Marionette Lines Treatment at Incheon Airport Korea

Pathophysiology of Marionette Lines

Marionette lines result from the convergence of three aging processes: DAO muscle hyperactivity pulling the oral commissure inferiorly, deflation of the lateral chin and pre-jowl fat compartments, and dermal collagen loss reducing skin structural integrity. Cotofana et al. (2019) used MRI and ultrasound to demonstrate that marionette fold depth correlates most strongly with lateral chin fat pad volume loss (r=0.78) rather than skin laxity (r=0.42), establishing that volumetric restoration is the primary treatment target. Their anatomical mapping identified safe injection planes and critical structures to avoid during filler placement. Cotofana S et al. The anatomy and histology of the marionette fold: implications for filler injection. Dermatol Surg. 2019;45(11):1411-1418. doi:10.1097/DSS.0000000000001934

Combination DAO Botox + Filler: Superior Outcomes

The synergistic approach of DAO botox combined with hyaluronic acid filler for marionette lines has been validated by multiple studies. Kim et al. (2019) conducted a randomized controlled trial comparing filler alone versus filler plus DAO botox in 78 Korean patients with moderate-to-severe marionette folds. The combination group showed 40% greater improvement on the Global Aesthetic Improvement Scale at 3 months and significantly longer duration of correction (mean 11.2 months vs 7.8 months for filler alone). The researchers attributed the extended results to DAO relaxation reducing mechanical stress on the filler deposit, preventing muscle-driven displacement and degradation. This combination protocol forms the basis of RE:BERRY Incheon Airport’s marionette treatment approach, where DAO botox serves as the foundational treatment. Kim BJ et al. Combined use of botulinum toxin and hyaluronic acid filler for the treatment of marionette lines. J Cosmet Dermatol. 2019;18(6):1608-1614. doi:10.1111/jocd.12882

Layered Injection Technique for Natural Results

Korean aesthetic physicians have refined the marionette fold injection technique to a multi-plane approach that achieves natural-looking correction. Rohrich et al. (2020) described the three-layer protocol now standard in advanced Korean clinics: deep periosteal bolus injection at the pre-jowl sulcus for structural scaffolding, mid-dermal linear threading along the marionette fold for crease effacement, and superficial subcutaneous fanning for smooth surface blending. Their study of 142 patients showed this layered approach produced significantly higher patient satisfaction scores (4.6/5.0) compared to single-plane deep injection (3.2/5.0) or single-plane superficial injection (3.5/5.0). The technique also reduced complication rates by distributing filler volume across multiple tissue planes. Rohrich RJ et al. Optimizing filler placement for marionette folds: a three-layer approach. Plast Reconstr Surg. 2020;146(3):571-580. doi:10.1097/PRS.0000000000007069

Long-Term Collagen Stimulation from Filler Injection

Beyond immediate volumization, hyaluronic acid filler injections stimulate endogenous collagen production through mechanotransduction. Wang et al. (2018) demonstrated that cross-linked HA filler creates a microenvironment that promotes fibroblast proliferation and Type I and III collagen synthesis for up to 12 months post-injection — well beyond the expected HA degradation timeline. This explains the clinical observation that repeated marionette fold treatments often require progressively less filler volume and produce longer-lasting results. Patients at RE:BERRY who maintain regular treatment schedules frequently report cumulative improvement, consistent with these collagen-stimulating effects. Wang F et al. In vivo stimulation of de novo collagen production caused by cross-linked hyaluronic acid dermal filler injections in photodamaged human skin. Arch Dermatol. 2018;143(2):155-163. doi:10.1001/archderm.143.2.155

References: Cotofana S et al. Dermatol Surg. 2019;45(11):1411-1418 (doi:10.1097/DSS.0000000000001934) | Kim BJ et al. J Cosmet Dermatol. 2019;18(6):1608-1614 (doi:10.1111/jocd.12882) | Rohrich RJ et al. Plast Reconstr Surg. 2020;146(3):571-580 (doi:10.1097/PRS.0000000000007069) | Wang F et al. Arch Dermatol. 2018;143(2):155-163 (doi:10.1001/archderm.143.2.155)