Filler or Botox for marionette lines/ DAO muscle? (Photo)

Question

I have marionette lines that I feel age me. I feel like the bottom part of my face feels heavy, literally. It feels like my face muscles pull me down and it can actually feel a bit sore. I asked my injector about DAO Botox, but she said it doesn’t seem like I need it and opted for filler in the area instead because she said it looks more like volume loss. I want to fix this, but I am scared because I have heard many people stating to never put filler in this area. What can I do to solve this.

Anya Costeloe, DO · Answer

Thank you for the photos and your question. Based on your description and your photos, I recommend starting with toxin (botox, dysport etc) to the DAO. It will help with the heavy feeling like something is pulling your face down. You may also benefit from the Nefertiti lift - this involves injecting botulinum toxin into the platysma muscles in the neck and the muscles along the jawline. These are the muscles responsible for pulling the jawline downward. By relaxing the platysma muscles, the injectable treatment toxin reduces their downward pull on the jawline, allowing the muscles that elevate the face to create a more lifted and defined jawline and neck contour. Prior to haveing this, make sure you have a consultation with a facial plastic surgeon who has a deep understanding of facial anatomy. If the wrong muscles are injected it can cause mouth and smile asymmetry.

Anna Chacon, MD, FAAD · Answer

Thank you for sharing your concerns and your photo. Marionette lines and the heaviness in the lower face can indeed be troubling, and it's essential to choose the right treatment to address these issues effectively.

Dermal Fillers:

Volume Loss: Your injector's suggestion to use fillers is based on the idea that marionette lines often result from volume loss in the mid-face and lower face. Restoring this volume can provide a more youthful and lifted appearance.
Types of Fillers: Hyaluronic acid-based fillers like Juvederm or Restylane are commonly used and are safe when injected by an experienced professional.
Concerns: While some people express concerns about fillers in the marionette area, complications are rare when performed by a skilled injector. Always ensure your provider is board-certified and has extensive experience with facial fillers.
Botox for DAO Muscle:

Dynamic Wrinkles: Botox can be effective if your marionette lines are due to muscle activity, particularly the depressor anguli oris (DAO) muscle, which pulls the corners of the mouth downward.
Combination Approach: Sometimes, a combination of Botox and fillers can provide the best results. Botox can relax the DAO muscle, reducing the downward pull, while fillers can restore lost volume and smooth out the lines.
Alternative Treatments:

Thread Lift: A thread lift can provide a subtle lift to the lower face and improve the appearance of marionette lines without adding volume.
Laser Treatments: Laser treatments can stimulate collagen production, improving skin texture and elasticity, which can help reduce the appearance of marionette lines.
Ultherapy: This non-invasive treatment uses ultrasound energy to lift and tighten the skin, providing a gradual improvement in the lower face.
Consultation and Personalized Approach:

Professional Evaluation: It's crucial to have a thorough consultation with a board-certified dermatologist or plastic surgeon who can assess your facial anatomy and recommend a tailored treatment plan.
Safety and Efficacy: Discuss your concerns and treatment goals with your provider. They can explain the benefits and risks of each option, ensuring you feel comfortable and confident in your decision.
Ultimately, the best approach will depend on your specific anatomy and aesthetic goals. Combining treatments might offer the most natural and satisfying results.

Best of luck with your aesthetic journey!

Best regards,

Nelson Lee Novick, MD · Answer

Fillers have literally been used for decades to elevate and smooth downturned angles of the mouth and incipient marionette lines. Botox Can be used, but in my experience over the years, is neither as effective as the filler treatment nor do its results last very long. I prefer a robust HA Lifting filler for this purpose. You would be wise to consult with an experienced, board certified cosmetic dermatologist filler expert and make sure to ask to see his/her personal before and after photos of this treatment before agreeing to proceed. Hope this helps and best of luck.

David Hansen, MD · Answer

It is rare for botox around the mouth to help.  It usually causes one side to  look weird over the other.  Fillers almost always work great and consistently improves the look you want.

Camille Cash, MD · Answer

You may want to explore Juvederm Volux.  This filler is specially designed for the jawline to help sculpt and define.  It can subtly enhance and give structure to the jawline.  Visit with an experienced injector near you or my website to learn more.

Priya Arcot-Joshi, DO · Answer

Marionette lines can definitely make the lower face feel heavy and give a tired or aged appearance, and it's completely normal to want to find the right solution. It sounds like your injector suggested filler because they believe the lines are caused by volume loss, which is common as we age. Filler in this area can help lift the lower face and smooth out the lines, making the face look more refreshed.
It's understandable that you’re concerned, especially since you’ve heard mixed reviews about filler in this region. The truth is, when done by a skilled injector with a light hand, filler can give very natural results. The goal is to add subtle volume without making the area look heavy or overdone.
If you’re still unsure, you might want to explore a combination of treatments. Sometimes a little Botox to relax the muscles, combined with a small amount of filler for volume, can do the trick. There are also other options like skin tightening treatments that don’t involve filler but can help with that “heavy” feeling you’ve been experiencing.
The most important thing is to have a conversation with your injector about your concerns. If you’re still feeling uncertain, it never hurts to get a second opinion. You want to feel totally confident with both the plan and the person doing the treatment.
Disclaimer: Please note that this information is for educational purposes only. There is no patient-doctor relationship established. Please consult your healthcare provider for individualized recommendations.

Stefan Weiss, MD · Answer

Filler is the appropriate choice for the lower third of the face. But if you think that your face feels heavy 2-3 units in the DAO would be fine to try. The wonderful thing about Botox is that it is not permanent and if you do not like the end result in 4-6 it wears off.

Jacquelline Leva, DO · Answer

Botox will definitely relax Dao muscle producing the marionette but and also make the dermal filler last longer. Make sure it's not a heavy g prime filler

Filler or Botox for marionette lines/ DAO muscle? (Photo)

Answers (8)

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