. Chemical peels and skin resurfacing should be done at least 5 to 7 days after, but can be performed earlier, depending on treatment severity. Avoid exfoliating skin treatments before Morpheus and expect a period of 2-4 weeks for skin contraction to set in.

Best,
Dr. Karamanoukian
Realself100 Surgeon

I recommend fillers to soften the nasolabial folds themselves and also lift around the mouth and cheeks to build underlying anatomical support. In our practice we combine Sculptra with other fillers "layered" on top and lasers, skin tightening treatments such as Thermage, Fractora, and Renuvion (J Plasma), thread lifting, and peels to get the most conservative, natural look. I suggest seeing a facial sculpting expert for a formal consultation. Best, Dr. Emer

Hello.  I am not a fan of Botox for your situation.  You are more likely to dislike the resulting facial affect, in my opinion.  Thermage is not likely to be a winner, either.  You should do great with a filler.  Start there.

Your photograph shows some tear trough depression and flattening of the normal rounded inner cheek. You have probably lost ample amounts of fat content in the deep facial planes that has caused you to lose support of the lower cheek. This then falls and creates the small jowls and pushes the inner cheek over the smile crease and over the marionette line. Botox injected in the DAO muscle may help lift the corner of the mouth slightly but if it were to be injected to soften the perioral lines, there could be unwanted side effects of weakening the smile and speech muscles.  

Lifting can be accomplished with either Thermage or Ultherapy.  Having used both devices on my patients, I have found Ultherapy to be more effective in lifting facial features than Thermage. Neither, however, comes close to the amount of lift a surgery can do but it is ideal for patients such as you who don't have significant jowls. Volumizers and or fillers should be done after the tightening with Ultherapy.

Different doctors prefer different volumizers such as Sculptra and fillers such as Radiesse, Fat injections, Perlane, Restylane, Juvederm UltraPlus or Juverderm Ultra and Belotero.

The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice.  The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs