Marionette Lines Treatment in Korea: Fill, Reduce or Lift?

I'm Dr. Jong Seon Kim, a director at Gangnam HERA in Seoul. I'm a board member of the Korean Society of Aesthetic Surgery and of the International Petit Medical Society. Marionette lines — the lines running down from the corners of the mouth — are one of the hardest areas to treat well, and filler is not always the answer. In this video I asked my colleague Dr. Jong Hoon Lee to explain where they come from and how we decide what to do.

My short answer: marionette lines come from three things — sagging, hollowing and too much jowl fat. Lift what sags, fill what is hollow, reduce what is too full. Most faces need a mix, and filler alone can make some cases worse.

What are marionette lines?

They are the vertical lines running down from the corners of the mouth toward the chin. As Dr. Lee explains, the name comes from the marionette puppet: to make it look like it is talking, its lower jaw is cut so it can move, which leaves a long line beside the mouth. When the same kind of line appears on a face, it gives a tired, sad or stern look, even when you are relaxed.

What causes marionette lines?

Dr. Lee's view is that they are almost entirely due to aging — you rarely see them in teenagers or children. Within that, several things contribute, and they often appear together:

• Mouth corners that turn down.
• A hollow below the mouth corner, where volume has been lost.
• Too much fat in the jowl just above the line — what Koreans call the "grumpy cheek" fat — which hangs over it.

Marionette lines very often come with nasolabial folds. There has long been debate about the exact anatomy: many earlier papers blamed a firm ligament near the jaw, while more recent ones point to the muscles that pull the mouth corners down becoming relatively stronger, and differences in skin firmness and density. The details matter less to you than the practical result — the line can have more than one cause, and the treatment should match the cause.

Do exercises and massage help?

A little — not dramatically, but they are not useless either. Expressions or exercises that lift the skin below the lips upward can help slightly. Dr. Lee also answered some common questions:

• Does being angry cause them? Not really, in our experience.
• Does smiling help? A gentle smile uses the muscles that lift the mouth corners, so it can help. A big, strong smile tends to deepen the nasolabial folds instead — the balance between the two lines matters.
• Does weight loss matter? Yes. Losing a lot of weight quickly, over two or three months, tends to deepen both nasolabial folds and marionette lines.

Muscle-relaxing injection or filler?

Filler is more often the effective option, but it must be placed carefully. A wrinkle-relaxing injection into the muscle that pulls the mouth corner down can help in some people — specifically those with a strong downward-pulling muscle — by letting the corner lift slightly. It does not help every marionette line.

Filler works in more cases, but this is where I want to be honest. If it goes into the wrong layer or in too large a volume, it can push the jowl fat above the line further forward. Then the result is weaker, or the marionette line actually looks deeper. Filling the hollow is only safe and useful when you also look at what is sitting above it.

How is each cause treated?

Dr. Lee organizes it into three causes, each with its own approach.

1. Sagging — lift it

For mild sagging, energy-based devices can be enough: ultrasound and radiofrequency treatments such as Ultherapy Prime, titanium lifting or Thermage help the skin tighten and firm. When sagging is more pronounced, physically lifting with dissolvable threads works better. When it is very advanced, only surgical lifting is enough — that is a separate surgical conversation, outside the non-surgical options here.

2. Hollowing — fill it

Filler is the most common tool. Collagen-stimulating injections such as Juvelook can also help. Some threads, while they do not add volume themselves, can soften the border between the bulging area and the hollow.

3. Excess jowl fat — reduce it

When the amount of fat is modest, our signature Sok-Sok injection, a fat-dissolving injection, is an easy option: there is little recovery to worry about, and it can be repeated and adjusted until the volume is right. When there is a lot of fat, energy-based fat reduction is the stronger approach.

Why "fill, reduce, lift"?

Because sagging, hollowing and excess volume appear with age everywhere on the face — the only difference is how much of each. That is how I explain it to patients: we fill what has hollowed, reduce what is too full, and lift what has dropped. Choosing which to focus on is the real decision.

The cases in the video show this. In the first, there was some volume and some sagging, so threads lifted the tissue first and filler was placed in the nasolabial and marionette areas at the same time. The later cases were advanced enough that surgical lifting was needed before filler could finish the job, and in one of them some jowl fat was also reduced. If a patient like that came in asking only to "fill it", filler alone would not solve much — it would just make the face look strange.

What does marionette line treatment look like at HERA?

1. Find the cause. We look at sagging, hollowing and jowl fat, from the front and at 45 degrees.
2. Plan the mix. Usually two of the three approaches, sometimes all three, staged around your trip.
3. Place filler last and carefully. Once the lift and volume are right, I fill only what is still hollow, in the right layer.
4. Itemized written estimate before anything is done, with an English interpreter throughout.

Filler and Sok-Sok injections have very little downtime; mild swelling or bruising usually settles within a few days. Threads involve a little more swelling. For more on the lifting side, see the thread lift patient guide; for the collagen-booster option, the Juvelook skin booster guide.

The honest limits

Marionette lines soften; they rarely disappear. Very advanced sagging may not respond enough to non-surgical treatment. Habits matter too — pouting hard, pressing the lips down or resting the chin on your hand can deepen the lines again. Results vary from person to person.

The good news is that, matched to the right cause, these lines can improve noticeably without a long recovery. Because they so often come with nasolabial folds, our video on nasolabial fold treatment is a useful companion. You can see real HERA results in our before-and-after gallery.