Marionette Lines and a Downturned Mouth: Why the Fold Beside Your Chin Is Mostly a Jowl Problem, What a Few Units in the Depressor Anguli Oris Can and Cannot Lift, Where Filler Helps and Where It Makes the Lower Face Heavier, and When the Honest Answer Is a Facelift

The corner of the mouth is the one part of the face that reports a mood the owner does not have. A brow can be lifted, an eye can be brightened, a cheek can be filled, and a patient will still be told at the school gate that she looks tired or annoyed, because the corners of her mouth have settled a few millimetres below the horizontal and a fold has opened from each corner down toward the chin. The folds are called marionette lines, after the hinged jaw of a ventriloquist's dummy, and the downturn is called, in the anatomy texts, commissural ptosis. Patients call it a sad mouth. Injectors call it the most requested lower-face treatment after the lips.

It is also the lower-face treatment most likely to disappoint, because it is sold as a line and is mostly not one. A marionette line is a valley, and a valley is defined by the hills on either side of it. The hill on the outside is the jowl, a pad of cheek fat that has slid down over the jawline and come to rest against a ligament that will not let it go further. The hill on the inside is the chin. The valley between them deepens when the jowl descends, when the chin loses bone and fat, when the skin thins, and when a small triangular muscle called the depressor anguli oris pulls the corner of the mouth down toward the jaw a few thousand times a day. Filler fills the valley. Toxin weakens the muscle. Neither moves the hill.

This piece covers the anatomy of the fold and the downturned corner, what a few units of toxin in the depressor anguli oris actually achieve, where hyaluronic acid and biostimulatory filler help and where they make a lower face heavier, when the honest answer is a facelift, and how to tell which kind of marionette line you have before anyone opens a syringe.

What a marionette line actually is, and why it is mostly a jowl problem

The short answer: a marionette line is the labiomandibular fold, a crease that runs from the corner of the mouth down toward the jawline, deepened on its outer side by the descending jowl, on its inner side by loss of bone and fat in the chin and prejowl area, in its floor by thinning skin, and at its top by a mouth corner pulled down by the depressor anguli oris; only the last of these is a muscle problem, and only the third is a skin problem.

Anatomists call the fold the labiomandibular or melomental fold. It begins at the modiolus, the dense knot of muscle fibres just lateral to the corner of the mouth where the muscles of expression around the mouth converge, and runs down and slightly outward toward the border of the mandible. In a young face it is invisible at rest and appears only with a frown or a downward pull of the lip. In an aging face it becomes a shadow, then a crease, then a groove that continues below the jawline into the neck. Above the groove, on the cheek side, sits the jowl. Below and inside it, on the chin side, sits a depression called the prejowl sulcus, the small hollow just in front of the jowl where the jawline seems to dip before the chin. Together the jowl, the sulcus, and the fold are one structure viewed from three angles, and treating one without understanding the others is how most disappointing lower-face injectable work happens.

The jowl is the key. Rod Rohrich and Joel Pessa's 2007 mapping of the facial fat compartments in Plastic and Reconstructive Surgery showed that cheek fat is not a single sheet but a series of discrete pockets separated by fibrous septa, and the jowl is the lowest of these pockets, sitting over the body of the mandible. With age the septa above it loosen, the fat compartments deflate and descend, and the jowl pocket becomes both fuller (from what has slid into it) and lower. It stops where it does because of the mandibular ligament, a short, tough band described by David Furnas in 1989 that runs from the bone of the anterior mandible directly to the skin, roughly a centimetre behind the chin. The ligament tethers the skin firmly. The fat behind it bulges. The tethered skin in front of it forms the sulcus. The fold above is the line where the bulging jowl meets the skin it cannot lift. Every marionette line, in other words, has a jowl at the top of it, and the piece on jawline contouring at forty explains why the jowl itself is a soft-tissue descent problem that only repositioning corrects.

The bone matters more than most patients expect. Robert Shaw's group at the University of Rochester published computed tomography measurements of the mandible in 2010, comparing young, middle-aged, and older adults, and found that the mandible loses height and length with age and that the angle of the jaw opens. Bryan Mendelson and Chin-Ho Wong's 2012 review in Aesthetic Plastic Surgery reached the same conclusion for the whole facial skeleton: bone resorbs selectively, and the areas that resorb most are exactly the ones the soft tissue needs for support, including the prejowl region of the mandible and the chin. A face that has lost a few millimetres of bone under the marionette area has less scaffolding for the same skin and fat, and the fold deepens even in a patient whose jowl is modest. The piece on chin augmentation covers the chin end of this: a retrusive or resorbed chin lets the whole lower face fall toward the midline, and marionette lines are one of the things that show it. Teeth are part of the same story. Loss of the back molars, an overclosed bite, or a lifetime in dentures reduces the vertical height of the lower face and folds the soft tissue around a shorter frame, which is why marionette lines are noticeably worse in edentulous patients and why a good injector asks about dental work before discussing filler.

