Marionette lines are the hardest of all aging lines to treat, and the sign of aging people most want to get rid of. Nasolabial folds make you look about five years older at most, but once marionette lines appear, you suddenly look ten years older. When nasolabial folds and marionette lines both become severe enough to join into one continuous line, the face looks aged, like Yubaba in the picture below.
Marionette lines are a sign of advanced aging and never appear overnight. They are not just ordinary skin wrinkles; they are also related to fat accumulation in the jowls, bone atrophy, and weakening ligament support.
I hope this article reaches you while you are still young, so you can understand why marionette lines form and which aesthetic treatments can help prevent them later on.
How to Get Rid of Marionette Lines? The Short Answer
Marionette lines are lines caused by "sagging," not by "hollowing," so they need lifting, not filling. The main minimally invasive treatment is a thread lift (about 80%), with ultrasound used after the procedure to help reduce fat (about 20%). In order of effectiveness: thread lift > ultrasound > radiofrequency.
What really needs to be treated to get rid of marionette lines is the jowls. Jowls that have sagged for a long time press the lines into the mouth corners, so treating only the line itself addresses the symptom but not the cause.
The most common mistake is injecting filler. Beneath marionette lines there is no hollow space to hold the material in place, so a bolus of hyaluronic acid slides downward and makes the marionette lines look even deeper. Injecting collagen stimulators such as Ellanse or Radiesse is even more troublesome, because they cannot be dissolved.
Key Points at a Glance
| Question | Short answer |
|---|---|
| What are marionette lines? | Vertical lines running down from the corners of the mouth. They look like the seams at the mouth of a marionette puppet, and are also called "disappointment lines." |
| At what age do they appear? | Usually after age 40. However, skeletal structure, fat distribution, facial expression habits, and rapid weight loss can make them appear earlier in younger people. |
| What are the 3 main causes? | Reduced bony support in the mid and lower face (a receding chin), fat accumulation in the jowls, and loosening of the ligaments around the mouth. |
| What is the most critical factor? | The jowls. Sagging jowls press out the marionette lines, so if you do not treat the jowls, the work is wasted. |
| Which treatment should I choose? | A thread lift as the main treatment, with ultrasound as support. Severe cases need intraoral fat removal or a facelift. |
| Can I get hyaluronic acid filler? | Not recommended. Marionette lines are sagging, not hollowing, and filler makes that area bulge more. |
| Does botulinum toxin work? | The effect is very slight. Botulinum toxin relaxes the depressor anguli oris muscle, but if the jowls are not treated, it is hard to see improvement. |
| Does massage work? | No. Massage cannot reverse bony support loss, fat displacement, or skin laxity. |
| How much does a thread lift cost? | About NT$40,000–80,000; ultrasound about NT$30,000–60,000; intraoral fat removal NT$100,000–150,000; facelift NT$300,000–500,000. |
| How long do the results last? | Thread lift and ultrasound about 1 year; surgery about 5–10 years. |
| How long is the recovery? | After a thread lift, swelling lasts about 2–3 days, and within a week you can move normally, eat, and laugh. |
| Can they be prevented? | Yes. Regular lifting maintenance before marionette lines appear is much more effective than treating them after they appear. |
Index
- How to Get Rid of Marionette Lines? The Short Answer — Key Points at a Glance
- 1. What Are Marionette Lines, and How Do They Differ from Nasolabial Folds? — What are marionette lines? What are nasolabial folds? Marionette lines vs. nasolabial folds at a glance
- 2. The 3 Main Causes of Marionette Lines — (1) Reduced bony support in the mid and lower face (2) Fat accumulation in the jowls (3) Loosening ligaments
- 3. What Are the Ways to Get Rid of Marionette Lines? 5 Methods Compared — Why I am against filler for marionette lines
- 4. Marionette Line Treatment 1: Thread Lift — (1) TL1 upward lift → a more defined jawline (2) TL3 lateral lift → lifting the jowls upward (3) TL4 jawline lift → lifting the marionette lines; Layered thread lift case: a 48-year-old woman
- 5. Marionette Line Treatment 2: Ultrasound Lifting
- 6. Marionette Line Treatment 3: Facelift Surgery and Liposuction
- 7. Can Marionette Lines Be Prevented?
