Marionette lines

Three things combine. Bone support in the lower face and along the jaw resorbs, so the framework retreats. The fat compartments of the cheek descend, and the tissue that used to sit high on the face collects lower down, either side of the chin. And the ligaments that held everything in place slacken.

There is a muscular component too: the depressor anguli oris pulls the corners of the mouth downward, and as the tissue supporting those corners weakens, its pull becomes relatively stronger and more visible.

We are extremely good at reading mouth-corner position. A downward turn at the corners is one of the most reliable visual cues for sadness, and we read it automatically and unconsciously in other people's faces.

So a structural change that lowers the mouth corners by a few millimetres changes how strangers interpret your mood. That is why people report being asked if they are alright, and why treating this area often matters to people more than the size of the line would suggest.

Structurally, and usually not by filling the line. Restoring support along the jawline and at the chin rebuilds the framework the tissue slid off, and restoring midface support stops more tissue arriving from above.

With the structure rebuilt, small amounts of product can then support the mouth corners directly, lifting them a little and softening the line that runs from them.

Where the downward muscular pull is a major contributor, relaxing that muscle allows the corners to sit higher. It is a supporting move rather than the main event, and used alone it rarely achieves much.

This surprises people. A chin that has lost projection shortens the lower third and lets everything above it crowd downward. Restoring chin projection frequently improves marionette lines more than treating the lines themselves would — and it improves the profile at the same time.

It is a good example of why I assess the whole face before treating a line. The thing that fixes your complaint is often somewhere you were not looking.

Where the line is etched into the skin as well as being a structural fold, microneedling or skin boosters improve the etched component. Structure first, then skin.

Realistically: substantial softening and a mouth that no longer turns down at rest is achievable for most people. Complete erasure of a deep, long-standing line is not, and where skin laxity is advanced the honest answer may be that surgery would do more.

Marionette lines run from the corner of the mouth downward, and the instinct — the clinic's as much as the patient's — is to fill the groove. It is usually the wrong move, for three reasons.

1. The line is the bottom of a slope. Tissue has descended from the midface and gathered above it, and the crease is simply where the gathering stops. Filling the crease does nothing about the slope, so it flattens the shadow and leaves the heaviness.
2. The area is highly mobile. Product placed superficially in a crease that folds thousands of times a day tends to become visible as a ridge, particularly while you talk.
3. Adding volume low in a face that is already heavy low makes it heavier. The result reads as fuller rather than fresher, which is the opposite of the brief.

Support above and to the sides — restoring midface volume, rebuilding the jawline and chin — takes tension off the corner of the mouth and softens the line as a consequence. It is the less intuitive approach and the one that ages well.

The step people want to skip to is the fourth, and doing it first is the commonest reason marionette treatment disappoints at considerable expense.

Two things sit outside what this category can do, and being told so is worth more than being sold a plan.

Significant skin laxity — where the skin has genuinely lost elasticity rather than lost its support — cannot be corrected with volume, and adding volume to it makes it heavier. The pinch test is the quick version: skin that springs back has elasticity left to work with, skin that stays where you put it does not.

And a downturned mouth corner caused by strong muscular pull downward is a movement problem rather than a volume one. It is worth identifying, because volume placed against an active downward pull is money spent fighting a muscle.