Marionette lines, what is best option? Approximate cost? Doctor recommending a lower facelift? (Photo)

Marionette lines are developing on my face. They became noticeable about 3 years ago. I've been getting regular botox on the 11's for 7 years and mentioned this concern to the nurse who injects me at my PS. She did put Juvaderm Voluma in my cheeks a couple months ago, which helped. But not much. Her current opinion is I need no more filler, but I see before and after photos of others that seem to take care of my issue with filler. She is recommending a lower face-lift with the PS instead.

Doctor Answers 14

​The inevitable facelift

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This is a common problem.  Fillers definitely do wonders. Many of the times the can ward off the need for surgery for many years. The benefits of fillers you have already been exposed to. They are quick, there is little downtime and they are relatively cheap. At the same time the results can be modest. 

As we age we lose fat, bone and minerals, and the skin loses elasticity. Fillers only treat volume loss. A lift can reposition the fat decent and skin laxity. In my hands about 70% of patients that get a facelift also get fat transfer to the face. That is because aging is a complicated process with more than one aspect of physiology affected. To maximize results we need to approach it realistically and reverse as many of the processes that lead to aging. 

Hope this helps. Best of luck,


Chicago Facial Plastic Surgeon
5.0 out of 5 stars 12 reviews

Concept Facelift Under Local Anaesthetic

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Thank you for your question and picture.  You can have a lower facelift under local anaesthetic therefor being less invasive than traditional methods as there is less scarring, bruising and swelling for a significantly quicker recovery period.  The Concept™ facelift is suitable for men and women who wish to reduce sagging in the lower face and neck and regain a more natural, rejuvenated appearance.  

What are the benefits of a local anaesthetic facelift?

  • Minimally invasive as it is a short scar facelift
  • There is minimal bruising and swelling, especially when compared to traditional facelifts
  • As the procedure is performed under local anaesthetic, you can go straight home following the procedure
  • Full recovery in a matter of days rather than months
  • Significantly less risk than Facelifts performed under general anaesthetic
  • Fresh, youthful and long lasting results

The Concept Facelift can be combined with other facial procedures or shaping such as dermal fillers, neck lift, upper blepharoplasty surgery etc. Please make sure you find a reputable and qualified plastic surgeon who can assess you properly to give you a realistic idea of what outcome you can achieve.  All The Best 

Lower face rejuvenation

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Hello Normarupp and thank you for your question. You do have options rather than just a facelift. Although many of my patients opt for a facelift after considering their options, some just are not ready to proceed with that route. Realize that you will likely need 2+ syringes and results will be temporary and subtle, but noticeable improvement. You may want to get a second opinion if your injector is not comfortable with injecting the marionette lines. Best of luck!

Marionette lines, what is best option?

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 Hi, I have performed facelifts for over 30 years and have performed many minimally, invasive type facelifts.  From the photos your cheeks are flat anteriorly (in the front), there is a significant amount of fullness in front and below the cheeks (either fat or dermal filler), jowls (the leading fold of the jowls are called the Marionette lines) are present and the chin is weak.  These factors combine to create an elongated, 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.  Liposuction to reduce the facial fullness in front and below the cheeks would allow further shaping of the cheeks.

 When the chin is weak, this 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.

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 and no incisions extend or are placed within the hair.
  • minimal tissue dissection = less bruising and swelling = rapid recovery ( several days instead of weeks or months with the more invasive type facelifts mentioned)
  • 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.

Hope this helps.

Marionette lines, what is best option? Approximate cost? Doctor recommending a lower facelift

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I agree that your best option is a facelift. Resorting to more filler in the marionette lines will just make yo look fuller and heavier.

About a Lower Facelift

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Patients who desire facial rejuvenation that is affordable, quick, and effective should consider the Lite-lift™. The LiteLift™ is an innovative facelift developed by board-certified plastic surgeons Dr. Larry Nichter and myself. The goal of the #LiteLift is to provide a less invasive natural looking option for both men and women desiring to refresh their appearance with less downtime and risks. The LiteLift® is a “real” facelift, which does address the underlying muscle, tissue and overlying skin.

The technique requires limited incisions and takes a vertical lifting approach, in contrast to the traditional facelift, which requires extensive incisions and lifts or pulls the face towards the ears horizontally. The modern techniques used allow us to perform most LiteLift® procedures in the office under local anesthesia. Also, removing the risk of general anesthesia opens the door for more people to pursue facial surgery. All too often people do not move forward with undergoing the desires facelift surgery due to their overwhelming fear of the risks associated with general anesthesia.
This is a modified facelift that can be performed in the office with a local anesthetic and improve signs of aging around the neck, jawbone and lower face. These procedures are not "Thread-lifts" or "String-lifts". We do not use the "barbed" sutures employed in these other lifting operations. The Lite-lift™ uses longer lasting techniques that are discussed below. Because the incisions are limited, there is less bruising, swelling and healing time for most patients. Many patients can be back to work in one to two weeks looking rested and more youthful.
The best candidates for #LiteLift are non-smoking patients 35-60 years old with early changes of the lower face and the neck. Older patients who cannot or do not wish to have a longer operation or general anesthetic can be improved with a Lite Lift™.
The #price of a #Facelift is always a concern when deciding whether or not to have a cosmetic procedure. Patients’ needs and goals vary, so there is no fixed price for a facelift. The contributing factors to the cost of a facelift include the surgeon’s fee, facility fee, medication cost and the anesthesia fee. Estimated fees may also be found here on Real Self, and the American Society of Aesthetic Plastic Surgery website,, or
Secondly, your procedures should be performed by a #PlasticSurgeon who is board-certified and has a great deal of experience specializing in cosmetic #surgery. You will then greatly improve your chances of getting the result you desire, and, without the need for a revision surgery. I suggest you view before and after photos of the surgeons actual patients, and read patient reviews. Gathering all of this information will help you make a well-informed decision.


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A facelift will help pull back the jowls and loose skin.

Your volume depletion in the midface, nasolabial folds, marionette lines, and besides your chin will still need some fillers for maximal improvement.

You can try more fillers first and see how you like the result.

The aging face

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Thanks for your question.  Fillers will help a great deal, but as we continue to age the decent of fat and increased skin laxity will lessen the effectiveness of just fillers alone.  Fillers only treat volume loss, which is also a part of the aging face, but many other factors enter into it.  It is quite a battle, but keep up the fight!  I hope this helped--best of luck.

Marionette lines, what is best option? Approximate cost? Doctor recommending a lower facelift?

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I agree the best option is a facelift.  At the same setting I would also do some fat grafts to your nasal labial folds.

Best Options for Marionette Lines?

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The photo that you provided doesn't give us too much information, but what can be seen is that you are beginning to develop early jowls which is commonly seen in conjunction with the emergence of Marionette lines. Volumizing fillers such as Voluma, placed into the cheek area, can help restore some of the volume lost with facial aging, but it will not give you the lifting effect that is needed to correct the jowls and/or neck if that is also needed. Having a facelift is a much more complete correction of these problem areas, and when done properly it will give a more complete and natural rejuvenation. In conjunction with a facelift I would typically recommend autologous fat transfer to the areas of the face that are affected by the volume loss (fat atrophy) which is also a major component of facial aging. This would include fat transfer into the pre-jowl area (location of marionette lines) as well as your cheeks, nasolabial fold, and possibly the temporal area.

If you are definitely not ready to consider a facelift procedure there is a technique for injecting filler very superficially into the dermis just beneath the visible marionette line. This requires very precise technique and the use of a filler which disperse into the dermal tissues and thus not leave a visible line where it is injected.

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.