- Marionette Lines FAQ — Does botulinum toxin work for marionette lines? Can young people get marionette lines? Can massage get rid of marionette lines? Can hyaluronic acid filler improve marionette lines? What if hyaluronic acid filler for marionette lines fails? Can I inject Radiesse or Ellanse for marionette lines? What is the most effective way to get rid of marionette lines? How are marionette lines related to jowls? How much does marionette line treatment cost? How long is the recovery after a thread lift for marionette lines? What if the jowl area becomes hollow after a thread lift? Do radiofrequency and ultrasound work for marionette lines?
- Medical Review and Source Notes
1. What Are Marionette Lines, and How Do They Differ from Nasolabial Folds?
What are marionette lines?
Marionette lines are vertical wrinkles running down from the corners of the mouth. They usually start to appear gradually after age 40. Their shape resembles the seams at the mouth of a marionette puppet, hence the name. They are also called "disappointment lines," and even when you are not making an expression, the face can look droopy and even slightly sad.
The drooping line beside the mouth corner in the picture below is a marionette line. As we age, the buccal fat pad and superficial fat sag due to gravity, creating a vertical line running down from the corner of the mouth. This line is what is commonly called a "marionette line."
What are nasolabial folds?
Nasolabial folds are the lines running from the side of the nose to above the corner of the mouth. Their causes are more complex, and the way to treat them needs to be tailored to each person.
Nasolabial folds fall into three main types: muscular, hollow, and sagging.
Nasolabial folds caused by a hollow at the base of the nose can be filled with hyaluronic acid or a collagen stimulator. Sagging-type nasolabial folds, pressed out by drooping apple cheeks, usually appear together with marionette lines. The best way to improve both sagging-type nasolabial folds and marionette lines is a thread lift.
Using threads to lift the apple cheeks and jowls upward together is what improves nasolabial folds and marionette lines.
The marionette line massages and home-use lifting devices you hear about are basically an "IQ tax" (a waste of money), and offer little real help in getting rid of nasolabial folds or marionette lines.
To learn more about which type of nasolabial fold you have, see my article on the 4 types of nasolabial folds.
Marionette lines vs. nasolabial folds at a glance
| Marionette lines | Nasolabial folds | |
|---|---|---|
| Location | Vertical lines running down from the corners of the mouth | Lines from the side of the nose to above the corner of the mouth |
| Other names | Mouth corner lines, disappointment lines | Nasolabial fold |
| Main causes | Mainly sagging: fat accumulation in the jowls, loose ligaments, a receding chin | 4 types: hollow, sagging, muscular, fat |
| Hollow or bulging? | The adjacent jowls bulge too much, so the line looks relatively hollow | The hollow type is truly sunken |
| How to treat? | Lifting (mainly thread lift) | Hollow type with filler; sagging type with lifting |
| Can filler be used? | Not recommended | Yes for the hollow type; see How to Choose Aesthetic Treatments for Nasolabial Folds |
The two lines often appear together. For how to treat them together, see What Is a Thread Lift for Nasolabial Folds? The Best Solution for Nasolabial Folds and Marionette Lines. If your whole face is sagging, start with What to Do About a Sagging Face? Causes and Solutions.
2. The 3 Main Causes of Marionette Lines
| Cause | What happens | Typical appearance | Corresponding treatment |
|---|---|---|---|
| Reduced bony support | The mandible atrophies and the chin recedes, so the tissue above loses its support | Short chin in profile, blurred jawline | Rebuild chin support plus lifting |
| Fat accumulation in the jowls | A pouch forms at the mouth corner, and superficial fat presses down on the corner of the mouth over time | A bulge on the outer side of the mouth corner | Mainly lifting; add fat reduction if there is a lot of fat |
| Loosening ligaments | The three muscles around the mouth contract and pull downward | The mouth corners seem to turn down even without an expression | Thread lift to pull the fascia layer upward |
(1) Reduced bony support in the mid and lower face
The main reason Asians develop marionette lines more easily than Westerners is a receding chin. As everyone ages, the mandible begins to atrophy. As the mandible keeps receding, the muscles above lose the support beneath them and sag, and the marionette lines become more severe.