Then there is the muscle. The depressor anguli oris is a flat triangle, broad along the jawline below the canine and premolar teeth and narrow at its insertion into the modiolus, and its only job is to pull the corner of the mouth down and slightly out, the movement of a frown, a grimace, or the face people make when they are told bad news. It is opposed by the muscles that lift the corner: the zygomaticus major from the cheekbone, the levator anguli oris from just below the eye socket, and the risorius across the cheek. In youth the lifters win at rest and the corner sits level or slightly up. With age the lifters weaken and descend with the cheek, the depressor keeps its short direct pull on the jaw, and the corner drifts down. The platysma, the broad sheet muscle of the neck, sends fibres up into the same corner and adds to the pull, which is why the piece on the neck lift belongs in the reading on a downturned mouth. Toxin in the depressor anguli oris addresses this last component and no other.

The skin is the smallest part of the problem and the one most treatments aim at. Decades of ultraviolet light thin the dermis, degrade its elastin, and let a fold that was once dynamic become etched at rest, the process the piece on skin thinning with age describes. An etched marionette line has a fine crease at its floor that filler placed underneath will soften but not erase, because the crease is in the skin itself. That is the part resurfacing treats. Everything else in the fold is beneath the skin, and a laser cannot reach it.

What toxin in the depressor anguli oris can and cannot do

The short answer: two to five units of botulinum toxin per side placed low in the depressor anguli oris, near the jawline and well away from the lip, weakens the downward pull on the corner of the mouth so that the lifting muscles win at rest, which raises the corner by a millimetre or two and softens the top of the marionette fold in patients whose corners actively turn down; it does not fill the fold, does not move the jowl, lasts three to four months, and is off-label, with an asymmetric smile from spread into the neighbouring lip depressor as its characteristic complication.

The treatment is one of the small lower-face toxin sites that have accumulated around the drug's labelled indications. The FDA has approved botulinum toxin type A for the glabellar lines (2002), the crow's feet (2013), the forehead lines (2017), and, in 2024, the vertical bands of the platysma. The depressor anguli oris is not on that list. Its use is supported by expert consensus documents, most influentially the facial rejuvenation consensus recommendations Jean Carruthers and colleagues published in 2008, and by a handful of small open-label series and split-face comparisons, none of them large and none of them placebo-controlled for long. The piece on the toxin brands explains why the same drug carries different unit counts under different names; the numbers here are for onabotulinumtoxinA, and the equivalents scale.

The injection itself is more anatomy than pharmacology. The depressor anguli oris lies just under the skin along the jawline, roughly a centimetre lateral to the vertical line dropped from the corner of the mouth and a centimetre above the bony border of the mandible. The reliable way to find it is to ask the patient to pull the corners of the mouth down hard, as if grimacing through a long "eee," and palpate the firm band that stands up beside the chin. The injector places the dose low in that band, near the jaw and far from the lip. Placing it too high, too medial, or too deep risks the depressor labii inferioris, the muscle immediately underneath and inside that pulls the lower lip down to show the lower teeth. Weaken that muscle on one side and the patient's smile becomes asymmetric, the lower lip fails to descend evenly, and she cannot drink from a straw, whistle, or pronounce certain consonants cleanly on that side. This lasts as long as the toxin does, which is to say months, and there is no reversal. It is the reason the depressor anguli oris is treated as an intermediate-level injection in most training programmes, and the reason the piece on who is injecting you is relevant to a site that a glabella-trained injector may never have been taught.

What the treatment achieves when it works is real but modest. Published and clinical estimates of corner elevation cluster around one to two millimetres at rest, which on a mouth is enough to change the expression from downturned to neutral and enough for the patient to notice in photographs. The upper third of the marionette fold, where the depressed corner was pulling the skin down into the crease, softens. The lower two-thirds, where the jowl and the sulcus define the fold, does not change. Patients who present with a genuinely active depressor, who can be seen pulling their corners down when they concentrate, read, or listen, are the ones who respond. Patients whose corners sit low because the whole cheek has descended and the lifters have gone slack respond poorly, because weakening a depressor does nothing if there is no lifter left to win.

