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Chapter 6. DAO

Marionette Lines (DAO) Anatomy

Marionette lines run down from either side of the mouth

(Adapted with permission from Ipsen.)

Marionette lines are caused by contraction of the depressor anguli oris or DAO, a triangular muscle that inserts in the fibers of the mouth corners, interweaving with the mouth elevators in concert with the action of the platysma muscle. The DAO is superficial in the lower lip/chin area.

Deep marionette lines give the impression of being unhappy. The approximate injection treatment zone is indicated by the blue ovals in the illustration.

Marionette Lines Treatment Approach

Treatment of the DAO plays an important role in lower face rejuvenation.

The aim of treatment is to reduce the muscular strength of the DAO and the fibers of the platysma and thereby induce a lift of the corners of the mouth while the patient is at rest.

(Adapted with permission from de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. Berlin, Springer-Verlag; 2007.)
Treatment targets the DAO and the platysma.

Marionette lines are typically treated via 1 injection point into the posterior aspect of each DAO. Injections should be at least 1 cm lateral to the mouth corner to avoid adverse outcomes. A second injection site may be added laterally to target the platysma. The blue circles in the illustration indicate specific, common injection points.

Marionette Lines Case

Dose ranges in marionette line treatment are 6 to 20 DYSPORT Units in total or 3 to 8 BOTOX Units in total. The goal of treatment is to reduce the action of the DAO and lift the corners of the mouth. This patient seen in the photo received 20 DYSPORT Units in total, 10 units per side, at injection points indicated by blue circles.

Marionette Lines Injection Demonstration

The total dose was 20 DYSPORT Units.

Marionette Lines Results

Neurotoxin treatment effectively softens marionette lines.

The patient is shown in the photo, in full expression, 28 days after DYSPORT treatment (20 Units, 10 per side) to her DAO.

The same patient shown in video - from rest to full expression - 28 days after DYSPORT treatment.

Marionette Lines Treatment Summary

Neurotoxin treatment effectively softens marionette lines, although most dramatic and rejuvenating results in lower face treatment are best seen in combination therapy with injectable fillers.

Lower face treatment requires careful assessment to avoid adverse events, such as asymmetry, decreased support of lower face, and unintended placement of neurotoxin in the depressor labii inferioris. Titrating the dose, starting with a low dose and titrating up, is advised.