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

disliking this entire puffy area around my mouth. marrionette lines from corners down are present at rest, front/ side and with smile. my dads bulldog jowls creeping in! at 43, I used to rock 35 nicely until last year. tired of being called M'aame! have had one consult: doc says Botox in corners to soften lines. however, i would like them gone more than the results i have seen in before/after botox photos. she has also says thermage for jowls--opinions here suggest otherwise.

Doctor Answers 10

Treatment for jowls and marionette lines

Deeper fillers such as Radiesse are ideal for deeper applications like cheek folds and marionette lines as well as hollowing in the cheeks and under the eyes. Using fillers for contouring can correct problems due to volume loss and can also be used for enhancing cheekbones, chin and jaw line. I think you would be wasting your money on Botox and Thermage to treat your problem. I also recommend you ignore advice such as that below from plastic surgeons suggesting you only see a plastic surgeon.

South Burlington Dermatologic Surgeon
5.0 out of 5 stars 10 reviews

Seek multiple opinions

Honestly I don't like either of the options you were given. I hate Botox around the mouth because many, many people experience severe problems from bad technique here, including drooling, inability or strange speaking, affected smiles, etc. Unless you know your injector quite well, it's not something I recommend! I would suggest seeing a great, physician injector and getting a syringe (or two) of filler in the NLF lines and around your mouth. Personally I'd probably start with Restylane, and add a second syringe a few weeks later. As well as possibly adding some under the eyes. I had a Thermage machine for years and I treated people on the highest possible settings (under anesthesia so we could go as high as possible). The results were minimal at best, and I traded the machine in over 8 years ago. At this point I find the Venus Freeze fantastic for tightening the face and neck and truly, the machine is comfortable and amazing. Thermage is old, painful technology with mediocre results at best. I'd seek consults with other physicians in person. But the two procedures you mentioned, neither would I recommend for you.

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

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.

John J. Corey, MD
Phoenix Plastic Surgeon
4.7 out of 5 stars 33 reviews

Filler, filler, filler and maybe some skin tightening

I think you are still rocking 35 but a great way to keep it that way is to restore facial volume with fillers - often referred as the liquid face lift (which I really think of as more full face). Your medial cheeks under your eyes (the area immediately above the nasolabial or cheek folds) are flat and the goal of filler would be to restore the natural convex curvature and contour of the cheek. Also as we age, we lose volume in our chin area accenting marionette lines and making a jowl look more prominant and filler here would be a quick and easy fix. Forget a facelift for at least another 10 years - maybe more if you keep up fillers and botox (between brows - I think you will have minimal effect on corner of mouth but it only takes about 5 units total and can't hurt) and maybe add in some skin tightening procedures (think exilis or ultherapy)!

BTW - we are the same age and I think you are looking great!!

Treatment of Jowls and Marionette Lines

Based on the pictures, I would recommend a combination of injectable filler and laser skin tightening. I also do  not agree with Botox to the mouth corners as the results are unpredictable. I recommend you get a second opinion with a board-certified dermatologist or facial plastic surgeon. Click on the link below to view a video of laser skin tightening with the GentleYag.

Jowls and sagging around corners of mouth

I am not a big fan of botox around the corners of the  mouth because it may cause a facial droop.  It is better to get evaluated by a plastic surgeon. A filler procedure or even a lift may help this area.

Steven Wallach, MD
New York Plastic Surgeon
4.1 out of 5 stars 24 reviews

Get a second opinion

I would recommend seeking out a board certified Plastic Surgeon with extensive experience in facial cosmetic surgery and injectables.  In my opinion Botox is not the ideal treatment for your marionette lines and puffy area around your mouth.

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 414 reviews

Sagging of a young woman's face treated with volume and Ultherapy or Thermage

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


Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 36 reviews

Lines of mouth and jowls.

From your photos you appear to have several options to treat your concerns.


If you want a quick, no down time remedy that is temporary, using a filler is a good option. This will plump the depressions nicely. I also would NOT recommend Botox for you in this area. Botox paralyzes the muscle and you would benefit from volume to plump the area.


Another potential procedure is a RadioFrequency (RF) tightening procedure such as Viora Reaction. This can reduce some of the fatty excess and tighten the overlying skin as well. It will take a little longer and may need maintenance treatments to maintain the results, but there is no down time.


Lastly, a surgical procedure such as a mini facelift will help to soften these areas for a longer time, but requires incisions and some recovery.


I would suggest discussing with a physician who can perform all of these modalities. If you seek advice from a doctor that cannot provide all options, they will recommend only what they do even if something might be better. It is like the old adage, "If all you have is a hammer, then everything looks like a nail."

Brian J. Lee, MD
Fort Wayne Plastic Surgeon
5.0 out of 5 stars 12 reviews

Treatment of jowls and early marionette lines.

A mini lift will give you the best result and ultimately be more cost effective than having repeated fillers. See an experienced facelift surgeon for a proper consult. 

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 32 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.