Technique for eliminating marionette lines and wrinkles at the corners of the mouth

Dr. Frank Rosengaus describes the technique for eliminating marionette lines and lip folds, and the importance of understanding the anatomy of the face.

Removal of lip folds and puppet lines is very difficult due to bumps, lines, creases, depressions and hyperkinetic parts of the muscles that need to be acted upon to ensure good results.

My goal – achieve the well-known smile of Mona Lisa: the skin should be perfectly smooth, and the corners of the mouth – directed upward. How can this be achieved?

Anatomy of the face and marionette wrinkles

For 15 years we thought that all the wrinkles in the upper part of the face – the result of muscle hyperactivity, therefore, toxins are mainly used to eliminate them. In the lower part of the face, lines and folds – the result of a loss of firmness and volume, so fillers are used to eliminate them.

However, are muscles one of the causes of wrinkles and lines in the lower third of the face?

Eight muscles are responsible for the physiology of the mouth. All of them act at a point called the muscular node and is located at a distance of 1 cm from the wrinkles at the corners of the mouth.

If you consider how they interact, all muscle movements, especially the drooping corner of the mouth muscle, constantly pull the corners of the mouth down, leading to the appearance of wrinkles in this area. A ligament is located on the anterior upper part of the muscle that lowers the corner of the mouth. It runs from the corner of the mouth to the border of the lower jaw. On the CT scan, you can see the components of the superficial fat pads.

There is a distance between the jaw and labio-chin fat pad. A small amount of fat is located in the central part of the face – upper and lower, especially around the ligament connecting the corner of the mouth with the lower jaw. Also in this area, the skin and muscles are closely connected.

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Technique

I always explain my actions to patients. First of all, it is necessary to note the location of the ligament connecting the lip and lower jaw, as well as the area to which you want to add volume. I explain to each patient the amount of the necessary drug and the place of its administration.

Another important element in this zone is deep fat. That is why we have a second chin, which is the spread of the fatty body of the cheek.

First I look at what tissue needs to be tightened, then I choose the product and the appropriate tool. I use cannulas because clinical trials show better results and no complications. I also use a subcision cannula to separate the skin from the muscle.

I am creating a lateral entry point because if necessary I can turn around and work on the nasolabial folds as well. I go through the ligament medially, make incisions, subcisions and model the zone.

I use a 25 or 23 gauge microcannula (Sogtligt). The procedure is painless – it's pretty unexpected. I use a microcannula to subcut the skin, separate the labiomandibular ligament from the skin, proceed to a triangle located under the corner of the lips, and continue the subcutaneous division medially to the submandibular area.

This way, you will not inject the product where it is not needed, for example, into the fat located in the jaw area. Remember that security – first of all.

In the area below the corner of the mouth, special care and precision must be taken. Here I draw a triangle. Subcision of the skin ligaments ensures normal muscle mobility without the formation of deeper wrinkles at the corners of the mouth. I also create the space needed to insert the filler.

Results

I have treated a patient with wrinkles, skin irregularities, marionette lines and downturned corners of the mouth. As a result, a significant improvement in the position of the corners of the mouth was achieved. They can be raised by one, two or three millimeters and provide a happy look to the face, which was required to achieve. And this is the ideal result – smoothness of the skin around the mouth and lifting of the corners of the lips. This technique helps to remove marionette lines in both younger and older patients.

The disadvantage of this technique is the longer time it takes, as well as possible pain and inflammation around the corners of the mouth, which pass through 48 – 72 hours