ProductsYou may have heard that Botox can soften the lines running from the corners of your mouth towards your chin. Someone else may have told you that filler is the only treatment that works. Both can help, but the right choice depends on what's causing your marionette lines.
For most people, Botox for marionette lines treats only half the problem. Filler, or Botox followed by filler, usually gives a better result. A simple mirror test takes about thirty seconds and shows which treatment fits you.
Marionette lines are the creases that run downward from the corners of the mouth toward the jawline, named for the hinged mouth of a puppet. They usually come from two things at once. A small muscle pulls the mouth corner down, which gives a downturned mouth, and the skin loses its underlying support over time.
The thirty-second mirror test
Sit facing a mirror in even lighting. Relax your face completely, with your lips together and your jaw loose, and look at the corners of your mouth.
You'll see one of three things.
- Mostly muscle pull: the corners turn down, but the skin between them and your jaw is fairly smooth, and stretching leaves little or no crease. The problem is mostly muscle.
- Mostly a crease: a defined crease stays visible even while you gently stretch the skin. The problem is mostly a fold and lost support.
- Both muscle pull and a crease: the corners turn down and a crease stays when you stretch the skin. The answer is usually both treatments.
This test is a starting point, not a diagnosis. At a consultation I watch the same area while you talk and smile, because a mouth corner can look normal at rest and pull down only when your face moves.
What Botox for marionette lines can do
Botox works on the muscle that pulls the corner down, so it's the right fit if your result was muscle pull. It can't fill a crease or replace lost support.
Botox relaxes the muscle it's injected into for a few months. Here, I treat a small muscle that pulls each mouth corner down toward the chin. Doctors call it the depressor anguli oris, or DAO. When this muscle relaxes, the corner usually lifts slightly and the crease softens.
Using Botox here is off-label, meaning the mouth corners aren't on the FDA's approved list for Botox Cosmetic. Placement here needs care, because Botox that spreads to nearby lip muscles can affect your smile. That's why I study how your face moves before planning any injection.
On a deep fold, Botox alone usually gives a slight improvement. If your mirror test showed a crease it's less likely to give you the result you want. Many people who say Botox did nothing for their marionette lines had this pattern. It's the same reason Botox alone is sometimes not enough elsewhere on the face: it relaxes muscle but can't fill a line that stays when your face is at rest.
What filler does here
If your result was a crease, filler is usually the better choice, because it replaces the support under the crease. It doesn't stop the muscle from pulling.
A hyaluronic acid filler is a gel made from hyaluronic acid. Hyaluronic acid is a sugar molecule your skin makes naturally. The gel holds water and supports the tissue under the skin, so the fold looks less deep. I often place filler higher than the line itself, in the mid face or along the jawline. That's because the sagging that creates a marionette line usually starts higher up.
Product choice and depth matter. A firmer gel placed deeper gives structure, while a softer gel suits finer work near the surface. Too much filler, especially soft filler placed in the line itself, can make the lower face look heavy. That's a large part of why filler results vary between injectors. The American Academy of Dermatology recommends choosing a board-certified dermatologist for your skin care, and that matters a lot for dermal filler injections.
I take a conservative approach to filler, focusing on natural-looking results. I start with a small amount and add more at later visits if you need it, so your face doesn't look overfilled. Hyaluronic acid filler is also reversible. If needed, I can dissolve it with hyaluronidase, an enzyme that breaks it down. Filler can cause bruising and swelling, and rarer complications are possible, which I go over with you before treatment.
When to use Botox and filler together
When the corners pull down and a crease stays, you usually need both, because each treatment handles a different half of the problem. If you're weighing the two for other areas, Botox or filler: which should you choose covers that.
I treat the muscle first and see you at the two-week follow-up, where I can add a touch-up if needed. Once the muscle relaxes, part of what looked like a groove often softens on its own. Then I determine how much filler you still need. Patients who start with filler can end up using more product than they needed.
If you already had Botox and saw little change, the crease probably comes mostly from lost support, which tells me where filler should go.
Your answer, by mirror result
- If your result was muscle pull: start with Botox and review at two weeks.
- If your result was a crease: start with filler to rebuild support, often just one syringe at first.
- If your result was muscle pull and crease: start with Botox and add filler after the two-week visit.
- If the jawline itself sags or the skin folds over it: Botox and filler are less likely to be enough on their own, because Botox doesn't lift jowls. You may need radio frequency skin tightening.
What to expect and who this suits
A combined plan usually takes two visits and about a month. It suits people whose skin still springs back after a gentle pinch. Before either treatment, I review your medical history, medications and allergies. That includes lidocaine, a numbing medicine many fillers contain. Here's how a combined plan usually goes:
- Botox day: I use a Veinlite to see blood vessels and a Zimmer chiller to cool and numb the skin, and the treatment takes minutes.
- Around two weeks: Botox reaches full effect, and we review it at your follow-up.
- Filler visit: most of the change shows immediately, and swelling usually settles over one week.
- Around one month: we look at the combined result together.
When the skin is loose or crepey and folds over the jaw, I'll recommend the approach that fits your skin at the consultation, which may include skin tightening.
FAQ
Does Botox work for marionette lines?
Only partly. It relaxes the muscle that pulls the mouth corner down, which helps most when your mirror result is Pull. On a crease that stays visible under stretch, the improvement is usually slight. Full effect takes about two weeks.
Is filler better than Botox for marionette lines?
It depends on your mirror result. For Groove, filler usually does more because it replaces lost support. For Pull and groove, using both usually works better than either one alone.
How long do the results last?
Botox usually lasts 3 to 4 months, and many of my patients repeat it on that schedule. Filler usually lasts much longer, and how long depends on the product, the area, and your metabolism. The guide to how long dermal fillers last explains how to keep results up.
Can I have both on the same day?
You can, and for some faces I do. For marionette lines, I usually prefer Botox first and filler after the two-week review. Waiting lets me see how much of the crease softens once the pull is gone.
What the first visit involves
During your consultation, I review your medical history and look at your whole face, how it's built and how it moves, not only the mouth corners. I repeat the mirror test with you, watch both sides at rest and in motion, and check whether early jowls or loose skin are part of what you're seeing. What to expect at your first visit walks through the rest.
From there, I recommend Botox, filler, or both, depending on what's causing your lines. Treating the muscle first often means you need less filler.
If you'd like me to check which of the three results you have, request an appointment at 931 5th Ave on the Upper East Side, or call . I've injected Botox in New York City since 1992, and I do every injection myself. You can read more about how I approach Botox and how I place dermal fillers before you come in.