Duration is the standard three to four months, and the usual reasons a toxin seems to wear off early apply here as everywhere. The site is often treated at the same visit as the masseter (the piece on masseter Botox covers that muscle) or the platysma, which is sensible in a face where all three contribute to a heavy lower third, and less sensible as a reflex add-on in a face with only one problem. A single site at four to ten units total is a small sale, and the temptation in a fee-per-area practice is to bundle it into a lower-face package whether or not the patient's corners actually move.

Where filler helps, where it fails, and what it does to the lower face over years

The short answer: hyaluronic acid filler placed deep in the prejowl sulcus and beneath the top of the fold restores the missing support under the marionette line and lifts the corner a little, and filler in a resorbed chin does the same from further in; filled properly the fold softens for nine to eighteen months, but the fold itself is the wrong target, because filler placed in the valley to match a jowl that keeps descending produces, over several years, a lower face that is uniformly heavy rather than one that is lifted.

Filler is where marionette lines are usually treated and where the treatment most often goes wrong, and the reason is the hill-and-valley problem described above. The naive approach, still common in practices that treat by the line, is to run a thread of filler along the crease. This works for a few months in a shallow fold and fails in every other case, because it fills the floor of the valley without touching the hill, so the jowl still bulges above a slightly higher groove, and the face reads as fuller rather than younger. The piece on filler migration covers what happens to filler placed superficially and repeatedly in a mobile area, and the mouth is the most mobile area on the face.

The better approach, which experienced injectors converged on over the last decade, treats the fold as a symptom of lost support. The primary target is the prejowl sulcus: filler placed deep, on or near the bone of the mandible just in front of the jowl, restores the contour of the jawline where bone and fat have resorbed, and by lifting the floor of the sulcus reduces the height difference between it and the jowl. The second target is the chin itself, when it is retrusive or has lost projection, because projecting the chin forward pulls the whole soft-tissue envelope of the lower face with it and shallows the folds on either side. Restylane Defyne was approved by the FDA for chin augmentation in 2021 and Juvederm Volux for the jawline in 2022, and the thicker calcium hydroxylapatite product Radiesse followed with a jawline indication; the piece on biostimulatory fillers covers the differences between the two families. The third and smallest target is the top of the fold under the corner of the mouth, where a small volume placed under the modiolus gives the corner something to rest on. None of the US filler labels names marionette lines; the labels say nasolabial folds, chin, jawline, or "facial wrinkles and folds such as nasolabial folds," and marionette treatment is either off-label or covered by the general wording depending on the product.

The volumes involved are modest per session and large over a career. A typical first treatment of the prejowl area and the fold uses one to two millilitres across both sides, a chin adds one to two more, and the result lasts nine to eighteen months depending on the product and the patient. In Los Angeles a syringe of a mainstream hyaluronic acid filler runs seven hundred to twelve hundred dollars, so a properly done lower-face first session is two to four thousand dollars and a maintenance visit a year later somewhat less. The American Society of Plastic Surgeons counts around five million hyaluronic acid filler treatments a year in the United States, second only to the more than nine million neurotoxin treatments, and the lower face is a growing share of them as the nasolabial fold, which was the original filler indication, has fallen out of fashion as a target.

The failure mode is not the first session. It is the eighth. Filler in the lower face is placed into a structure that keeps descending, so each year the injector fills a slightly deeper valley beside a slightly lower hill, and a patient who began with a millilitre a side is being maintained on three or four. Hyaluronic acid in the lower face also lasts longer than the twelve months on the label, as the imaging studies described in the same filler migration piece make clear, so successive sessions stack on residual product. The result after five or six years is the face that injectors have started to call, ruefully, filler jowl: a lower third that is smooth, full, and heavy, with the corners of the mouth no higher than they started because the weight of the filled tissue below them is pulling down as much as the depressor ever did. The piece on dissolving filler is the exit from that face, and the piece on delayed filler nodules covers the inflammatory lumps that appear months or years after treatment, which the perioral area produces more than most sites because of its movement and its proximity to the mouth and teeth.

Then there is the vessel. The facial artery runs up past the corner of the mouth roughly a centimetre and a half lateral to the commissure and gives off the inferior labial artery to the lower lip near the modiolus, and the mental artery emerges from the bone just below the fold. All three are in the marionette field, and the piece on filler vascular occlusion describes what happens when filler enters one of them: blanching, pain, dusky mottled skin, and, untreated, necrosis of the lip or chin. The lower face is not the highest-risk filler site (the nose and the glabella are worse), but it is not a low-risk one, and deep placement on bone in the prejowl area, which is the correct technique, requires a cannula or needle to travel past the mental foramen. Injectors who treat the area should have hyaluronidase in the room and know the dose.

