The Surgical Secret to Marionette Lines No One Else Tells You – by Dr. Returning
Hello, this is Dr. Kim Yong-woo (Dr. Returning), a board-certified plastic surgeon.
In this post, we will explore the causes and solutions for Marionette Lines (lines around the mouth), which, along with nasolabial folds, are considered the "two major mountain ranges" of deep facial wrinkles.
The primary concern for patients who decide to undergo a facelift and come in for a consultation is typically nasolabial folds and marionette lines. To give you the conclusion first: A facelift can resolve marionette lines. However, satisfaction can vary depending on how accurately the individual’s anatomical differences and condition are diagnosed and how the surgery is performed.
Etymology of "Marionette"
Etymology: The shape of the mouth of a marionette puppet used in puppet shows.
The word "marionette" refers to a puppet manipulated from above using strings attached to its joints, used in puppet shows. To allow the puppet to move its mouth, slits (joints) are made downwards from both corners of the mouth. Because these resemble the wrinkles that form around the mouth due to aging, the term "Marionette Lines" came into use.
Causes of Lines Around the Mouth
1. Bone Volume Loss due to Aging or Facial Contouring Surgery
As I have mentioned several times in previous posts, sagging due to aging is accompanied by bone resorption (bone loss).
[Image: Bone resorption caused by aging] [Red Arrow] Mandibular bone resorption worsens lines around the mouth.
As we age, bone resorption occurs in the skull as shown above, and the tissues attached to it begin to sag. Cheek sagging caused by facial contouring surgery is ultimately the same mechanism as sagging caused by aging. At this time, the height of the mandible decreases, and the body of the mandible near the premolars (red arrow) retreats. Consequently, the sagging of the tissue located in this area worsens, intensifying jowls and marionette lines.
2. Retaining Ligaments and Facial Spaces ★Key Point★
[Image: Retaining ligaments located between blue spaces] Retaining ligaments located between the blue spaces.
The face consists of several "spaces" and retaining ligaments. A "space" does not mean it is empty; rather, it refers to a layer where the adhesion between tissues is loose. The boundaries of these spaces are marked by retaining ligaments. Because the adhesion in these spaces is loose, the tissue located there is prone to sagging due to gravity. However, the retaining ligaments that border these spaces are strongly attached from the bone to the skin, so they cannot sag. As a result, deep grooves (wrinkles) form at the site of the ligaments.
[Image: Curtain analogy] The operating principle of a stage curtain helps in understanding retaining ligaments and tissue sagging.
To explain using a stage curtain as an example: if you pull up a loose curtain from the top, the fabric between the fixed points droops down. If you think of the fixed points as the retaining ligaments, the drooping curtain as the tissue, and the gaps between the tissues as the wrinkles, it will be easier to understand.
[Image: Diagram of facial ligaments] With retaining ligaments as fixed points, tissue sags due to aging. (Source: Surgical anatomy of the lower face; Bryan C. Mendelson)
Now, let's look at why lines form around the mouth. The tissue covering the loose space in the cheek sags due to aging and other factors. At this point, the Mandibular Ligament acts as a strong fixed point, creating a deep wrinkle.
You can understand all wrinkles on the face as "tissue covering a space" that sags with the retaining ligament as the boundary. This applies to tear troughs, Indian bands (nasojugal grooves), and nasolabial folds.
[Image: Tear trough diagram] [Example] Tear troughs also occur due to the sagging of the upper fat (orbital fat) with the orbital retaining ligament acting as a fixed point.
The Surgical Secret to Marionette Lines
by Dr. Returning
Everyone knows that the solution to facial wrinkles is a facelift, and that "the important part of a facelift is cutting the retaining ligaments and pulling up the sagging tissue."
Then, should we also cut the mandibular ligament and lift the tissue to fix marionette lines?
No. This area is different from tear troughs, nasolabial folds, or Indian bands. First of all, the mandibular ligament is located at the very end of the jowl (the sagging tissue causing the line), so there is no need to cut and pull it. Furthermore, the facial nerves are located very dangerously around the mandibular ligament, and there are many anatomical variations. Therefore, the risk of nerve damage during dissection is very high. Because the risk is too great compared to the potential benefit, this is an area we do not dissect during a facelift.
[Image: Nerve anatomy] Nerves around the mandibular ligament show various anatomical variations. (Source: The Surgical Anatomy of the Jowl and the Mandibular Ligament Reassessed)
Then, is it enough to simply pull the skin during a facelift? If you approach it too simply, the wrinkles may form again over time, leading to unsatisfactory results.
Dr. Returning’s Surgical Method to Effectively Eliminate Marionette Lines
I always emphasize that for any surgery to be successful, you must identify the cause of failure and eliminate the aggravating factors. First, the reason marionette lines recur even after a well-performed facelift is sagging due to gravity. To be less affected by gravity, the tissue being pulled must be made as light as possible.
[Image: Jowl fat and Buccal fat illustration] Since jowls are caused by the sagging of jowl fat and buccal fat, efforts to reduce weight are necessary during a facelift.
Let's look at the anatomy again. The tissues creating the lines around the mouth (jowls) are the shallow Jowl Fat and the deep Buccal Fat Pad.
If we perform liposuction of the jowl fat and removal of the buccal fat pad during the facelift to eliminate the sagging tissue itself and make it lighter, we can significantly extend the duration of the results. However, a precaution here is that removing too much buccal fat can lead to severe hollowness in the cheeks, so only an appropriate amount should be removed based on a precise pre-operative plan.
[Image: Before & After photos] [Unretouched Review] Before and after facelift for a patient in their 60s, combined with jowl fat/buccal fat removal - by DR Returning
[Image: Before & After photos side view] [Unretouched Review] Before and after facelift for a patient in their 60s, combined with jowl fat/buccal fat removal - by DR Returning
So far, we have looked in depth at marionette lines, a symbol of aging, and I have introduced my own surgical know-how involving buccal fat removal.
I hope this post helps many of you who are worried about buccal fat removal and marionette lines.
This has been Dr. Kim Yong-woo, Chief doctor of Returning Plastic Surgery. Thank you!!
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