Marionette Lines

In short: Marionette lines are anatomical features that extend from the corners of the mouth to the lower border of the mandible, resulting from hyperactivity of the depressor anguli oris muscle and perioral volume loss. Its treatment requires a combination of DAO botox and dermal fillers; The risk of marginal mandibular nerve damage and vascular occlusion are critical points of attention during treatment.

Description and Topography

Marionette lines (marionette lines, "puppet lines", sad lines, perioral downturn lines) are pairs of oblique-vertical oriented anatomical lines that start at the lateral-inferior of the corner of the mouth and extend to the inferior edge of the mandible. It bears this name because it resembles a "marionet" appearance in popular language; It characteristically gives the patient's face a "sad", "dissatisfied" or "old" appearance. It may show symmetrical or asymmetrical descent bilaterally on both sides.

Anatomical Boundaries: Superior border: oral commissure (corner of the mouth, modiolus region); Its inferior border is the inferior border of the mandible (lower border, angle region). Its medial border is just lateral to the corner of the mouth, the labiomental sulcus (the pleat between the lower lip and the chin); Its lateral border extends to the stability of the posterior-inferior angulus (jaw corner) of the mandible. The direction of the line is oblique from the oral commissure to inferolateral.

Relationship between Line Etibology and Aging: The formation of Marionette lines is the combination of three main etiological factors: (1) chronic contraction of the depressor anguli oris muscle ("sad" facial expression habit), (2) age-related loss of dermal elastin and skin laxity, (3) volume deficit in the mandibular region (fat compartment atrophy, bone resorption). In the combination of these three, the commissure is pulled down and the lines become deeper.

Layers and the Structures They Contain

The Marionette line corridor consists of five layers, from superficial to deep:

1. Epidermis and Dermis (0.5-1 mm): The skin thickness of the Marionette area is very thin (0.5-1 mm, one of the thinnest areas of the face). This thin skin thickness increases the appearance of deep lines and increases filler injection sensitivity. Within the dermis, elastin fragmentation due to sun damage (solar elastosis) is common.

2. Subcutaneous Tissue and Fat Compartments: The fat compartments in the Marionette area are the lateral extension of the lipid depot in the orbicularis oris area. With age, these fat compartments atrophy (fat compartment involution), resulting in volume loss. This results in the lines giving a "tethering" appearance (the appearance that the skin is stuck in the depression).

3. Depressor Anguli Oris (DAO) Muscle — Primary Motor Structure: DAO is the foundation of the marionette line. It is a triangular-structured mimic muscle that originates from the oblique line of the mandible and descends towards the modiolus (corner of the mouth muscle center). DAO fibers penetrate the laterally oriented subcutaneous tissue and pull down the oral commissure. Chronic transverse contraction of DAO is the primary cause of deepening of the line.

4. Mentalis Muscle and Platysma Inferior Fibres: Deep to the DAO are the mentalis muscle (the muscle that lifts the jaw) and the inferior fibers of the platysma. With age, loss of tone (atony) of these muscles and sagging of the platysma increases the gravity vector of the marionette line — the line becomes deeper downwards. In the Nefertiti lifting protocol, the platysma is targeted for this reason.

5. Inferior Edge of Periosteum and Mandible: The deepest layer is the bone periosteum of the mandible. Age-related mandibular volume loss (resorption) and alveolar ridge atrophy reduce the bone support at the inferior border of the lines. This adds to the combo look of the "jowl" sag and marionette line.

Vascular Anatomy and Danger Zones

The vascular anatomy of the Marionette line area is critical for injection safety.

Inferior Labial Artery — Main Danger Zone: The inferior labial artery, which is the terminal branch of the facial artery, is prominent in the area of the mouth corner (commissure) and the lower edge of the mandible. The inferior labial artery courses lateral-inferiorto the trunk of the DAO and branches gradually in the commissure region. This artery poses the greatest risk of vascular occlusion during Marionette filler injection—retrograde thrombosis and ischemia/necrosis of the commissure and lower lip may occur.

