Marionette lines

Our face is part of our identity and bears the marks of our life history. The lower face is a visible determinant of an individual’s perceived age. The youthful lower face is characterized by an indistinct transition from the midface, well-defined lower jaw border, smooth facial skin devoid of redundant wrinkles and folds, and proportionate upper and lower lips and chin. 

The attractive face is one in which the cheekbones are the widest part of the face, which taper smoothly into the chin. Lower facial rejuvenation is an important complement to midface rejuvenation and brings harmony to the aesthetic outcome.

How Does It Manifest?

Marionette lines occur with age and run obliquely from the corner of the mouth to the sides of the chin and are a classic sign of lower facial aging. They start appearing in the fourth decade of life and impart a heavy appearance of the lower face and add to a person’s perceived age. Other signs of lower face aging include wrinkles, irregular skin pigmentation, loss of the well-defined border of the lower jaw and squaring of the face. Individuals with aged lower faces are often described as angry or tired.

 

Marionette Lines: Filler Injection, Structural Fat Grafting, MFU Thread Lift & Facelift

How does it arise?

Midfacial aging is a complex multi-factorial process involving the skin, subcutaneous fat, the facial muscle (SMAS) layer and the facial skeleton. These include:

  • Thinning of the skin leading to formation of fine wrinkles due to reduced elastin and collagen fiber production, and reduction of hyaluronan in the skin. This results in formation of fine wrinkles
  • Irregular deposition of skin pigment
  • Loss of fat from the superficial and deep fat compartments resulting in cheek flattening and descent. Loss of facial fat results in progressive prominence of the bony skeleton and contributes to skin excess and laxity. This is an important mechanism of ageing in individuals who have significant weight loss 
  • Drooping of facial soft tissue that is unsupported by the facial ligaments. This leads to the formation of the laugh lines and jowls
  • Changes in the facial skeleton occur after the fourth decade, especially bone loss in the lower half of the eye socket, at the base of the nose and the upper jaw. This results in loss of support for the facial soft tissue and contributes to its drooping

The most important mechanism of facial ageing is the progressive lengthening and laxity of the SMAS muscle layer. Lifelong repeated use of our facial muscles for critical functions such as facial expression, speaking and eating results in its gradual elongation. The SMAS elongates in a downward and inward direction and is contributes to the formation of the laugh lines and marionette lines.

 

treatment

Attaining beautiful and bespoke results that retain an individual’s emotional expressivity is frequently possible and requires a combination of accurate assessment, precise execution and an experienced practitioner. Rejuvenation of the lower face is often performed together with the midface for harmonious results. The options for the treatment of marionette lines include filler injection, structural fat grafting, microfocused ultrasound (MFU), thread lift, mini face lift, and face lift. Successful outcomes help to restore self-confidence and improve social functioning.

Face Lift & Neck Lift (Rhytidectomy): Treatment Facial & Neck Drooping

 

Filler injection

Filler injection is a popular ambulatory procedure and is often used for restoring soft tissue volume and lifting areas where age-related fat loss has occurred. There is a wide range of fillers with various different characteristics to suit each individual’s unique anatomy and help them meet their aesthetic goals. A detailed explanation of filler injection for lifting the lower face may be found here.

Structural fat grafting

Structural fat grafting involves harvesting fat from areas of excess, purifying it, then grafting it in volume-deficient areas. A high proportional survival of fat cells may be attained with the use of specialized fat grafting cannulas available at Picasso Plastic Surgery. Structural fat grafting delivers elegant and long-lasting results. Structural fat grafting is a minimally-invasive ambulatory surgical procedure performed under local anesthesia, with optional intravenous sedation if requested. A detailed explanation of structural fat grafting to the lower face may be found here.

MIcrofocused Ultrasound Face Lift

There is an increasing interest in non-surgical facial rejuvenation and microfocused ultrasound (MFU) has emerged as one of the effective and safe technologies for tightening of the skin and subcutaneous tissues. This is a popularly requested procedure for rejuvenation. The MFU face lift is an ambulatory procedure performed under local anesethesia nerve block and intravenous sedation for optimal effect. A detailed explanation of microfocused ultrasound face lift to the lower face may be found here.

Thread Lift

Thread lift procedures are based on the use of barbed sutures to elevate the skin and soft tissue of the face. It does not reduce the facial skin excess, replace the fat volume loss nor tighten the SMAS muscle layer. This is an ambulatory procedure performed under local anesthesia, with optional intravenous sedation if requested.