(2) Fat accumulation in the jowls
The biggest culprit behind marionette lines is the 'jowls.' In the picture below, my wife is thirty now and does not yet have marionette lines, but you can already see a faint 'mouth-corner pouch' at the corner of her mouth.
As she ages, superficial fat accumulates in this pouch and turns into jowls.
If she does no lifting aesthetic treatments, ten years from now marionette lines will really appear in the circled area. So her husband (me) works hard to give her a thread lift and ultrasound every year, to keep my wife young forever, lol
Jowls that have sagged for a long time press out 'marionette lines,' so the most important task in getting rid of marionette lines is actually getting rid of the jowls.
(3) Loosening ligaments
Three important ligament-muscles around the mouth hold up the lower face. As we age, these three muscles contract and pull downward, forming marionette lines.
Depressor anguli oris (DAO)
Located below the corner of the mouth, its main action is to pull the mouth corner downward, and it has the most direct relationship with marionette lines.
Mentalis
Located at the center of the chin, it lifts the chin skin and pushes the lower lip forward. Overactivity may deepen the lines from the lower lip to the area around the chin.
Platysma
Extending from the neck to the mandible and the area near the mouth corners, its contraction may pull the lower half of the face and the mouth corners downward
3. What Are the Ways to Get Rid of Marionette Lines? 5 Methods Compared
The direct answer: There are currently two main minimally invasive ways to improve marionette lines: thread lift and ultrasound fat reduction, and in order of effectiveness: thread lift > ultrasound > radiofrequency. Marionette lines are lines caused by sagging, not hollowing, so what I recommend least is filling with hyaluronic acid or Ellanse. Severe marionette lines require a facelift or intraoral fat removal surgery.
Rome was not built in a day, and marionette lines do not appear in a day either.
Never wait until marionette lines appear to start treatment, because the improvement is very limited by then. I hope you read this article while you are young and start 'preventing marionette lines' early.
There are mainly the following 5 ways to get rid of marionette lines. Mild to moderate marionette lines can be improved with a thread lift and radiofrequency/ultrasound, while severe marionette lines need surgery for a more noticeable result.
| Treatment | Principle | Advantages | Disadvantages | Recovery | Duration | Cost |
|---|---|---|---|---|---|---|
| Thread lift | Directly lifts the jowl fat | Immediate results, short recovery | Limited improvement for severe marionette lines | About 2–3 days | One year | NT$40,000–80,000 |
| Ultrasound | Dissolves jowl fat | Good results, no wounds | Limited improvement for severe marionette lines | None | One year | NT$30,000–60,000 |
| Radiofrequency | Lifts the skin surface only | No wounds, firmer skin surface | Limited improvement for severe marionette lines | None | One year | NT$50,000–100,000 |
| Intraoral fat removal surgery | Removes the jowl fat | Greatly reduces jowl volume | Long recovery, general anesthesia required | Long | 5–10 years | NT$100,000–150,000 |
| Facelift surgery | Similar in principle to a thread lift | Most noticeable results, long-lasting | Long recovery, general anesthesia required | Long | 5–10 years | NT$300,000–500,000 |
For the full price list, see Golden Apple Clinic Treatment Prices.
Why I am against filler for marionette lines
Whichever method you choose, what I recommend least is injecting hyaluronic acid or Ellanse for marionette lines.
At my clinic I have seen far too many clients who came to have their marionette line hyaluronic acid dissolved, so I want to give you one very important concept, which I stress throughout this article: 'Marionette lines are lines caused by sagging, not by hollowing.' So the treatment of marionette lines must never follow the same idea as filling nasolabial folds.
The picture below shows a client who came to me after a failed marionette line hyaluronic acid injection. There is an abnormal bulge below her marionette line (ordinarily jowls sit beside the marionette line, but her bulge is below it). The main reason is what I mentioned: there is no 'hollow' under marionette lines to hold the hyaluronic acid, so the whole bolus of hyaluronic acid slid downward and made the marionette line look worse.