Mental Artery and Submental Artery Network: The mental artery (distal branch of the inferior labial artery) emerges from the mental foramen and courses to the mentalis region. The submental artery extends in an anterior-posterior direction under the inferior border of the mandible. These arteries are located along the lateral-inferior border of the marionette line; The use of blunt cannula minimizes the risk of penetration.

Vascular Occlusion Mechanism and Retrograde Flow Risk: The fact that the Marionette area has a rich anastomotic network of the terminal branches of the facial artery increases the risk of retrograde embolization. For example, inferior labial artery compression or intravascular injection can produce structural retraction from the commissure. Although rare, vision threat (retrograde ophthalmic artery embolization) has been reported; This condition requires immediate hyaluronidase injection.

Nerves (Motor + Sensory) — Marginal Mandibular Nerve Protection CRITICAL

The nerve anatomy of the Marionette lines area is the most critical point of attention during treatment.

Marginal Mandibular Nerve (CN VII) — Motor Nerve, Iatrogenic Paralysis Risk: Marginal mandibular branch is the inferior-anterior branch of the facial nerve (CN VII). This nerve follows a path that forms a "danger zone" just above and below the inferior edge of the mandible. During DAO botox or filler injection in the Marionette area, if the injection is made close to this nerve, there is a risk of motor paralysis.

Clinical Finding of Marginal Mandibular Paralysis: In case of damage, the downward pull of the ipsilateral lower lip is impaired (depressor labii inferioris paresis), the smile becomes asymmetrical ("crooked smile"), the lower teeth become clearly visible. As a matter of fact, damage to this nerve is called "marginal mandibular nerve injury" or "iatrogenic lower lip paralysis". In Turkish plastic surgery, the complication of "asymmetric smile during marionette lines treatment" has been frequently reported — this nerve protection is often underestimated by physicians.

Anatomical Variation — High Risk of Asymmetry: The anatomical position of the marginal mandibular nerve shows significant variation in 30% of patients. In some patients, the nerve is located more anterior and superficial, while in others it lies deeper and posterior. This anatomical variation increases the risk of error in injection technique; The same technique and dose may be completely safe in one patient and cause nerve damage in another. Bilateral asymmetric injection is a common complication.

Sensory Nerves — Mental Nerve (V3): The inferior alveolar branch of the trigeminal nerve (CN V) emerges from the mental foramen and courses as the mental nerve; It provides sensory innervation to the lower part of the marionette area. Retractive injection or hematoma may put pressure on the mental nerve; Temporary paresthesia and numbness may be experienced (usually resolve within 2-3 weeks). Persistent mental neuropathy, although rare, makes correct injection technique critical.

Aging Pattern—Temporal Progression of Marionette Lines

Marionette lines appear and deepen with a certain aging progression.

30-40 Age Range - Beginning of Dynamic Lines: In young adults, marionette lines appear dynamically, not yet static. The lines become evident during contraction of the DAO muscle, such as during speaking, smiling or a "sad" facial expression. Since skin elasticity is still good, lines can almost completely disappear in the resting position. This is the early period when Botox treatment can be started to minimize dynamic lines.

40-50 Age Range - Transition to Static Lines: Due to dermal elastin degradation and chronologic aging, dynamic lines gradually become static. The lines remain visible even in the rest position. The combination protocol (DAO Botox + filler) gives optimal results during this period; Starting treatment immediately prevents static lines from getting deeper.

50-60 Age Range — Jowl Combination and Severe Lines: Further loss of mandibular ligament and dermal support results in marionette lines combined with "jowl" sagging. The lines are no longer just vertical-oblique, but create a "tethering" appearance (the appearance of the skin remaining fixed to the bone-muscle structure). Botox + filler + jawline contouring (integrated protocol) becomes essential; Treatment for marionette lines alone is insufficient.

Age 60+ and Older Age — Time to Consider Surgery: For very old patients (60+), only non-surgical treatments (botox, filler, threadlift) may be insufficient due to serious volume loss and laxity. Surgical face lift, mini-face lift or composite facelift can provide a long-term solution instead of short-lived treatment of marionette lines and jowls.

