How to correct marionette lines with filler thread cross-threading?

Typically, marionette lines lose fat underneath the inner side, while fat accumulates above the outer side (jowl fat), creating a sharp demarcation. Additionally, the jowl ligament at the lowest point of the marionette lines causes tissue contraction on the inner side of the wrinkle line, restricting its movement and creating a sharp demarcation (Figure 1). The formation of marionette lines is influenced by facial anatomy and aging dynamics, and manifests as a noticeable sagging around the mouth. These lines are influenced by factors such as changes in muscle composition and tissue depth, giving the face a sagging appearance similar to that of a marionette mouth.
Effective improvement of corner mouth lines often requires a comprehensive approach that combines minimally invasive techniques such as thread embedding and fillers to reduce sagging and achieve lift.

Figure 1.

The cross-thread filling technique (CROSS TECHNIQUE WITH VOLUMIZING THREAD) corrects marionette lines by placing the filling lines perpendicular to the direction of the marionette lines, reducing the boundary between the two layers of fat (Figure 2). The filling lines are composed of multiple single lines. This design helps to relieve pain during surgery, reduce damage to surrounding blood vessels and tissues, and minimize postoperative bruising, swelling, and pain.

Figure 2. Vector illustration of fill line insertion.

The insertion point is either inside or outside the marionette lines, depending on the length of the filler thread used. The thread is passed through the marionette lines from the insertion point so that the filler thread provides support in the thick tissue below the marionette lines, while the upper part of the thread compresses and pushes the loose skin tissue above the marionette lines, creating a lifting effect. This method of inserting the filler thread perpendicular to the marionette lines promotes collagen growth along the thread direction and tightens the loose skin tissue above the marionette lines, thereby reducing the pressure and folding of the facial skin by the facial muscles during facial expressions. Care should be taken not to insert the thread too deep so that the thread does not protrude into the mouth.

When inserting the filler thread inside the marionette lines, care must be taken to avoid damaging the mandibular nerve and artery that emerges from the mandibular foramen below the corner of the mouth. The mandibular foramen is usually located near the midpoint of a vertical line from the corner of the mouth to the jawline.

In elderly patients with loose facial skin and tissue, marionette lines may be accompanied by a prejowl sulcus, which causes the area below the wrinkle line to appear compressed, resulting in an uneven jawline. The subcutaneous fat layer is thin in the area outside the mandibular tip, while the mandibular ligament along the mandibular line is attached to the skin, creating a strong traction (Figure 3). Due to this fibrous tissue, if the anterior mandibular groove is significantly sunken, it may be difficult to repair it smoothly using fillers alone. In this case, a combination of filler wires and fillers can achieve better results. During the treatment, it is recommended to perform pre-channel processing between the firm fibrous tissue to create enough space to insert the filler wires and fillers, so that the cannula can be smoothly advanced.

Figure 3.

The fat in the lower part of the inner side below the wrinkle line is reduced, while the fat in the upper and outer side (premandibular fat) accumulates, forming a clear boundary.

The needle entry point is near the junction of the chin and mandible, which is the anterior border of the obvious concave area. The needle is opened and then the cannula is inserted laterally to guide the filler thread along the depressor anguli oris and platysma muscles or the subcutaneous fat layer. After the filler thread is inserted, the filler is injected into the dermis or subcutaneous tissue through the same puncture point to achieve a smoother appearance.

The overall contour around the corner of the mouth is improved by lifting the loose tissue outside the marionette lines and restoring the concave area in front of the wrinkle line. To achieve a softer transition between the boundary of firm and loose tissue and reduce the folding, a softer filler thread or monofilament thread can be used. When inserting the thread parallel to the wrinkle line, placing it slightly inside the wrinkle line can reduce the skin layer difference caused by the concave area. Placing the volume filler thread or monofilament along the wrinkle line promotes collagen growth in the direction of the thread, tightening the skin tissue and reducing the appearance of skin concavity and folding in the area in front of the wrinkle line.