Many online articles on marionette lines promote hyaluronic acid, Vivabella, and the like, leading many people to mistake marionette lines for a kind of 'hollow line.' Even many doctors think injecting filler will fade marionette lines, so the tragedy of failed marionette line injections of hyaluronic acid, Ellanse, or Radiesse keeps repeating.
In my approach to treating nasolabial folds, I always stress: sagging needs lifting, hollowing needs filling.
The key to improving marionette lines is: lift, lift, lift. Only by stopping the face from sagging can you prevent marionette lines from getting deeper.
If you have already had filler and are not satisfied: hyaluronic acid can still be dissolved with hyaluronidase, while collagen stimulators are much harder to deal with. For a face that looks swollen and distorted overall, see What to Do About a Puffy Face? 2 Ways to Treat Puffiness.
4. Marionette Line Treatment 1: Thread Lift
The depressor anguli oris is a strong pull that drags the mouth corner downward, and over time it creates a downward line at the mouth corner that eventually becomes a marionette line.
Many people want a smiling lip. Although it creates an upturned smile curve at the lip corners, the two marionette lines beside it turn downward, so the smile comes with sad lines. To lift marionette lines upward as a whole requires strong physical lifting, and a thread lift is currently the best option among minimally invasive methods.
Scarless fascia lift is an emerging thread lift technique in which absorbable threads are placed in the fascia layer, and the barbs on the threads produce a physical lifting effect. Compared with marionette line surgery, it causes less damage to the surrounding connective tissue.
To treat jowls and marionette lines with a scarless fascia lift, I use TL1 (horizontal line at the tail of the eyebrow), TL2 (horizontal line at the outer corner of the eye), TL3 (anchor point in front of the ear), and TL4 (anchor point behind the earlobe) for distributed thread placement, which achieves a good lifting effect with very little discomfort after the procedure. For details, see my article on combined treatment for nasolabial folds.
The threads Golden Apple mainly uses are Mint Lift (Mint Lite) and Meteora Thread. For the differences between thread types, see What Is a Thread Lift? 6 Types of Threads and Their Costs Revealed.
(1) TL1 upward lift → a more defined jawline
All I can say is that TL1 is truly the top priority, and the core of everything is TL1. Most thread lifts out there treat the jowls based on TL1.
Note: TL1 placement must not be too shallow. Some doctors adjust the depth improperly, placing TL1 too shallow, so that after lifting a hollow appears in the jowl area, and the hollow becomes even more severe when laughing.
The solution is to loosen the threads to release the original barbs, which relieves the skin hollow in the jowl area.
For other situations that may occur with thread lifts and how to handle them, see Can a Failed Thread Lift Be Fixed? Analysis of 6 Types of Thread Lift Failures and Complications.
(2) TL3 lateral lift → lifting the jowls upward
TL3 is inserted from the anchor point in front of the ear and placed deep, all the way to the deeper buccal fat pad. If we only use the TL1 upward lift, the jowls get only an 'upward' vector but no 'outward' vector, and the face easily looks 'stiff' during expressions. With TL3 as a lateral supplementary lift, not only are the jowls improved, but the face also looks more balanced and natural during expressions, greatly improving satisfaction.
(3) TL4 jawline lift → lifting the marionette lines
As mentioned at the start in the causes of jowls, besides making you look older, the most annoying thing about jowls is that they make the jawline look bulky, giving the lower face a lot of 'excess flesh.' After using TL1 and TL3 to lift the jowls upward and outward, finally inserting TL4 (anchor point behind the earlobe) can largely restore the jawline as it was before the jowls formed, making the side profile more defined and refined!
Layered thread lift case: a 48-year-old woman
This client is 48 years old and gets radiofrequency and ultrasound regularly every year, yet her main complaint is still obvious marionette lines and nasolabial folds — which shows that heat-energy treatments offer limited help for sagging that has already formed. The sequential record after treating her with Mint Lift layered placement is as follows (taken June 2025):
When treating jowls and marionette lines with a thread lift, you need a thorough understanding of the anatomy of the muscles and ligaments and of the changes in superficial and deep fat!