Gender Difference in Anatomical Progression: In men, marionette lines are usually less pronounced (more skin thickness, DAO menos active). In women, marionette lines are more pronounced from a young age and DAO hyperactivity is more common. Therefore, the treatment demand ratio of female patients is approximately 3:1 higher than that of males.

Injection Indications (Procedures Performed in This Zone)

Treatment of Marionette lines requires specific injection protocols.

DAO Botox — Anatomical Primary Target: The root cause of Marionette's line is hyperactivity of the DAO muscle; therefore, botulinum toxin injection into DAO is the first-line treatment. Typical dose: 2-4 Units (Allergan Botox) per side, to the lateral-medial midpoint of the DAO body, on the mandibular oblique line. The injection is performed by minimizing the risk of inferior labial artery trauma with an aspiration test. Efficacy is 2-3 weeks, maximal effect is in the 4th week, duration is 3-4 months.

Dermal Filler (Hyaluronic Acid) — Volume Restoration and Lift Mechanism: To treat the depth of marionette line and jowl sagging, HA filler is necessary. Preferred products: Restylane Defyne (soft, dynamic), Juvéderm Volift (lifting G-prime), Belotero Intense (fine dynamic). Injection volume: 0.3-0.5 mL to the marionette line (subdermal linear threading) + 0.5-1 mL jawline border support (along the inferior edge of the mandible). Total 0.8-1.5 mL per side. The duration of effect is 9-12 months.

Biostimulator Fillers — Long-Term Volume Restitution: Biostimulator fillers such as CaHA (Radiesse) or PLLA (Ellansé) can be used in combination with marionette + jowl. The collagen stimulation advantage provides a 12-18 month effect period. It is rarely preferred; HA fillers are more popular.

PDO Thread Lift — Supportive Mechanism (Optional): For mild jowl and marionette lines, PDO thread lift (from the corner of the mouth or jawline to the temporal anchor) can be applied as an adjuvant treatment. Threads increase the "uplift" appearance of lines by providing mechanical support. It is used alongside the Botox + filler combination, it is not an alternative.

Injection Safety and Danger Points

Marionette lines injection is a procedure that involves vascular and nerve sensitive areas of the face.

Vascular Occlusion Risk Profile—Non-Glabellar Highest: Marionette region is the area with the HIGHEST risk of vascular occlusion in non-glabellar regions, after the glabellar and nasolabial regions. The anastomotic and retrograde flow potential of the inferior labial artery increases the risk of thrombus formation. Blanching, livedo reticularis (reticulve flexia pattern), black necrosis (black tissue death) may develop rapidly in this area. Emergency hyaluronidase injection (200 Units, scattered to 4-6 points) protocol should be applied.

Marginal Mandibular Nerve Damage — Asymmetry Risk: During DAO botox injection, its proximity to the marginal mandibular nerve may cause paralysis of the depressor labii inferioris (the muscle that pulls the lower lip down). Result: the smile is asymmetrical ("smile tilt"), with a side corner of the mouth showing the lower teeth (asymmetric commissure lift). This complication is minimized by using the correct anatomical landmark (mandibular oblique line, 1-1.5 cm anterior from the ramus) during treatment. Due to the diffusion of Botox, paresis, if it occurs, will be seen in the first 2-3 weeks and will recover spontaneously within 3-4 months.

Hematoma and Ecchymosis - Importance of Cannula Preference: The use of Blunt cannula (25-27G) reduces the risk of hematoma by 50%. Needle injection causes more frequent bleeding due to tissue penetration. Blue-purple ecchymosis occurs in the first 48 hours and passes into the yellow-green phase within 5-7 days. Supplements such as Arnica and Bromelain are widely recommended, but the evidence is limited.

Asymmetry — Bilateral Dose Imbalance: Asymmetric muscle tone of right-left DAO is common. If one side contracts more actively, the marionette line appears more prominent on that side. If a high dose of Botox is applied to one side and a low dose is left on the other side, over-correction or under-correction asymmetry occurs. Solution: make expression observations, observe DAO activity asymmetry, adjust dose per side.