Sawtooth Thread Lift: In elderly patients, the looseness of the skin and connective tissue of the lower face not only leads to the appearance of marionette lines, but is often accompanied by anterior mandibular grooves. This makes the area below the wrinkle line appear sunken, resulting in an uneven jawline, while the area above the wrinkle line is more prominent. The subcutaneous fat layer in the area outside the jawline is thinner than the tip of the chin, and the mandibular ligament is firmly attached to the skin along the jawline, creating a strong traction. In order to address the displacement of fat that causes chin sagging and achieve a more harmonious effect, it is recommended to combine an oblique zigzag line lift with a vertical lift along the wrinkle line, directing the thread to the ear area (see Figure 4). This combined treatment helps target the specific fat deposits that cause chin sagging, achieving a more comprehensive effect.

FIGURE 4.

To correct fat displacement that causes jowl ptosis and achieve a more harmonious effect, it is recommended to combine an oblique zigzag lift with a vertical lift along the wrinkle line, directing the threads toward the ear area.

Anterior Mandibular Sulcus Filling: For the anterior mandibular sulcus that is significantly depressed due to the tightening of the ligamentous tissue, it is recommended to use a combination of filler wires and fillers (see Figure 5). First, the tight ligamentous tissue is channeled to create enough space for the insertion of filler wires and fillers. The blunt needle entry point is usually located in the border area between the tip of the chin and the mandible, which is the area of depression in appearance. The needle punctures the anterior border of the depressed area, and the cannula is inserted laterally to place the filler wire along the depressor anguli oris and platysma muscles or the submuscular fat layer. After the filler wire is inserted, the filler is injected into the dermis or subcutaneous tissue through the same puncture point to address surface irregularities and achieve a smoother appearance.

Figure 5.

For obvious depression of the anterior mandibular groove caused by ligament tension, it is recommended to use a combination of filler wire and filler.

The combined use of multiple threads can effectively prolong the lifting effect (see Figure 6). In particular, the crossover technique of filler threads can cross both tissues to reduce the difference between loose tissue and jowl ptosis, induce adhesion, and significantly prolong the duration of the effect. In addition, after resetting the loose tissue outside the marionette lines and restoring the depressed area in front of the wrinkle line, softer filler threads or monofilament threads can be used to fine-tune the overall contour. When inserting the thread parallel to the wrinkle line, placing it slightly inwards inside the wrinkle line can help improve the difference in skin layers caused by the depression. Inserting filler threads or monofilament threads along the wrinkle line can stimulate collagen growth in the direction of the thread, tightening the skin tissue and reducing skin folding in the area in front of the wrinkle line. Using multiple threads can create a synergistic effect and enhance the overall effect.

Figure 6.

Combining multiple wires can help achieve longer-lasting results.

Cases

Case 1: 53-year-old female, preoperative (Fig. 7A) and 4 months postoperative (Fig. 7B) photos. Combined treatment included: inserting two lines of 27G polydioxanone (PDO) filler threads (LVDR Volume / Sihler, South Korea; Volume S Secret / Hyundaimeditech, South Korea) perpendicular to the marionette lines. This method of embedding can stimulate collagen production along the thread direction, tighten the skin tissue, and improve the appearance of skin depressions and folds. Before embedding, 0.1cc of dental lidocaine was injected at the insertion point for local anesthesia. An 18G needle was used to puncture the opening, and then the filler thread was accurately guided to the subcutaneous layer. The filler thread was inserted into the subcutaneous layer (second layer) while pressing the chin fat with the palm of the hand. After the thread embedding was completed, the cannula was rotated and retracted.

Case 2: 55-year-old female, preoperative (Fig. 8A) and 2 months postoperative (Fig. 8B) photos. 21G polydioxanone (PDO) filler thread (LVDR Volume / Sihler, Korea) was inserted in the anterior cheek; two sets of 27G PDO volume filler threads (LVDR Volume, produced by Sihler Inc., Korea; Volume S Secret / Hyundaimeditech, Korea) were inserted perpendicular to the marionette lines. Before thread embedding, 0.1cc of dental lidocaine was injected at the insertion point for local anesthesia, and then an 18G needle was used to puncture the opening and insert the filler thread into the subcutaneous layer (second layer). After thread embedding, the cannula was rotated and retrieved. After the operation, the depression of the anterior cheek and the marionette lines were significantly improved.

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