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A marionette line is a valley beside a hill, and the hill is a jowl. Filler makes the valley shallower. Toxin stops one muscle pulling on its upper end. Neither moves the hill, and a patient who fills the valley every year to keep up with a hill that keeps sliding ends up with a lower face that is full everywhere and lifted nowhere.

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When the fold is a jowl: surgery, threads, energy, and resurfacing

The short answer: when the marionette line is defined by a jowl that has descended over the jawline, the only treatment that corrects it is one that repositions the jowl, which means a facelift that releases the mandibular ligament and lifts the cheek's fat and fascia back up over the bone; threads do not hold, energy-based tightening produces a modest change in skin that does nothing for a fat pad, resurfacing treats only the etched crease at the floor of the fold, and the small surgical corner-of-mouth lift trades a downturned corner for a visible scar.

The recline test tells most patients which fold they have. Lie flat on your back, look up into a hand mirror, and watch the marionette lines. If they largely disappear, the fold is gravitational: the jowl has slid down under its own weight and gravity has just put it back. Filler will soften that fold when you are upright and a facelift will fix it. If the fold remains at the same depth lying down, it is structural (bone and fat loss, an etched crease, a chin that has retruded) and lifting will not correct it; support and volume will. Most patients over fifty have some of both, and the honest consultation says so, but the test sorts the two broad categories in thirty seconds and costs nothing.

For the gravitational fold the operation is a facelift, and specifically one that addresses the jowl. The piece on the deep plane facelift explains how the modern operation releases the retaining ligaments, including the mandibular ligament that defines the front of the jowl, and repositions the descended fat and fascia as a unit rather than pulling the skin over it. When that is done the jowl returns to the cheek, the prejowl sulcus fills from behind, and the marionette line loses its outer hill. The piece on the mini facelift covers the shorter operation that many patients with early jowling are offered and the limits of what a short-scar lift can reposition; a mini lift that does not release the mandibular ligament will improve the jawline behind the jowl and leave the marionette fold much as it was. The piece on the quiet end of the pull-tight facelift explains why the older skin-only operation made marionette lines worse in the long run by stretching skin over a jowl it had not moved. Surgery is the only treatment on this list that addresses the actual cause of most deep marionette folds, and it is the one least often mentioned in an injectables consultation.

Threads are the treatment most often sold as the alternative to surgery for exactly this fold, and the piece on PDO thread lifts covers the evidence in full: barbed absorbable sutures placed under the skin of the cheek and pulled upward can lift a jowl for weeks to a few months, after which the suture loses its grip on tissue that was never designed to hold it, and the jowl returns. The lower face is the area where threads fail fastest, because the tissue being lifted is heavy and the anchor above it is mobile. Energy-based devices, covered in the piece on energy-based skin tightening, heat the dermis and the fibrous layer beneath it with radiofrequency or focused ultrasound and produce a measurable but small contraction of skin. A jowl is a fat pad, not loose skin, and tightening the skin over a fat pad changes its outline a little and its position not at all. Patients with early jowling and good skin are the ones who see a difference; patients with a fold deep enough to be called a marionette line generally do not.

Resurfacing is the right tool for the wrong part of the fold. The etched crease at the floor of a long-standing marionette line is in the skin, and the piece on ablative versus non-ablative laser resurfacing and the piece on the deep phenol peel describe the treatments that remodel it. A fractional ablative laser or a medium to deep peel over the perioral area will soften the fine crease and the vertical lip lines that often accompany it. It will do nothing to the jowl above or the sulcus below, and a patient who has the whole fold resurfaced expecting it to flatten will be disappointed for the same reason the filler patient is: the target was beneath the treatment.

The surgical alternatives for the corner itself are small and rarely worth it. The corner-of-mouth lift, or commissuroplasty, excises a small triangle of skin just above and lateral to each corner so that the corner is pulled up when the wound is closed. It works, in the sense that the corner is higher, and it leaves a scar at the corner of the mouth that is visible in a face that moves as much as a mouth does. Most facial plastic surgeons offer it rarely and to patients who have exhausted everything else. Direct excision of the marionette fold itself, cutting out the skin of the groove and closing it as a line, is occasionally done in very elderly patients and leaves a scar in the same place as the fold, which is a trade some are willing to make and most are not. Liposuction of the jowl, which is sometimes offered as a minor procedure, sits directly over the marginal mandibular branch of the facial nerve as it crosses the jawline, and the piece on facial nerve injury after facelift explains what damage to that branch does to the lower lip. It is not a minor procedure and it does not lift anything; it debulks a pad that was providing the little support the fold had left.