This case is published with the client's consent. Treatment results vary with age, fat distribution, degree of skin laxity, and the area treated, and do not mean that everyone who receives the same treatment will have the same result.
5. Marionette Line Treatment 2: Ultrasound Lifting
I hear many clients complain that they don't feel much after radiofrequency/ultrasound and wonder whether they wasted their money.
I tell clients that radiofrequency/ultrasound for nasolabial folds and marionette lines is not about direct improvement, but about preventing and stopping them from getting deeper, so you should treat it as maintenance and a long-term investment.
In the picture below, my loyal client comes in for ultrasound every single year without missing one. After four consecutive years (left photo 2022, right photo 2026), she looks younger and younger, and her marionette lines have not deepened but have actually become slightly shallower. But please remember: if you get ultrasound once and then skip it for four years, marionette lines will still appear because the face sags.
Radiofrequency/ultrasound is like buying a fund: you have to invest regularly and can't slack off. The biggest advantage of ultrasound over a thread lift is that it can dissolve fat, reducing fat accumulation in the jowls and delaying the formation of marionette lines.
If your jowls are fairly prominent, in addition to a thread lift I recommend pairing it with the 6.0 probe of Ultraformer III HIFU to dissolve fat.
The principle of Ultraformer III HIFU is to emit ultrasound energy that makes molecules vibrate at the treated site, raising the temperature of the target tissue to above 56°C and dissolving fat cells.
Because the ultrasound energy is highly focused at high frequency, tissue damage is limited to a small focal point, dissolving fat tissue without harming the surrounding tissue. It is therefore well suited, 3 to 6 months after a thread lift, to use Ultraformer III's 6.0 deep fat-dissolving probe to follow up and dissolve the excess buccal fat pad fat!
6. Marionette Line Treatment 3: Facelift Surgery and Liposuction
In the following two situations, I usually recommend that clients consider marionette line surgery directly, including facelift surgery or intraoral fat removal surgery (to reduce the jowls)
- Facelift surgery: suitable for those over 60 with severe marionette lines, for whom thread lift and radiofrequency/ultrasound treatments have limited effect
- Liposuction, intraoral fat removal surgery: suitable for those with higher body fat and severe jowls that can no longer be handled by ultrasound fat reduction alone
7. Can Marionette Lines Be Prevented?
Yes, and prevention is far more effective than treatment. Marionette lines do not appear in a day. Once they have already formed, the room for improvement is very limited. This is the point I have stressed throughout this article.
- Start lifting before they appear: Regularly scheduling a thread lift and ultrasound starting at age 35–40 is the most practical way to slow the descent of the fascia layer. I give my wife a thread lift and ultrasound every year for exactly this reason.
- Treat the jowls first: Jowls are upstream of marionette lines. It is easiest to treat them when the mouth-corner pouch is still only 'faintly visible.'
- Keep your weight stable: Repeated large short-term weight gains and losses are the most likely to damage facial fat and skin elasticity.
- Be diligent about sun protection and quit smoking: Both UV rays and smoking accelerate the loss of collagen and elastic fibers.
- Do not rely on massage or home devices: They cannot change the position of the fascia layer or reduce the number of fat cells.
Marionette Lines FAQ
Does botulinum toxin work for marionette lines?
The effect is very slight. Botulinum toxin mainly relaxes the depressor anguli oris muscle. If your jowls are significant and are not eliminated, it is hard to effectively improve marionette lines.
Can young people get marionette lines?
Yes. Natural bone proportions, fat distribution, facial expression habits, and rapid weight loss can all cause marionette lines in younger people.
Can massage get rid of marionette lines?
No. Massage cannot reverse bony support loss, fat displacement, or obvious skin laxity.
Can hyaluronic acid filler improve marionette lines?
I am strongly against injecting hyaluronic acid or collagen stimulators for marionette lines, because I often clean up the mess caused by marionette line hyaluronic acid. If marionette line hyaluronic acid is injected in the wrong place, it can actually make the marionette lines deeper.
Because marionette lines are formed mainly by sagging rather than hollowing, filling can only slightly improve marionette lines. If you really do want hyaluronic acid for marionette lines, it is usually used after a thread lift, with a small-molecule hyaluronic acid to slightly refine the surface lines.