Individuals in their thirties or early forties with minimal skin laxity seeking facial rejuvenation with minimal recovery time may consider thread lift procedures. Individuals with other accompanying signs of facial aging such as face or neck skin and muscle laxity, facial hollowing, double chin deformity etc. may wish to consider face lift surgery for comprehensive correction of these deformities.

The number of barbed sutures, their vectors, and their placement position are tailored to every individual. Local anesthesia nerve blocks are administered for maximal comfort during the procedure.

The effects of thread lift may be observed almost immediately following the procedure. The effect of thread lifts last for a few weeks. Stress relaxation is a basic plastic surgery principle and occurs here: skin lengthens in response to tension. This tension occurs because the underlying SMAS (muscle) laxity is not corrected by the thread and remains lax with this procedure. The SMAS continues to exert downward traction on the skin and results in its subsequent elongation. Historical experience with face lifts that only excise skin (in the 1950s) showed that the result of such face lifts lasted only a few weeks to months. Individuals require repeat treatments to maintain this result.

Very subtle swelling is expected after treatment, and will normally settle after one to two days. Most individuals are able to return to work on the day following the procedure.

Individuals are advised to avoid vigorous massage or rubbing of the treatment area for 24 hours to permit the threads to engage the soft tissue optimally and prevent loss of effect of the thread.

Mini Face Lift | Short Scar Rhytidectomy

The mini face lift effectively elevates the midface and lower face through a short, inconspicuous scar that is concealed between the ear and the face. This procedure significantly reduces the tear trough deformity, midcheek groove, laugh line and marionette line and keeps recovery time to a minimum. It produces sustained, elegant and natural-looking results and is a popular aesthetic procedure. There is often more significant improvement and long-term expenditure reduction with mini face lifts as compared with recurrent treatment with non-surgical therapies. It is performed as an ambulatory procedure under intravenous sedation and local anesthesia.

The following are good candidates for a mini face lift:

  • Individuals with mild-to-moderate midface and lower face skin and muscle laxity seeking long-term improvement. These are usually individuals in their thirties to forties.
  • Individuals with mild-to-moderate tear trough deformities, mid-cheek grooves, laugh lines and/or marionette lines
  • Individuals who have had suboptimal results with non-surgical treatment(s)

The mini facelift tightens and elevates the cheek and lower face eliminates unsightly droopy bulges and effaces the facial grooves, i.e. the tear troughs, midcheek grooves, laugh lines, jowls and marionette creases. The cheeks are elevated and revolumized, recreating the gentle concave contours seen in youthful faces. Excess loose skin is excised to create a crisp, smooth skin contour and the scars are inconspicuous when healed. The result is  elegant and harmonious improvement of the individual’s facial appearance and reduction of the perceived age. Successful outcomes help to restore self-confidence and improve social functioning.

Individuals are advised to stop herbal supplements and traditional medicine and start special medications 7 days prior to surgery to minimize bruising and swelling. Hypertension, if present, should be well-controlled, and smoking needs to be stopped for at least 2 to 4 weeks prior to surgery to minimize the occurrence of complications.

Mini face lifts are performed through incisions sited between the ear and the face for optimal scar concealment. The SMAS (muscle) layer is well-exposed permitting comprehensive tightening using proprietary techniques at Picasso Plastic Surgery, which achieve enhanced results while minimizing recovery time. SMAS tightening eliminates the facial bulges and grooves and restores a smooth contour in the midface and lower face. SMAS tightening is also the critical step in face lift surgery and delivers effective, long-lasting and natural-looking results. Face lift surgery is a fine art and strikes a balance between effective facial elevation and tightening whilst avoidance of an overly-tightened and unnatural appearance.

Stitches are removed on the 5th postoperative day. Mild swelling and bruising is expected, which will mostly resolve by the 10th postoperative day. Most individuals are able to return to work following removal of stitches.

Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed when asleep at night. Strenuous activity should be avoided for the first two weeks to minimize bruising.