Plan by pattern, cost, complications, and who should not be treated

The short answer: an active downturn with a shallow fold in a patient under forty-five is a toxin case; a structural fold with a resorbed prejowl and a weak chin is a deep filler case with the chin treated first; a gravitational fold with a real jowl is a facelift case in which injectables are at most a bridge; an etched crease over a corrected fold is a resurfacing case; and a lower face that has been filled yearly for five years and looks heavy is a dissolving case before it is anything else.

The patterns are worth stating plainly because the consultation rarely does. The patient in her thirties or early forties whose mouth corners turn down at rest, who has strong depressors that stand up when she grimaces, and whose fold is a shadow rather than a groove is the depressor anguli oris toxin patient. A few units a side, repeated three or four times a year, at a cost in Los Angeles of two hundred to four hundred dollars a session at the per-area rates most practices charge (the drug itself is a fraction of that), will keep her corners level and is a reasonable habit if she wants it. Adding filler to that face is usually adding a problem.

The patient in her late forties or fifties whose fold is a groove, whose jawline dips in front of a modest jowl, and whose chin has quietly retreated is the filler patient, provided the filler goes where the support has gone: deep in the prejowl sulcus and, when the chin is short, into the chin, with the fold itself treated last and least. That means two to four syringes at seven hundred to twelve hundred dollars each in Los Angeles, repeated at a lower volume every twelve to eighteen months, with the piece on Botox and filler at one visit covering the case for adding the depressor toxin at the same session. The biostimulators covered in the piece on the Sculptra timeline are a legitimate choice for the prejowl area in a patient who wants a slower, longer build, and a poor one for the fold itself, where nodules are harder to manage. Patients who have lost weight quickly, whose lower faces the piece on Ozempic face describes, are in this category with a heavier hand on the volume and a longer conversation about whether the weight is stable.

The patient with a real jowl is the facelift patient, and it does her no favours to spend three years and eight thousand dollars filling a valley that surgery would have closed from above. Injectables in that face are a bridge to the operation or a choice to decline it, and either is legitimate as long as it is named. The piece on what a plastic surgery quote covers puts the Los Angeles facelift in the low to middle five figures, and the arithmetic of a decade of lower-face filler against that number is closer than most patients assume. The piece on the limits of the non-surgical facelift covers the general version of this argument.

Complications are the ones already described, and they are worth listing in one place. Toxin: an asymmetric smile from spread into the depressor labii inferioris, an inability to purse the lips or use a straw, a slight lisp, and drooling at the affected corner, all lasting two to four months. Filler: lumps and visible ridges along the fold (the perioral skin is thin), the bluish Tyndall shadow from product placed too superficially, delayed inflammatory nodules, migration and a heavy lower face over years, and vascular occlusion of the facial, inferior labial, or mental artery with the risk of lip or chin necrosis. Surgery: the risks the facelift pieces cover, with the marginal mandibular nerve as the specific one for the jowl.

Who should not be treated is a shorter list than the marketing suggests but not an empty one. Patients whose corners are down because of a facial nerve palsy, a stroke, or a previous injury need a neurologist and possibly a reconstructive surgeon, not toxin in the working side. Patients with a collapsed bite or missing posterior teeth should see a dentist first, because restoring vertical height changes the fold more than any filler and makes the filler that follows work better. Patients with body dysmorphic disorder, whom the piece on BDD screening describes, fixate on the mouth corner more often than on almost any other feature, because it reads as an emotion, and the millimetre of lift toxin provides will not be enough. And patients whose lower faces are already full, smooth, and heavy from years of filler should be offered hyaluronidase before they are offered more product, and should be suspicious of any practice that does not raise it.

The honest summary

Marionette lines are a lower-face descent problem with a small muscular component and a smaller skin component, and the treatments are sold in the reverse order of their relevance. Toxin in the depressor anguli oris is a good, inexpensive, off-label treatment for a corner that actively turns down; it lifts by a millimetre or two, lasts a season, and has one characteristic complication, the asymmetric smile, that a well-trained injector avoids by staying low and lateral. Filler helps when it is placed where the support has gone, deep in the prejowl sulcus and the chin, and hurts when it is placed in the crease year after year to chase a jowl that keeps sliding, which is how a decade of conscientious maintenance produces a heavy lower face with the corners no higher than they began. When the fold disappears lying down, the cause is the jowl and the treatment is a facelift that repositions it, and an injector who never mentions that is treating a line rather than a patient. Recline in front of a mirror before the consultation, ask where the filler is going and what the plan is for year five, ask for the unit count and the landmarks if the depressor is on the list, and remember that the only thing on the menu that moves the hill is the one that is not on the injectables menu at all.