36 y/o female with marionette lines at rest. Can this be treated with Botox, filler, or lasers/peels? (Photo)

I have noticed in the last couple years that my laugh lines have gotten worse. On a positive note, I guess that means I smile a lot. However, I fell that it has made me look a little saggy. I am open to any suggestions that you might have.

Doctor Answers 21

Fillers are best since marionette/laugh/smile lines are caused by volume loss

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Thank you for your question. I understand you’re concerned about some smile lines, or marionette lines, around your mouth, and ask if Botox or fillers can improve their appearance.

I can provide you with some guidance on this issue. I am a Board-certified cosmetic surgeon, practicing in Manhattan and Long Island for over 20 years, and a Fellowship-trained oculofacial plastic and reconstructive surgeon. Interestingly, oculoplastic or oculofacial plastic surgeons and neurologists were actually the first doctors to use Botox.

Moving onto the question of smile lines, we must first understand what causes them. As we get older, volume loss occurs at many levels—particularly when you reach your early to mid-30s. In your teens and 20s, you could smile as you normally would, and your skin would just bounce back. As you get older, the lines caused by smiling or other facial expressions become more etched in and go from being dynamic to static and constantly present. This is caused by a combination of loss of skin collagen, loss of fat under the skin, and loss of elasticity in the skin.

In order to address this, a cosmetic filler—usually from the hyaluronic acid family, such as Juvederm or Restylane—can be used. These types of fillers are made of material that’s naturally found in the skin and help fill out or add volume to the superficial levels of the skin.

We usually divide the skin, epidermis, dermis and subcutaneous fat layer, and then we place the fillers in the level of the dermis. When it comes to the spectrum of fillers, there are fillers that are softer and last a short time, and there are those that are thicker in consistency and last longer. Often, people will opt to have a thicker and longer-lasting filler placed into their skin, but keep in mind that a thicker filler can also make it look more obvious that you have had fillers done, which is not an ideal look.

With the understanding that you’re looking for improvement and not complete erasure of the lines, I would suggest you use a softer filler to soften the lines and create a better overall balance for your face, so your lines are not a focal point when you look in the mirror.

In our practice, we do a combination of hyaluronic acid fillers and platelet-rich plasma (PRP). PRP is a concentration derived from your own blood, and its benefits include improved stimulation of collagen production, fibrovascular growth, and blood supply, as well as some wound-healing benefits. The combination of hyaluronic acid fillers and PRP, in my experience, seems to work better because there’s synergy and the concept of a matrix being formed with this combination. Essentially, we’re using PRP or your body’s own natural healing ability to rebuild collagen, while the hyaluronic acid filler provides a sort of scaffold.

I recommend you explore this option, as it is certainly worth considering. I hope that was helpful and I wish you the best of luck.

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36 y/o female with marionette lines at rest. Can this be treated with Botox, filler, or lasers/peels?

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Hi, the attached photos show signs of "jowls" and the resultant "Marrionette" lines as well as flat cheek anteriorly.  Botox will lift the corners of the moth slightly but will not decrease the jowls.  While you can use fillers to soften the marionette lines, this will add volume making the area larger, not smaller.  If you have "jowls" this is sagging facial tissues and an indication for some form of a facelift, not Cheek Augmentation. I have performed many Cheek Augmentations over the past 30 years and the notion that Cheek Implants or dermal fillers to the cheeks will lift tissues is an urban myth. Filler to the cheeks or cheek implants will not lift up the jowls. 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.

My most popular facelift is the minimally invasive, short incision facelift that has all the benefits of more invasive facelifts (traditional, mid-face 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 Perlane) or facial implants
  • most patients fly back home to parts all over the world in as little as 3 days post-op
Hope this helps.

Good Candidate for Fillers

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Thank you for your question. You have beautiful lips, and it's understandable that you'd want to keep the focus on them, not your smile lines. BOTOX COSMETIC is best suited for wrinkles around the eyes and forehead, so it would not be the best choice in your case. You appear to be an excellent candidate for dermal fillers, used conservatively. JUVÉDERM, or another high-quality filler such as TEOSYAL, is an excellent treatment designed specifically for this area. JUVÉDERM VOLUMA, which is designed specifically for plumping up the cheeks, may also provide you with a bit of "lift," which can sometimes improve the appearance of smile lines. Laser skin treatments might also soften some of your finer lines a bit and improve the overall texture of your skin. You can also consider skin tightening treatments such as Exilis Elite, which uses radiofrequency energy. I think fillers would be your best bet, though. Good luck!

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Thank you for your question. 
Fillers can help soften the appearance of marionette lines, along with different lasers to help tighten the skin. To be sure what is best for you, see two or more board-certified providers in your area for a complete evaluation to make sure you are a good candidate and that it is safe for you to have treatment.

I hope this helps.

Fillers Are Best for Treating Laugh Lines

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It sounds like you have a great sense of humor, but I understand your concerns about marionette lines. They commonly start to become a concern around your age. The photos you've attached (thanks!) indicate you could benefit from treatment with fillers. There are several options available. One of the most recent additions is Restylane® Silk, which is approved by the FDA specifically for treating lines around the mouth. JUVÉDERM is another popular option that patients have gotten great results with. Good luck, and keep smiling!

Susan M. Stuart, MD
San Diego Dermatologist

Marionette lines

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 Thank you for your question. If you had to choose one product or procedure, I would recommend using a dermal filler. If however, you are open to multimodal approach, then I would recommend using an energy-based device such as Ultherapy or Profound to also help create more of a lifted and tighter structure in the face. 

Combination Ultherapy & Filler for Marionette Lines

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I'm a firm believer in a combination approach to treat areas such as the marionette lines. I also believe that you should start off conservatively with fillers. Perhaps a combination approach of Ultherapy to lift and tighten the skin on the face combined with a soft filler such as Juvederm would be a good place to start. However, the approach really needs to be customized with an experienced provider so that a frank a throughout discussion can be had about the pros and cons of each treatment. Hope this helps.

Marionette Lines

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Thank you for your question.  I think you would do amazing with fillers, particularly in your case I would recommend Juvederm Voluma to restore volume to your cheeks which is leading to the marionette lines you see.  You may also consider some skin tightening treatments like Ulthera or Infini to get a subtle lift.  Botox would not be an option to restore volume.  Regards, Dr. Matthew Elias

Matthew Elias, DO, FAAD
Fort Lauderdale Dermatologic Surgeon
5.0 out of 5 stars 5 reviews


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 I think you would do great with fillers, around the laugh lines and to your cheeks to help pull them up and out. I don't think Botox would be a very good option.
Good luck! 

Marionette Lines - Fillers Over Botox

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Botox relaxes muscles and softens dynamic lines which are caused by muscle movement.  It works best on lines between the eyebrows and for crow's feet.  The smile lines you are noticing result from changes in the fat pads in the cheeks and by skin laxity.  You would be best served by having fillers such as Juvederm or Juvederm Voluma injected by a skilled injector.  You could also have some skin tightening laser treatments in order to maximize your results and help to stay ahead of the game in the long run.

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