Treating Marionette Lines

Treating Marionette Lines with Hyaluronic Acid: In this article, discover all the essential information about this effective method for a younger, more dynamic appearance – and find out if it might be the right choice for you.

How Do Marionette Lines Develop?

Marionette lines are pronounced lines that extend from the corners of the mouth to the chin. They are called “Marionette lines” because they resemble the creases that run on either side of the mouthpiece in a puppet with a movable mouth. They often make us appear significantly older than our actual age. Prominent Marionette lines also create a frustrated, disappointed, or dissatisfied facial expression. Therefore, they are considered to have the strongest negative impact among age-related facial features, second only to frown lines.

Loss of Firmness

But how do mentolabial folds, as they are called medically, develop? The main cause is the aging process: Over time, our skin loses elasticity and firmness. This is due, among other factors, to the decrease in production of collagen and elastin. These proteins are responsible for the firmness and elasticity of the skin.

In addition, the cell renewal process slows down, resulting in thinner skin and a diminished ability to retain moisture. This leads to the formation of wrinkles, including Marionette lines. Significant contributors to their formation are the shrinking and sagging of the soft tissue base in the mouth region. The muscles that pull the corners of the mouth and lips downward (such as the depressor anguli oris and depressor labii inferioris muscles) also contribute to their formation.

Facial Muscle Strain

Similar to the eye area, the region around the mouth also lacks supportive fatty tissue. Certain facial expressions triggered by laughing, smiling, and speaking directly affect the skin as a result. This also leads to the formation of lines and wrinkles. With strong and frequent strain, Marionette lines can develop over time.

The mentioned factors can individually or in combination lead to the development of Marionette lines. To effectively treat Marionette lines, it is important to understand the underlying factors contributing to their development and take effective measures accordingly.

Botox and Hyaluronic Acid

In minimally invasive aesthetic medicine, the primary method for addressing Marionette lines is through the injection of hyaluronic acid (commonly referred to as hyaluron). Augmenting Marionette lines with hyaluronic acid is a quick, low-risk, and cost-effective method. In my practice, I have consistently had positive experiences using hyaluronic acid for Marionette line treatment.

Treatment with Botox is also an option for Marionette lines, as long as they are not yet deeply etched and predominantly caused by facial expressions. This can be recognized by the fact that expression-induced wrinkles can be voluntarily brought about or intensified.

Botox or Hyaluronic Acid for Marionette Lines?

As mentioned before, the standard procedure for Marionette lines is the injection of hyaluronic acid. However, in the case of fresh and primarily expression-induced wrinkles, treatment with Botox can also be successful. In other cases, it can complement hyaluronic acid injections to achieve even better results. Both procedures have their advantages and disadvantages. Here are some factors to consider when making your decision:

Depth of the fold:

Botox is more suitable for less deep wrinkles that are primarily caused by facial expressions. Botox, in this case, only reduces the muscular pull that causes the skin to fold into wrinkles. It does not have a direct impact on the skin itself. The injection of hyaluronic acid, on the other hand, does have an influence on the skin itself. Hyaluronic acid is injected under the wrinkle, lifting the sunken skin. For deep and prominent wrinkles, hyaluronic acid injections typically yield better visual results compared to Botox.

Type of effect: Botox relaxes the muscles, while hyaluronic acid adds volume. Hyaluronic acid leaves the muscular activity of the mouth area completely intact. This can be important to avoid complications that may arise from excessively weakened muscles. With Botox, such complications are possible, and they mainly manifest as difficulties in speaking. There have also been reported cases where brass musicians were unable to properly operate their instruments. Such side effects are excluded with hyaluronic acid.

Duration: Botox typically lasts 3-6 months, while injections with modern hyaluronic acid fillers can last between 6 and 12 months, often even longer. The durability of hyaluronic acid depends heavily on individual factors such as metabolism and facial muscle activity.

Combination: In some cases, a combination of Botox and hyaluronic acid can be beneficial. Specifically, when both muscle relaxation and volume enhancement are required for optimal results.

Cost: If Botox treatment is still feasible, it generally incurs lower costs compared to hyaluronic acid injections. In general, Botox treatment for Marionette lines typically involves a single injection into the depressor anguli oris muscle on each side, with a dosage ranging from 2 to 5 units. Such a treatment with approximately 10 units in total can be available for €100-300, depending on the individual conditions of the patient. Hyaluronic acid filler augmentation will typically cost between €300-500 if the usual volume of 0.5-1ml filler is not exceeded. (All price indications mentioned are approximate values, individual billing will follow the GOÄ fee schedule).