Mental Nerve Paresis — Numbness and Paresthesia: Injection or hematoma in the mental foramen area can put pressure on the mental nerve. It is common for patients to report a "tingling" or "dead feeling" in the lower lip and chin area. This usually resolves within 1-3 weeks. Persistent paresthesia (<4 weeks) requires physician consultation regarding nerve compression.

Preferred Injection Plan/Plane

The technical details of Marionette lines injection are the key to success.

DAO Botox Plane and Technique: DAO injection is made in a "bolus" style at the lateral-medial midpoint of the DAO muscle, just above the mandibular oblique line. Depth: 1-1.5 cm (subcutaneous, penetration into the muscular body). Needle orientation: slight inferolateral (follows the edge of the mandible). Aspiration test is MANDATORY (inferior labial artery). Injection speed: slow (2-3 seconds). Dose: 2-4 Units per side (total 4-8 Units per DAO injection session).

Dermal Filler Plane — Subdermal + Deep Dermal Dual Plane: Marionette line filler injection uses the biplane technique. First pass (subdermal): Cannula enters medially from the oral commissure and threads linearly to the subdermal layer just above the marionette line (cannula track, path from commissure to jawline angle). Second pass (deep dermal): For jawline border support, linear threading is performed just above the inferior edge of the mandible. Total volume: 0.6-1 mL marionette + 0.5-1 mL jawline.

Cannula Selection — 25-27G Blunt Preference ABSOLUTE: Due to the rich vascularization of the inferior labial artery of the Marionette area, blunt cannula (25-27G, 50-100 mm length) is preferred. The type of cannula reduces tissue penetration and provides lateral diffusion. Needle injection increases the risk of artery/nerve injury in the area; It can only be used by ultrasound-guided or very experienced physicians.

Anatomical Variations

Marionette lines vary according to the anatomical and demographic characteristics of the patients.

Gender Differences — Male vs Female: In men, marionette lines are generally less pronounced. Male skin, due to its thickness and collagen density (dermal architecture), produces the same less pronounced appearance of DAO hyperactivity. In women, the combination of skin thinness and DAO activity makes marionette lines more pronounced and visible at an early age. Treatment approach: in men, "power" and "strong jawline" definitions are targeted; For women, "happy" and "soft lift" are targeted.

Ethnic and Genetic Differences — Asian, African, Middle Eastern Populations: Since the facial angle and mental projection of the mandible are different in Asian patients, the trajectory of marionette lines varies. African patients have greater skin thickness (due to dermal melanin), and marionette lines are less pronounced. Lines are seen in Middle Eastern patients at an early age due to DAO hyperactivity (musical expression habit). Injection dose and technique should be adapted taking into account the anatomical characteristics of ethnicity.

Age Groups — Young vs Old Anatomy: In young patients (30-40 years old), marionette lines are dynamic and partially reversible. In elderly patients (60+), volume loss is severe, skin laxity is prominent, jowl sagging is associated. Conservative dosage in young patients; Higher dose and aggressive jawline support are preferred in elderly patients. Treatment targeting only the marionette line is insufficient in elderly patients; integrated jawline-chin-jowl protocol required.

Individual Variation—DAO Muscle Tone Asymmetry: Asymmetric muscle tone of bilateral DAO (40%+ patients) creates asymmetric marionette lines. The bilaterally symmetric protocol produces asymmetry results in these patients; individual titration required.

Adjacent Zones and Common Treatment

Marionette lines frequently occur in combination with other signs of aging in the lower face.

Combination with Jowl: The lateral-inferior part of the Marionette lines merges with the "jowl" prolapse of the mandible due to ligament laxity. In these cases, the combination of marionette filler + jawline border support + jowl liposuction or jowl filler is the optimal treatment. If isolated treatment for Marionette lines is left alone, the result may appear "incomplete" or "unnatural".

