One of the hallmarks of aging around the  mouth area is the development of marionettes lines. Also known as melomental folds, this groove or fold (some call it a rhytid or wrinkle but this is not an accurate term) is the transition of the more fixed chin tissues against which the more loose skin from the side of the face (jowls) falls over. While a facelift can significantly soften this fold by pulling back the overhanging skin, the most common method of treatment is non-surgical filler injection.

All of the available injectable fillers work equally well for softening this fold but they do differ in how long they last. Regardless of the filler composition, their biggest drawback is that they are not permanent. Any method that would prolong the duration of their effect, even for a few months, would be of benefit.

One fundamental approach to prolonging the effects of injectable fillers, in some facial areas, is to weaken the surrounding muscles by Botox or Dysport injections. Strong or continuous muscle activity ‘pounds’ upon a filler site and can hasten its absorption. The most common use of this combined filler and muscle paralysis approach is in the treatment of very deep vertical glabellar furrows between the eyebrows.

This approach has now been reported in the treatment of the marionette lines. In a recent issue of Dermatology Times, the results of a clinical study from UCLA (Dr. David Beynet) was reported using  Juvéderm in combination with Botox for greater cosmetic improvement and an extended duration of benefit compared with correction using the filler alone. In a randomized, double-blind, split-face study, twenty-three (23) patients  received treatment with the filler on both sides of the face. On one side of the face, Botox was injected into the depressor anguli oris muscle and saline was injected into the other side. At two and four weeks after injection, there was a better cosmetic result on the filler-Botox side. This result was maintained more than six weeks longer than filler alone. (39 weeks vs 32 weeks)

While the benefits of combining muscle paralysis with fillers for a better effect is well known for glabellar folds, their use in the lower face has not previously been demonstrated. A small dose of Botox (4 units) into the depressor anguli muscle works by weakening the downward pull of the corner of the mouth. This avoids any pressure or strain on the marionette line area. Whether higher doses of Botox would be even more effective or repeating Botox injections (which wear off after 4 months while the filler lasts much longer) would make the effect even better remains theoretical. I suspect that this small dose is probably near or is the optimal therapeutic dose.

The injectable treatment of the marionette line is a useful facial cosmetic treatment. But like the treatment of all facial folds,  it never lasts as long as we would like. Any adjunctive method that has a synergistic effect, and is economically reasonable, would be useful. Botox certainly seems to fill that role.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis