Marionette Lines Injection Techniques: A Multimodal Approach
- Admin
- Sep 29
- 4 min read
According to Hong, Wong, Yoon, Wan, and Yi (2025), marionette lines, or static labiomandibular folds, are age-related perioral wrinkles extending from the oral commissures to the mandibular border. They can significantly impact facial aesthetics, particularly in Asian populations. Their development is multifactorial, influenced by anatomy, aging, and lifestyle factors. Clinicians need a comprehensive understanding of facial anatomy, wrinkle etiology, and appropriate injection techniques to achieve optimal results while minimizing risks.
Anatomical Considerations
The formation of marionette lines is closely tied to the positioning of the modiolus, a muscular convergence point of perioral muscles. In Asian populations, the modiolus is generally located ~11 mm laterally and ~9 mm inferiorly to the oral commissure. This lower, more lateral position predisposes patients to commissural ptosis and wrinkle formation even at rest.
Key anatomical contributors include:
Depressor anguli oris (DAO) muscle: Its hyperactivity can pull down oral commissures.
Orbicularis oris layers: Superficial and deep fibers create distinct planes that influence wrinkle depth.
Lateral lower lip fat compartment: Atrophy in this region exaggerates fold depth and mouth corner drooping.
Mandibular ligament and prejowl sulcus: These structural elements can further accentuate marionette lines with age.
Understanding these relationships helps guide safe and effective filler placement.
Etiology of Marionette Lines
Several factors contribute to the formation of marionette lines:
Maxillary and mandibular bone resorption
Gravitational descent and skin laxity
Deep fat compartment atrophy beneath the DAO
Muscle compression and ligament tethering
Jowl and buccal fat ptosis
The interplay of these factors explains why a multimodal approach is often necessary for optimal outcomes.
Step-By-Step Procedure
Treatment of marionette lines aims to restore volume, smooth perioral contours, and improve facial expression. This requires a tailored combination of needle or cannula filler techniques and, when indicated, neurotoxin injection to the DAO muscle.
1. Patient Assessment
Evaluate skin laxity, marionette line depth, oral commissure position, and prejowl sulcus.
Assess fat compartment atrophy and hyperactivity of the depressor anguli oris (DAO).
Identify contraindications: active infection, neuromuscular disorders, or prior adverse reactions.
Discuss patient expectations for both aesthetic outcomes and maintenance.
2. Filler Selection
Mild lines: Softer fillers (G’ ~203 Pa) for subtle volume restoration and natural movement.
Pronounced lines / deep folds: Higher elasticity fillers (G’ ~338 Pa) for structural support and lifting.
3. Entry Point and Injection Plane
Commissural line / melolabial fold: Needle injections target the supramuscular fat layer using linear threading, retrograde fanning, or superficial “fern leaf” patterns.
Marionette lines (static labiomandibular folds):
Needle: For mild to moderate depressions in the subcutaneous layer, using linear threading or cross-hatching.
Cannula: For deeper submuscular layers in high-risk vascular areas.
Entry point: Typically medial to the marionette line, around two-thirds from oral commissure to mandibular border.
Techniques: Retrograde fanning, cross-hatching, and layering to restore volume in both supramuscular and submuscular compartments.
4. Injection Technique
Linear threading: Precise placement along the fold.
Retrograde fanning / cross-hatching: Broader volumization and smoothing of adjacent depressions.
Layering: Addresses both superficial and deep fat deficits to restore natural contour.
Use the non-injecting hand to compress superior tissue, preventing filler migration.
5. Neurotoxin Adjunct (if indicated)
Inject 2–4 units per side into hyperactive DAO to reduce downward pull on oral commissures.
Benefits:
Reduces downward force
Enhances filler effectiveness
Improves overall facial expression and harmony
This combination exemplifies a holistic, multimodal approach to perioral rejuvenation.
6. Safety Considerations
Be aware of perioral vasculature: facial, inferior labial, labiomental, and mental arteries.
Inject slowly, maintain safe planes, and use blunt-tip cannulas in high-risk areas.
Monitor for early signs of vascular compromise (blanching, pain).
Have hyaluronidase and emergency protocols ready.
Limitations of the Method
Volume-centric approach: Filler addresses structural loss but cannot reverse ligament laxity or bone resorption.
Temporary results: Repeat treatments required for maintenance.
Variable patient response: Outcomes depend on skin elasticity, muscle activity, and aging patterns.
Risk of complications: Bruising, asymmetry, swelling, or rare vascular events, particularly in complex anatomy.
Limited lift for severe sagging: Advanced jowling or extreme commissural ptosis may require thread lifting or surgical intervention.
Discussion
Successful marionette line treatment requires a tailored approach based on anatomical and volumetric assessment. Early intervention in younger patients may also include thread lifting or skin-tightening modalities to prevent progression. Combining fillers with neurotoxin injections allows clinicians to address both structural volume loss and muscular dynamics, resulting in a more natural and positive expression.
Conclusion
Marionette lines are complex, multifactorial wrinkles. Clinicians must integrate detailed anatomical knowledge, precise filler techniques, and adjunctive neurotoxin use to achieve safe and aesthetically pleasing outcomes. A multimodal approach ensures restoration of volume, smoothing of the marionette lines, and enhancement of perioral aesthetics, particularly in populations with anatomical predispositions.
Reference:
Hong, G. W., Wong, S., Yoon, S. E., Wan, J., & Yi, K. H. (2025). Anatomical-based diagnosis and filler injection techniques: marionette line (static labiomandibular fold). Journal of Dermatological Treatment, 36(1). https://doi.org/10.1080/09546634.2025.2452954
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