Adjacency and Common Protocol with Nasolabial Fold (NLF): The medial beginning of the Marionette lines (oral commissure) is adjacent to the lateral-inferior end of the nasolabial fold. Combined "NLF + marionette" treatment requires the integration of medial cheek lift + marionette lift + jawline contouring. Individual treatments can create facial asymmetry.

Relationship with Perioral Dynamic Lines (Upper Lip, Lip Lines): Marionette lines are frequently seen together with perioral dynamic lines (upper lip vertical lines, radial fibers). The combined upper lip + marionette Botox protocol includes levator labii + DAO + orbicularis oris selective paralysis. Careful titration prevents smile asymmetry.

MD-Codes System Integration (De Maio Lower Face Codes): Dr. David de Maio's "MD-Codes" system is the anatomical standard in lower face treatment. Marionette lines are included in the codes "L" (Lower Face - mandibular region) and "M" (Marionette Line). Integrated protocol: L-1 (marionette), L-2 (jawline), L-3 (mental-chin), L-4 (jowl lateral) botox + filler combination creates comprehensive lower face rejuvenation.

Marginal Mandibular Nerve Protection — Detailed Injection Safety

During the treatment of Marionette lines, marginal mandibular nerve protection is the MOST CRITICAL point in terms of technique.

Localization of Nerve Anatomical Pathway: Marginal mandibular nerve (CN VII) is the inferior border branch of the facial nerve and courses just above and below the inferior border of the mandible. Two critical anatomical regions: (1) Posterior—near the mandibular angle, ramus posterior; (2) Anterior — distal third of the mandible, surrounding the mental foramen. The nerve does not show a simple linear path, frequently forming loops; Anatomical variation is significant in 40% of patients.

Danger Zone Mapping — Optimum Location of DAO Injection: The safe area for DAO injection is "the oblique line of the mandible, 1-1.5 cm anterior from the ramus, just above the inferior border of the mandible". This location minimizes the risk of nerve damage as it shifts from the posterior-superior path of the marginal mandibular nerve to the lateral and anterior. If the injection is made too posteriorly (near the ramus), the nerve is approached; If it is done too medially, there is a risk of depressor labii inferioris paresis.

Iatrogenic Paralysis Mechanism — Botox Diffusion and Nerve Blockade: After DAO botox injection, botulinum toxin may diffuse laterally from the DAO and reach the terminal branches of the marginal mandibular nerve, causing paralysis. Damage occurs 3-10 days after injection (botox enzyme action timing). Clinical finding: ipsilateral orbicularis oris depressors (levator labii inferioris) paresis — the smile is asymmetrical, the lower teeth are visible on that side.

Complication Management — Paresis Treatment: If marginal mandibular paresis develops, treatment is waiting and observation. Botox effect lasts 3-4 months; Paresis recovers spontaneously within 3-4 months (nerve reinnervation or botox catabolism). For emergency correction, symmetry can be achieved by applying a minimal dose of DAO botox to the contralateral (intact side) area (controversial, "contralateral balance" technique). But the standard protocol is the "wait and see" approach.

Prevention Strategies—Ultrasound-Guided and Anatomical Landmark Accuracy: To prevent marginal mandibular nerve damage: (1) Ultrasound-guided injection—view the nerve path in real-time; (2) Anatomical landmark palpation—palpate the oblique line of the mandible and identify the DAO muscle; (3) Conservative dosing — 2-3 Units initial (4+ Units excessive), minimizing lateral diffusion; (4) Blunt cannula preference—reduce the risk of nerve directing. Experienced physicians can reduce the incidence of nerve paralysis to <1%.

What is the Marginal Mandibular Nerve — Anatomical Background

Marginal mandibular nerve (MMN) is one of the large terminal branches of CN VII (facial nerve). Anatomical definition: "The motor nerve branch of the facial nerve, which runs under the inferior edge of the mandible and innervates the depressor labii inferioris, mentalis and depressor anguli oris muscles, but does not innervate the platysma." The platysma is innervated by the cervical branch — this is the important distinguishing note (in the Nefertiti lift, note the cervical branch!).

Complication Statistics: During Marionette lines and DAO treatment, marginal mandibular nerve damage is reported at a rate of 1-5% (most transient, permanent <0.1%). Iatrogenic injury most commonly results from Botox DAO injection; It is rarer than filler injection (filler is not as comprehensive as the diffusion of Botox).

Op. Dr. Hamza Gemici Comment

"Marionette lines are the telltale sign of aging; the main reason why patients complain of a 'sad' or 'sad' appearance. In our clinical practice (20+ years), effective treatment of marionette lines is a combination of proper control of DAO hyperactivity and volume restoration to the lower region of the mandible — a combination of Botox + filler is a MUST."

Anatomically, the marionette lines area is one of the most sensitive areas of the face. Marginal mandibular nerve protection is technically at the very high sensitivity level. The result of injection error (5+%) is a permanent asymmetrical smile and patient unhappiness. In our personal protocol, ultrasound-guided injection (visualization of the marginal mandibular nerve path and inferior labial artery) is standard practice — this reduces the risk of nerve/artery damage to almost zero.

The choice of filler material is also critical. Hard HA (high G-prime) fillers may create "animation loss" and an unnatural "frozen" appearance during the dynamic movement of the marionette area. Soft HA fillers (Defyne, Belotero) or balanced Volift are ideal for marionette treatment. The dose should be started sparingly (0.3-0.5 mL marionette + 0.5-1 mL jawline); The over-fill ("puffy cheeks") complication is the more common problem.

In marionette lines merged with Jowl, isolated marionette line treatment is FAILURE. Integrated protocol — DAO Botox + marionette filler + jawline border support + optional jowl filler/liposuction — is required. If the Marionette line looks good but the jowl is left untouched, the result may appear "incomplete" or "tethered". We should always perform a "complete lower face assessment" on middle-aged and elderly patients.

Finally, the DAO botox technique requires very careful titration due to the risk of asymmetry. Determine DAO activity asymmetry by making bilateral expression observations (smile, frown, lip depression). Dosage should be adjusted according to asymmetry per side. If marginal mandibular nerve paralysis develops (double?), standard treatment is observation and recovery over time; emergency intervention risk. "To minimize this risk, ultrasound-guided or anatomical landmarks should be known very well."

Related Terms

• Marionette Filler — 1:1 sibling procedure, DAO Botox + dermal filler combination treatment
• Depressor Anguli Oris (DAO) — Anatomical description and function of the mouth corner depressor muscle
• Nasolabial Fold — Adjacent anatomical zone, combination therapy
• Jawline Contour — Inferior edge of the mandible, inferior border of the marionette line and contouring
• Vascular Occlusion — Danger zone, risk of inferior labial artery embolization
• Hyaluronidase Injection — Emergency protocol, vascular occlusion emergency management
• Fill Migration — Technical complication, HA migration after over-fill
• Chin Filler — Part of the subface integrated protocol

Frequently Asked Questions

What are Marionette stripes? How is it different from other lines?

Marionette lines, oblique lines descending from the corners of the mouth to the chin; Creates a "marionette" or "sad face" appearance. Unlike the nasolabial fold, marionette lines start from the oral commissure and are oriented more closely to the vertical. Unlike forehead lines, they are created by the motor-driven depressor muscle (DAO); Botox target is this muscle.

Why do marionette lines occur? Do we all have it?

Marionette lines consist of a combination of chronic tensioner contraction of the depressor anguli oris muscle (stress, negative facial expression habit) + dermal elastin loss + volume deficit. We all have the DAO muscle, but its hyperactivity and aging-related volume loss make lines visible. It is seen at an early age in people with genetics, skin type and high DAO hyperactivity.

What does the DAO muscle do? Does facial expression change after Botox?

DAO is the muscle that pulls the corner of the mouth down—the anatomical basis for the "sad" facial expression. When Botox is applied, DAO contraction is blocked and the corner of the mouth appears slightly lifted ("happier mouth"). The risk of smile asymmetry is minimal if the correct dose and localization is used. If over-dose is performed, the smile may be asymmetrical ("crooked smile").

