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A complete guide to marionette lines — the vertical lines from the mouth corners toward the chin — including causes, filler techniques, Botox options, and realistic expectations.
· By MedSpot Editorial · 5 min read
Marionette lines are the vertical creases that run downward from the corners of the mouth toward the chin — named for the puppet whose mouth segments are articulated by strings. Like nasolabial folds, they deepen with age through a combination of volume loss and tissue descent, and they're one of the lower-face concerns that responds well to a thoughtful combination approach.
The mandibular fat compartments and the jowl fat lose volume with age, removing the support beneath the oral commissure (the corners of the mouth). As this support deflates, the overlying skin descends and the groove deepens.
The depressor anguli oris (DAO) is a muscle that pulls the corners of the mouth downward — a downward-facing triangle of muscle at each oral commissure. As facial support decreases with age and the overlying tissue descends, the DAO's constant downward pull becomes more pronounced, deepening the marionette groove and pulling the corners of the mouth into a permanently downturned expression.
Progressive skin laxity allows the tissue above the marionette line to descend, while the chin remains relatively fixed — deepening the crease over time.
As with nasolabial folds, effective marionette line treatment starts with understanding the dominant cause:
Direct filler along the marionette groove and at the prejowl sulcus/chin area is the most effective standalone treatment.
Technique: Linear threading or serial puncture along the marionette groove, with product placed in the deep dermis or subcutaneous plane. Often combined with chin and pre-jowl filler for a comprehensive lower-face correction.
Products:
Amount: 0.5–1.5 mL per side depending on depth; often combined with chin and jawline product in the same session.
Duration: 12–18 months; Vollure has 18-month duration data.
Injecting 3–6 units of Botox into each DAO muscle reduces its constant downward pull on the oral commissure.
What it achieves: Subtle upward movement of the corner of the mouth; reduces the "downturned" expression that marionette lines can create. This is one of the most satisfying small-dose Botox treatments — patients often describe looking less sad or stern without looking changed.
Risk: Asymmetry of mouth movement during smiling if incorrectly placed; affects the smile mechanics. Requires an injector with specific experience in this area.
Cost: $50–$150 for the additional units.
Adding chin projection and/or height can indirectly improve marionette lines by supporting the lower face structure and balancing the jawline. A weak or receded chin allows the soft tissue above to descend more prominently.
See our chin filler guide for full details.
PDO barbed threads inserted along the lower face vector can lift tissue off the marionette groove. Most effective in early-to-moderate cases; limited effect in deep, established grooves.
Most providers treat marionette lines with:
This combination addresses the line directly, the muscle causing it, and the structural deficit below it.
Filler alone without DAO Botox: Filler in the groove fills the static crease, but the DAO's continued downward activity continues to deepen it. Adding DAO Botox extends filler results and addresses the dynamic component.
Botox alone: The DAO Botox reduces the downward pull but doesn't fill an established groove — works best for prevention or mild, early lines, not established deep marionette lines.
Surface treatments (peels, lasers): Surface treatments don't address the structural or muscle cause of marionette lines; they may improve skin quality in the area but won't significantly change the groove depth.
Before treatment: Clear understanding that marionette line treatment improves the lines — it doesn't eliminate them in most patients. Deep, established grooves may improve 50–70% but often require maintenance.
Post-filler swelling: The lower face swells more than the upper face. Assess results at 2 weeks, not immediately after treatment.
Maintenance: Annual retreatment for filler; quarterly for DAO Botox. Consistent treatment over time prevents progressive deepening.
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