Looking for Botox for marionette lines? Well, there are some fabulous surgeons out there who are well trained and can deliver some fabulous results using fillers and injections to break your skin and inject a semi permanent substance under the surface to reduce the appearance of wrinkles and folds known as marionette lines.

We’ve included a case study below, but what’s important is the note at the end, which we’ve summarised here:

This groundbreaking case report suggests that combined injection of neuromodulator, HA dermal filler and deoxycholic acid can rejuvenate the lower face with patient satisfaction and professional evaluation of improvement. However, a formal, multicenter study is needed to make recommendations on best practices and patient safety. As always, doctors should be careful when using unauthorized applications and in combination therapies.

The reason for the caution is that with Botox injections, even though it’s not necessarily deep into the tissue, the injections must be done with care.Especially around the face, because one wrong move can lead to a string of issues including nerve damage which causes your face to sag rather than be more plump.

This is why we treat marionette lines with radiofrequency therapy rather than Botox injected into your muscles.  We then also massage your face, including buccal massage which helps to strengthen and tone the muscles around the area, reducing marionette lines.

What is radio frequency (R) therapy?

fine line wrinkle reduction non surgical facelift mouth lipos

After only one session you can see how the lines to the side of the nose are less deep

This is how we bring the shape of your skin back to a more youthful appearance with no fillers. We (your experienced specialists) will temporarily heat the skin and tissue along the nasolabial lines to an exacting temperature that means your body will send collagen and elastin to the area. This will have the effect of naturally tightening your skin, giving you a more plump appearance and beating the signs of ageing.

This is a safe way to rid yourself of not only age folds which are aging but also to expedite the loss of that wrinkle you so hate. What’s better is that we improve your youthful appearance and lift your skin and tissue with no invasive surgery. You don’t need any daily care, once your body has produced and sent collagen to the site, it’s there. And you continue to age at your normal rate from this new benchmark.

Effectively, radiofrequency therapy is stimulating your body into improving your appearance itself. No fillers.And no adverse side effects. Treatments are even relaxing as well as being natural.

Plus, you’re not limited to one specific area, we can work the general area as well within the time that you book. So if you’re conscious of your lip and worried wrinkles will stand out more in this area once your marionette lines around your jowls are sorted, then we can use the same treatment to improve this area too.

So if you’re looking for Botox for marionette lines, there is a viable alternative which is cheaper, more natural, less maintenance and overall, a much nicer treatment experience too.

Is RF therapy the same as laser surgery?

No, this process uses heat that warms the dermal layer of your skin. You’ll feel relaxed rather than pain during these types of treatment. And you won’t be red or scarred afterwards, you can put your makeup on and get on with your day and people won’t be any the wiser. Perfect if you have active lifestyle habits.

Is the heat going to ruin my skin like the sun?

No, sun exposure drys the upper layers of the skin, we work with the dermal layers which stimulate your body to produce a natural healing serum that once activated will soften and pull up the trough of your sagging skin so that you have a noticeable smoother contour.

And there’s no risk. Your skincare regime can continue as you choose as there is no tear or break. This highly effective RF therapy is also medically researched and proven to improve the hydrated appearance of skin cells so you have more tone.

In summary of Botox experiment for marionette lines on sagging jowls

A 55-year-old woman who requested non-invasive rejuvenation of her lower face received multimodal injections in a single office visit to rejuvenate her cheeks. The patient had no side effects other than self-limited hematomas at the hyaluronic acid injection site and minimal edema. The results were evaluated as follows: (1) by the patient using the self-evaluated Face Q assessment and (2) by 5 plastic surgeons (none of whom authored this study) based on the WAS scale and before and after photos to evaluate mouth corners and puppet lines. This case study report suggests that the combined use of neuromodulator, hyaluronic acid dermal filler, and synthetic deoxycholic acid may rejuvenate the lower face as a minimally invasive alternative to surgery for patient satisfaction and 6 plastic surgeons (including the author).


The facial rejuvenation paradigm has shifted from the treatment of hyperdynamic 2D facial lines to a multimodal 3D approach.1 Botulinum toxin was used off-label to relax the Anguli Oris muscle (DAO), thus increasing lateral oral commissions and increasing the rhythms caused by 2 Botulinum The treatment with DAO toxins enhances the filling of the soft tissues of puppet lines by mitigating the contorsive effect of DAO.3 Injectable deoxycholic acid (Kybella) has been used safely and effectively for the reduction of submental fat4. HA (Juvederm Ultra) has been used to fill facial lines since 2003 and is found naturally in the skin, connective, epithelial and nerve tissues.5 HA provides volume through water absorption.