In the further course of this article, I would like to focus on the injection of hyaluronic acid for treating Marionette lines. I will address various aspects of the treatment in the following sections. I will also explain the expected costs associated with injecting hyaluronic acid for Marionette line treatment.

Augmentation with Hyaluronic Acid Filler

Augmenting Marionette lines with hyaluronic acid filler has become an established and effective method for treating this sign of aging. Hyaluronic acid is a natural substance that is found in various areas of the human body. Namely, in areas where large amounts of fluid need to be bound, such as in the eyeballs, joints, or skin.

In the skin, natural hyaluronic acid plays a significant role in elasticity and volume by binding moisture. In an augmentation, hyaluronic acid is used as a filler substance. Hyaluronic acid is injected beneath the skin to restore volume and fill in wrinkles. The effect of a hyaluronic acid filler is primarily mechanical, as it lifts the sunken skin within a wrinkle.

Which Hyaluronic Acid Filler is best for Marionette Lines?

There is a wide range of hyaluronic acid fillers available in the market. They differ in terms of their consistency, viscosity, and longevity. And also in terms of price. Therefore, when selecting the appropriate filler, it is not only about considering the depth and location of the wrinkle and the desired outcome. But also about how much you are willing to invest in getting Marionette lines treated with filler. Since the differences can be significant, I place great importance on discussing the cost aspect during the consultation with my patients.

Lighter fillers are suitable for fine lines and wrinkles, while denser fillers with a higher concentration of hyaluronic acid are used to treat deeper wrinkles and restore volume. Due to the significant facial muscle movement in the chin area, fillers that are appropriate for this region are also characterized by a high degree of cross-linking, ensuring their stability and longevity. Lighter fillers are typically more fluid and are often used for superficial fine lines to provide enhanced hydration to the skin. And thus improve the overall appearance of the skin.

The amount of hyaluronic acid needed varies depending on the depth and severity of the wrinkles. Typically, between 0.5 and 2 ml of hyaluronic acid are used per treatment. However, the exact amount required is always determined on an individual basis and adjusted during the treatment.

How Does the Treatment Process Go?

The process of the treatment is relatively straightforward and uncomplicated. First, the area to be treated is prepped with a numbing cream to make the treatment as comfortable as possible. After an approximately 30-minute waiting period, the hyaluronic acid filler is then injected.

There are various injection techniques that can be applied depending on the type and location of the fold. A common technique is the linear injection, where the hyaluronic acid is injected along the fold using a blunt cannula. In the so-called “fan” technique, multiple injections are made from a central point in different directions. This technique is particularly useful for broader or more extensive wrinkles.

Regardless of the chosen technique, the treatment typically takes only 15 to 30 minutes. The results are immediately visible. After the treatment, there may be slight redness or swelling, which usually subsides after a short period of time.

In summary, augmenting Marionette lines with hyaluronic acid is a fast and effective method for their treatment. By selecting the appropriate filler and applying the suitable injection technique, a natural and long-lasting result can be achieved. The risks are relatively low. Moreover, in the long run, augmenting Marionette lines with hyaluronic acid is also cost-effective.

Risks of Hyaluronic Acid Treatments

Although hyaluronic acid augmentation is considered a safe and effective method for treating Marionette lines, there are still some risks and side effects that should be taken into consideration.

Redness, Swelling, Bruising

Short-term side effects may include swelling and redness at the injection site. These are usually mild and subside within a few days. Mild bruising may also occur, especially in individuals taking blood-thinning medications.

Allergic Reactions

In rare cases, allergic reactions to the hyaluronic acid filler may occur. Symptoms of such a reaction may include itching, redness, and swelling at the injection site. A delayed allergic reaction, which can occur days or even weeks after the treatment, is a more serious but rare risk. It can manifest as persistent swelling, redness, and sometimes pain.

Very Rare: Arterial Occlusion

The most serious but extremely rare risk is arterial occlusion. This refers to a blockage of blood supply that can occur due to the inadvertent injection of the filler into a blood vessel. This is a medical emergency that requires immediate treatment to prevent permanent damage. However, it should be emphasized that the risk of arterial occlusion during the augmentation of Marionette lines with hyaluronic acid is extremely low.

