Changes around the mouth are among the most noticeable signs of lower-face aging—and often some of the trickiest to treat. “Marionette lines are often described as simple folds that run from the corners of the mouth downward, but in reality, they reflect a broader structural shift occurring in the lower face,” says New York dermatologist Julie Russak, MD. “Bone support diminishes, soft tissue begins to descend, muscles that pull the mouth downward become more dominant and the skin itself loses elasticity and resilience.”
Because several factors are at play, treating the lines alone rarely produces the most natural-looking outcome. “The most effective approach is to restore balance across the lower face and support the skin’s ability to withstand constant movement and mechanical strain,” says Dr. Russak. Luckily, there are several in-office treatment options available, but the right one depends on the severity of your lines and your goals, which is why consulting a qualified provider is a must, adds Delray Beach, FL, dermatologist Dr. Janet Allenby.
Ahead, we’re breaking down some of the most common in-office treatments doctors use to soften marionette lines.
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Filler
Both hyaluronic acid and biostimulatory fillers are useful tools for combating marionette lines, but techniques vary depending on the patient’s anatomy and needs. “In many patients, carefully placed hyaluronic acid filler can reestablish structural support in areas such as the chin, jawline and pre-jowl region. When these foundational structures are restored, the shadowing associated with marionette lines often softens without directly filling the line itself,” explains Dr. Russak. Meanwhile, biostimulatory injectables, like Radiesse, work by “stimulating collagen production and helping rebuild the skin’s internal framework gradually, improving firmness and elasticity over time,” she explains.
Dr. Allenby also likes filler as a minimally invasive option for marionette lines. “I usually will use sturdier fillers in the outer face or upper cheeks or even into the scalp because it’s usually the skin hanging that’s the problem,” she says. “I may use a filler to improve the shape of the chin, giving it a little more augmentation or projection, which will sometimes relieve the depth of the marionette lines. Or I fill in the marionette line directly if it’s not too deep,” notes Dr. Allenby.
“Beyond structural support, strengthening the skin itself is essential. Techniques such as the Fern Pattern Filler Technique, which distributes micro-supporting strands of hyaluronic acid within the dermis, help reinforce the skin’s internal scaffolding,” says Dr. Russak. “Rather than simply adding volume, this approach improves the skin’s ability to resist repetitive folding caused by constant muscle movement around the mouth.”
Neuromodulators
Dr. Russak says neuromodulators can also help resolve certain patients’ marionette lines. Dr. Allenby notes that a product like Botox can help relieve the frown-like appearance. “Relaxing the depressor anguli oris muscle helps reduce the downward pull at the corners of the mouth, which contributes to the deepening of these lines over time,” explains Dr. Russak.
Devices
“Energy-based treatments such as radio-frequency with microneedling or ultrasound tightening can further support tissue remodeling,” which may be beneficial for marionette lines, says Dr. Russak. “If I am considering using a device, it may be a standalone device or a combination of devices,” says Dr. Allenby. For example, Dr. Allenby would consider combining “Ellacor to remove the excess skin and the Helix CO2 laser to penetrate deeper into the tissue to tighten up the area.” She notes that she’s also seen improvements with Morpheus8 and EVERESSE Monopolar RF.
PDO Threads
Dr. Russak says PDO threads may be an option to help lift the tissue up and out. PDO threads are dissolvable sutures that help tighten the skin while stimulating collagen production.
PRP, Exosome and Peptide-Based Treatments
“Regenerative therapies, including platelet-rich plasma, exosomes and peptide-based treatments, may enhance the skin’s repair capacity and overall quality,” says Dr. Russak. It’s best to discuss with your doctor whether any of these regenerative approaches may be appropriate for addressing your specific concerns.