What if hyaluronic acid filler for marionette lines fails?
A failed marionette line hyaluronic acid injection can at least be dissolved, but if Radiesse or Ellanse was injected, the consequences are dire. I have encountered at least several heartbreaking cases, and basically there is no solution.
Can I inject Radiesse or Ellanse for marionette lines?
Not long ago I saw a doctor inject Ellanse into his own marionette lines, and I thought that was incredibly brave, to say the least. I followed him for quite a while to see how the collagen stimulation turned out. The marionette lines did fade, but he looked… cute.
When a collagen stimulator is injected at the mouth corner, it easily becomes puffy around the mouth. Fading marionette lines does not mean you will look better overall.
This is also why I am so against filler for marionette lines
What is the most effective way to get rid of marionette lines?
The minimally invasive approach is mainly a thread lift (about 80%), with ultrasound used after the procedure to help reduce fat (about 20%). In order of effectiveness: thread lift > ultrasound > radiofrequency. Marionette lines are lines caused by sagging, not hollowing, so they need lifting, not filling. Severe marionette lines require intraoral fat removal or a facelift.
How are marionette lines related to jowls?
Jowls are upstream of marionette lines. Jowls that have sagged for a long time press on the mouth corner and press out the marionette line beside it. So the most important task in getting rid of marionette lines is actually to treat the jowls first.
How much does marionette line treatment cost?
A thread lift costs about NT$40,000–80,000, ultrasound about NT$30,000–60,000, and radiofrequency about NT$50,000–100,000. For surgery, intraoral fat removal costs about NT$100,000–150,000 and a facelift about NT$300,000–500,000. Thread lift and ultrasound results last about one year, and surgery about 5–10 years.
How long is the recovery after a thread lift for marionette lines?
Immediately after the procedure there is slight swelling because a fair amount of local anesthetic has to be injected during the process. At the one-week follow-up the swelling had completely gone, and moving, eating, and laughing were all unrestricted.
What if the jowl area becomes hollow after a thread lift?
This is usually caused by TL1 being placed too shallow or the depth being adjusted improperly, so that a hollow appears in the jowl area after lifting. The solution is to loosen the threads to release the original barbs, which relieves the skin hollow in the jowl area.
Do radiofrequency and ultrasound work for marionette lines?
They help, but you need the right expectations. Radiofrequency/ultrasound does not directly improve marionette lines; it prevents and stops them from getting deeper, and should be treated as a long-term maintenance investment. I have a 48-year-old client who gets radiofrequency and ultrasound regularly every year but still complained of obvious marionette lines and nasolabial folds; she improved greatly only after being treated with Mint Lift layered placement.
In summary, aesthetic treatment for marionette lines needs a combined approach (Cocktail Treatment), mainly a thread lift (80%), with ultrasound as supplementary treatment after the thread lift (20%), to achieve the best satisfaction.
Of course, as a minimally invasive doctor I must be honest: the thread lift plus ultrasound lifting described above are all minimally invasive and are only suitable for mild to moderate improvement of marionette lines. If your expectations are high, or your marionette lines are very severe and you want to eliminate them noticeably, the most effective approach is still to have a facelift!
Consult now about ways to get rid of marionette lines!
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Medical Review and Source Notes
- Written and updated by: Dr. Ou Chia-Hung (Founder and Director of Golden Apple Aesthetic Clinic) | Last updated: October 4, 2026.
- The costs in this article are public reference ranges for the Taiwan market and our clinic, and are not individual quotes; actual costs depend on the number of threads, the area treated, and the doctor's assessment.
- The results, recovery times, and durations in this article are commonly seen clinical ranges, not a guarantee of results, and individual results vary with age, bone structure, fat distribution, and skin condition.
- Thread lifts and energy-based treatments can still cause reactions such as swelling, bruising, hollowing, or asymmetry; filler injections also carry risks of infection, nodules, and vascular complications.
- This article is health education information and cannot replace an in-person consultation. Whether any treatment is suitable for you must be decided after a doctor's assessment.