It is important to be aware that any medical procedure carries risks, and a comprehensive consultation with a qualified specialist is essential for full understanding. Furthermore, the treatment should only be performed by an experienced specialist to minimize the risk of complications.

Who is Not Suitable for the Treatment?

Hyaluronic acid augmentation is an effective method for treating Marionette lines, but it is not suitable for everyone. There are certain factors and conditions that should be taken into consideration before opting for this type of treatment.

First, it is essential to understand that hyaluronic acid augmentation works best for mild to moderate wrinkles. For patients with advanced elastosis, a skin condition characterized by degeneration of the elastic tissue of the skin, and significant skin laxity, the treatment may be less effective or may not achieve the desired results. In such cases, other treatment methods, such as surgical tightening, may be more suitable.

Pregnant and breastfeeding women should also avoid the treatment. Although hyaluronic acid naturally occurs in the body and is generally considered safe, the effects of injecting hyaluronic acid fillers on the unborn child or infant have not been sufficiently studied. In addition, many hyaluronic acid fillers contain the local anesthetic lidocaine to enhance comfort during the treatment. Lidocaine should be avoided during pregnancy and breastfeeding as it can pass into breast milk and potentially affect the child.

Individuals with a known allergy to hyaluronic acid or lidocaine should also avoid this treatment. Similarly, caution should be exercised in individuals with active skin conditions such as acne or rosacea, or those prone to keloids or hypertrophic scars.

Individuals with an acute infection or inflammation in the treatment area must allow it to resolve before undergoing the procedure.

Ultimately, it is important to have a thorough consultation with a qualified physician before deciding to undergo hyaluronic acid augmentation. The physician will be able to assess the individual situation and recommend the most suitable treatment option. In Munich, I prioritize providing comprehensive information about all risks and side effects to my patients.

Cost of an Augmentation

The costs for augmenting marionette lines with hyaluronic acid can vary depending on their type and depth, particularly based on the amount of hyaluronic acid required. In my practice in Munich, I typically use between 0.5ml and 1ml of filler for marionette lines augmentation, which is estimated to cost around €350 to €500.

A larger amount of filler is usually required when not only the marionette lines themselves, but also a larger portion of the chin area needs to be augmented for a satisfactory result. In such cases, 2ml or more of filler may be necessary. The costs in such cases typically range from €800 to €1300.

Please consider the mentioned price range as approximate guidelines. The individual billing of a medical procedure is always done according to the regulations of the German Medical Fee Schedule (GOÄ).

In addition, please be aware that health insurance providers and private health insurance companies typically do not reimburse the costs for marionette lines augmentation.

Conclusion: Augmenting Marionette Lines with Hyaluronic Acid

Marionette lines are a natural consequence of aging, but they can be effectively treated through augmentation with hyaluronic acid. This method is non-invasive, with immediate visible results, and the treatment is typically painless.

There are other treatment options available, but injecting hyaluronic acid into the marionette lines offers several specific advantages. The costs can vary, so it is important to seek comprehensive advice from an experienced expert before deciding on a treatment.

And as always, remember that good skincare and a healthy lifestyle can help keep your skin youthful and healthy, and delay the appearance of wrinkles.

If you require supplemental information or would like to discuss your personal situation with me, please feel free to contact me or schedule a consultation appointment at my practice.

I look forward to your visit!

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About the author:

Dr. med. univ. Eva Maria Strobl is the owner of LIPS and SKIN Aesthetic Medicine practice in Munich. She is a trained specialist in general medicine (MedUni Vienna) and has over 10 years of specialization in non-surgical aesthetic procedures. Dr. Strobl is a member of the German Society for Aesthetic Botulinum Therapy e.V. (DGBT), the German Society of Anti-Aging Medicine e.V. (GSAAM) and of Network Global Health. She publishes regularly on her blog and on DocCheck.

Sources of this article:

Sattler/Sommer, Bildatlas der ästhetischen Augmentationsverfahren mit Fillern, KVM
Sattler/Kolster, Bildatlas der ästhetischen Botulinumtoxin-Therapie, KVM
Seo, Facial Volumization with Fillers, Springer

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