They gave one patient multimodal injections in a single practice visit to rejuvenate the cheeks with the sequence (1) botulinum toxin, (2) hyaluronic acid, and (3) deoxycholic acid.

They injected the DAO muscle with 2 units of Botox halfway between the commissure and the lower jaw. They kept the injection 1 cm on the side of a plumb line from the lateral commissure to avoid the labial depressor muscle and on the edge of the mandible to avoid the marginal mandibular nerve. An injection that is too medial could weaken the lower lips and an injection too high in the laughter, resulting in an asymmetrical smile.1 Lateral platism also contributes to frowning and can compensate after the DAO is blocked.

The marionette line, which extends from the lateral corner to the edge of the mandible has been injected with hyaluronic acid into the deep middle dermis with a 30 gauge needle to fill the lines and restore volume, disguising the cheeks.


The fat-rich subcutaneous jaw area was injected into a right triangle with the 3 vertices, 1 cm next to the corner of the mouth, 1 cm above the lower edge of the jaw and 1 cm ahead of the gum line.

During injection, the 30-gauge 0.5 inch needle was inserted vertically and 0.1 cm3 was injected subcutaneously at a distance of 1 cm. The patient had no other side effects other than bruising at the injection site and minimal edema, expected transient side effects of HA and Kybella. The patient completed the Face-Q satisfaction assessment with facial appearance6 after 3 months.

Overall results based on the 10 facial questions show that she rated her facial image at 44% before and 84.5% after multimodal injections. They illustrate this significant improvement in the photos above and 3 months after. Qualitatively, this patient wrote: “I am very happy.” External file containing an image, an image, etc.

Independent evaluations by 5 plastic surgeons who used before and after images and the standardized WAS assessment (0 = no wrinkles; 5 = very deep wrinkles, redundant fold).

Outcome patterns reflected those of the patient; overall improvement averaged 2 points (range 1-3). Qualitatively, his comments were unanimously positive, for example: “For me, the result is remarkable: excellent correction of the puppet lines” and “Significant result without surgery”.

What’s the other alternative?

iPRF (injectable platelet-rich fibrin) presents a promising alternative to Botox when addressing marionette lines, those pronounced lines that run from the corners of the mouth to the jawline. Unlike Botox, which works by paralysing muscles, iPRF promotes natural collagen production and tissue rejuvenation when injected into the affected areas.

This collagen boost effectively plumps and tightens the skin, reducing the depth of marionette lines and restoring a more youthful appearance. iPRF’s results are gradual but long-lasting, offering a subtle and natural enhancement without the temporary nature of Botox treatments.

Furthermore, iPRF carries a lower risk of side effects and provides a safe, non-toxic solution for individuals seeking to address marionette lines without the use of neurotoxins. If you’d like to have this and radio frequency at the same time, then this is completely possible and safe and something we would recommend for maximum long term benefits.

DISCUSSION about Botox for marionette lines

Aesthetic patients received over 10 million injectable procedures in 2016, highlighting the popularity and acceptance of injections. Botulinum toxin and hyaluronic acid injections have been among the two most important non-surgical procedures in the last 8 years. We should set expectations for repeated injections that result in a cumulative or maintenance effect.

The injections promote a long-term relationship with the patient and the opportunity to offer non-invasive complementary procedures, such as photo rejuvenation or energy-based skin tightening. They gave the patient an injection of complete bella into the lacrimal canal, which may have affected her satisfaction with her entire facial image. However, the evaluation of plastic surgeons focused only on the corner of the mouth and the puppet line and improved by 2 points in WAS. Injecting the upper part at the same time as the bottom is beneficial for both sides.

Patients should be informed so that they can expect bruising, swelling and pain. Patients should be informed about the possibility of problems with the terminal branches of the facial nerve, the lower marginal jaw and possibly the oral area. Side effects of a submental injection of Kybella included marginal paresis of the mandibular nerve, which accounted for 4.3% of the 250 patients injected.

The symptoms were mild, transient and resolved without intervention. The patient should be asked to smile for identity asymmetry before injecting Kybella. 9 Ideally, patients should have thick skin on the lower face and too much subcutaneous fat, otherwise injecting Kybella could cause lower facial rhythms, which would be an undesirable result. Over one injection may be needed at least 1 month apart to get the desired effect. For successful rejuvenation of the lower face, a direct injection approach is possibly more effective than the remote lateral facelift plication, which is likely to be loosened by movements such as expression, speech, and feeding.

Repeating an operation such as facelift is an important task from a financial, emotional and physical point of view, and they can interpret review procedures as a failure of the operation. While botulinum toxin and hyaluronic acid are expected to be repeated procedures for maintenance and fine tuning.