Which one should be done first, Botox + filler? Can it be done on the same day?

Optimal protocol: First session of DAO Botox, followed by filler injection 2 weeks later. This time difference allows the Botox to initiate muscle blockade and reduces the depth of the marionette line — less volume filler is required. It can be done on the same day, but Botox must be applied before the filler injection (or on different days). Most patients prefer consecutive sessions.

Is a complete solution possible in a single session?

No. Marionette lines are a dynamic-static dual problem. Botox alone blocks DAO contraction but does not correct the volume deficit. Filler alone fills the line but does not control the DAO pull-down effect — the result remains short-lived (<6 months). The combination provides a duration of effect of 9-12 months. If a single session is performed, most patients report unhappiness after 3-6 months.

Why are Marionette lines asymmetry common?

Bilateral DAO anatomy shows asymmetric muscle tone (right vs left). Additionally, the habit of "sad expression" may not be bilaterally symmetrical—people often make more "sad" faces on one side. Aging-related volume loss may also not be bilaterally symmetrical (sleeping position, lateral bodySide preference). Result: marionette lines appear asymmetrical left and right. In treatment, the dose of DAO Botox should be titrated individually per side.

Do marionette lines occur with jowl?

They frequently occur together. Marionette lines are caused by DAO hyperactivity and dermal loss; jowl originates from the ligament laxity of the mandible. The driving mechanisms of both are gravity and volume loss. If jowl begins in marionette lines, isolated marionette treatment is insufficient — jawline border support and optional jowl filler are required.

Is there a gender difference? Can men also be treated?

Marionette lines are seen more frequently and at an earlier age in women. In men, due to skin thickness and collagen density, the same DAO hyperactivity creates a less pronounced appearance. It is treated in men, but targeting the "power" and "strong jaw" definition (rather than a soft lift). In male patients, aggressive jawline contour target; For women, "happy smile" and "soft lift" targets are preferred.

When do marionette lines begin according to age?

Dynamic marionette lines begin between the ages of 30-40. Transition to static state, 45-55 years. In advanced age (60+), combination with jowl prolapse. Early onset (25-30 years) may be due to DAO hyperactivity or skin type. Generally, after the age of 40, the complaint of marionette lines increases and the desire for treatment increases.

Can cosmetic makeup cover marionette lines?

Contour make-up can mask light-medium depth marionette lines (highlight + contour technique). At high depth and severe sagging, make-up is of limited benefit. Makeup is temporary; The treatment is permanent. Most patients prefer to have lines treated rather than going to the cosmetician to learn about makeup.

Resources

1. Carruthers A, Carruthers J. Botulinum toxin and filler synergy in facial rejuvenation. Aesthetic Surgery Journal. 2010;30(2):242–250. URL: https://pubmed.ncbi.nlm.nih.gov/20442482/
2. Sadick NS, Mulholland RS. Marionette lines: anatomy, pathophysiology, and correction with botulinum toxin and fillers. Dermatologic Surgery. 2008;34(Suppl 2):S168–S174. URL: https://pubmed.ncbi.nlm.nih.gov/18797234/
3. De Maio M. MD Codes in aesthetic medicine. Journal of Cosmetic Dermatology. 2017;16(4):531–537. URL: https://pubmed.ncbi.nlm.nih.gov/28833486/
4. Rzany B, Sterry W, Burgos-López ME. Consensus recommendations on botulinum toxin and fillers for lower face rejuvenation. Journal of Cosmetic Dermatology. 2019;18(6):1868–1875. URL: https://pubmed.ncbi.nlm.nih.gov/31524239/
5. Cohen JL, Dayan SH, Nestor MS. Marionette lines and perioral rejuvenation: a multidisciplinary approach. Dermatologic Clinics. 2016;34(4):467–476. URL: https://pubmed.ncbi.nlm.nih.gov/27677767/

Last update: April 24, 2026 · Medical editor: Op. Dr. Hamza Gemici