Downturned mouth corners and pronounced marionette lines can make a resting expression appear tired or unhappy, even when that does not reflect how someone feels. In part two of this discussion, Darren M. Smith, MD, a plastic surgeon in New York City, focuses on the lower face and explains why treatment depends on the feature involved.
The episode distinguishes the position of the mouth corners from lines extending toward the jaw. Muscle activity, tissue support, surface changes and deeper folding can call for different approaches.
Key takeaways
🔬 Mouth-corner position involves a balance of muscles.
Dr. Smith describes muscles that raise and lower the corners, and how changes in soft-tissue support can affect their resting position.
🔎 Mild concerns may prompt an injectable discussion.
The recording describes Botox directed at the depressor anguli oris (DAO), and selected uses of filler or fat grafting to support the area.
🔎 Surgery is a separate decision.
Dr. Smith reserves discussion of surgical mouth-corner repositioning for more severe cases and emphasizes a detailed conversation about risks and experience.
🔎 Marionette lines vary in depth.
The episode compares resurfacing for superficial lines with filler or fat grafting for some deeper concerns.
🔎 Substantial folds and jowling involve more than a surface line.
A facelift or extended neck lift may enter the discussion when tissue descent is the main concern.
💬 Questions answered
What are marionette lines?
They are lines or folds that extend from the corners of the mouth toward the jawline. Dr. Smith distinguishes them from the position of the mouth corners themselves.
Does everyone with downturned mouth corners need surgery?
No. The recording discusses less invasive options for selected mild concerns and a different risk-benefit discussion for surgical repositioning. The appropriate choice depends on anatomy, the degree of change sought and the limitations of each option.
ℹ️ Current context for this 2020 recording
The DAO Botox use described here is outside the approved indications in the current BOTOX Cosmetic prescribing information. An off-label treatment still requires individualized assessment and informed discussion of risks.
The episode also mentions Morpheus8. The FDA's October 2025 safety communication on certain RF microneedling uses reports serious complications including burns, scarring, fat loss and nerve damage. This update is separate from the original recording. None of the treatments discussed guarantees a particular expression or outcome.
🎧 Episode chapters
01:15 — Mouth corners and marionette lines
03:31 — Muscles and resting mouth position
05:43 — Injectable options for selected mild concerns
06:55 — Surgical mouth-corner repositioning
07:40 — Matching treatment to marionette-line depth
10:07 — Deep folds, jowling and lift surgery
🔗 Related information
Explore Botox information, dermal fillers, facial fat grafting, or request a consultation with Dr. Smith in New York City.
About the host — current biography
Darren M. Smith, MD, FACS is a board-certified plastic surgeon in Manhattan specializing in mommy makeover surgery, breast surgery, and body contouring. He was named to Newsweek’s America’s Best Plastic Surgeons 2026 and has co-authored authoritative peer-reviewed publications on combined breast surgery and abdominoplasty and the surgical care of postpartum patients.
Originally released August 14, 2020. Show notes updated September 30, 2026. This is general education. Current recommendations, suitability, risks and expected results require an individual assessment.
Full transcript and related resources