Dr Yeo is passionate about facial rejuvenation with non-surgical and surgical methods, and he delivers lectures in the Asia Pacific region on this topic. He applies proprietary SMAS modification techniques that are the key to delivering enhanced results, while keeping postoperative recovery time to a short duration. Administering effective and safe treatments are the cornerstones of our care delivery philosophy at Picasso Plastic Surgery. Picasso Plastic Surgery has an en suite operating facility that assures you maximal privacy and convenience, and keeps facility and equipment costs contained.

Face Lift | Rhytidectomy

Rhytidectomy is the most comprehensive method of rejuvenation of the midface, lower face and neck. It addresses the multiple causes of facial aging and produces effective, elegant and long-lasting results. The scars are well-concealed at the junction between the face and the ear, and between the posterior hairline and neck. 

Rhytidectomy corrects many of the aging changes that cannot be effectively achieved by non-surgical methods because of its ability to tighten the SMAS (muscle) layer, and to excise loose and redundant skin. There is often more significant improvement and long-term cost saving with rhytidectomy as compared with recurrent treatment with non-surgical therapies. It is performed as an ambulatory procedure under intravenous sedation and local anesthesia.

The following are good candidates for a face lift:

  • Individuals with any degree of midface, lower face and neck aging seeking long-term improvement
  • Individuals with significant facial bulges and grooves, including tear trough deformities, midcheek grooves, laugh lines and/or marionette lines
  • Individuals with significant loss of facial fat and skin laxity
  • Individuals who have had suboptimal results with non-surgical treatment(s)

The face lift tightens and elevates the cheek, lower face and neck, eliminates unsightly droopy bulges and effaces the facial grooves, i.e. the tear troughs, midcheek grooves, laugh lines, jowls and marionette creases. The cheeks are elevated and revolumized, recreating the gentle concave contours seen in youthful face. The contour of the lower face and neck is improved. Excess loose skin is excised to create a crisp, smooth skin contour and the scars are inconspicuous when healed. The result is elegant and harmonious improvement of the individual’s facial and neck appearance and reduction of the perceived age. Successful outcomes help to restore self-confidence and improve social functioning.

Individuals are advised to stop herbal supplements and traditional medicine and start special medications 7 days prior to surgery to minimize bruising and swelling. Hypertension, if present, should be well-controlled, and smoking needs to be stopped for at least 2 to 4 weeks prior to surgery to minimize the occurrence of complications.

The face lift is performed through well-sited incisions in the hairline, between the ear and the face, and between the neck and posterior hairline. This gives maximal visibility of the SMAS (muscle) layer and permits application of proprietary SMAS tightening techniques that deliver enhanced results whilst minimizing recovery time. SMAS tightening eliminates the facial bulges and grooves and restores a smooth contour in the midface and lower face. In the lower-face, SMAS tightening effaces the marionette lines and improves the lower jaw definition. SMAS tightening is the critical step in facial rejuvenation and delivers effective, long-lasting and natural-looking results. Face lift surgery is a fine art and strikes a balance between effective facial elevation and tightening whilst avoidance of an overly-tightened and unnatural appearance.

Structural fat grafting is often performed to reverse the age-related fat loss in the superficial and deep fat compartments. Finally, the excess skin is excised and wounds are meticulously closed for optimal postoperative outcome. In men with sideburns, special modifications are performed to prevent advancement of the sideburn hair onto the ear tragus.

In some cases, an incision may be placed at the back of the chin for further tightening of the neck muscles, excision of the double chin (fat) and recreation of an aesthetic neck angle.

Stitches are removed on the 5th postoperative day. Mild swelling and bruising is expected, which will mostly resolve by the 14th postoperative day. Most individuals are able to return to work after 1 week.

Neck swelling is improved by lying supine on a neck pillow only (without a head pillow) when sleeping at night for the first 2 to 3 days. Gentle face washing is possible from the second postoperative day onwards. Postoperative swelling is reduced by remaining upright during the daytime and by elevating the head of the bed when asleep at night. Strenuous activity should be avoided for the first two weeks to minimize bruising.

Facial rejuvenation with non-surgical and surgical methods is one of Dr Yeo’s key clinical interests, and he delivers lectures in the Asia Pacific region on these topics. He applies proprietary SMAS modification techniques that are the key to delivering enhanced results, while keeping postoperative recovery time to a short duration. Administering effective and safe treatments are the cornerstones of our care delivery philosophy at Picasso Plastic Surgery. Picasso Plastic Surgery has an en suite operating facility that assures you maximal privacy and convenience, and keeps facility and equipment costs contained.