The Happy Face Treatment: An Anatomical-Based Technique for the Correction of Marionette Lines and the Oral Commissures

November 2018 | Volume 17 | Issue 11 | Original Article | 1226 | Copyright © November 2018

Frank Rosengaus-Leizgold MD,a Elizabeth Jasso-Ramírez MD,bNathania Cárdenas Sicilia MDa

aFacial Plastic Surgery, Ultimate Medica, México City, México bFacial Plastic Surgery, ENT Department, Angeles Lomas Hospital, México City, México

When viewing the most famous smiles in history (Figure 1), two constants become apparent: a smooth perioral surface and oral commissures that are turned upward (or horizontal as a minimum). Patients are often fixated on improving both the marionette lines and the downward oral commissures as these distractions are one of the most noticeable areas in the aging face to the average person. In addition, the downward turn of the oral commissures gives an impression of sadness. Unfortunately, the anatomy of this area makes non-surgical treatments less than satisfactory, and unpredictable in many cases. The senior author has developed a novel technique to treat the marionette lines and turn the corner of the mouth upward that has been named the Happy Face treatment. The key for a successful outcome is the assessment of the perioral anatomy and the understanding of the physio dynamics of the jowl to produce a Mona Lisa smile and a Happy Face. J Drugs Dermatol. 2018;17(11):1226-1228.
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The lower third of the face reflects many of the most prominent changes of aging. The loss of structural support is reflected by the corner of the mouth, which falls downward creating a depressed triangle, accentuating the appearance of the jowl and the labiomandibular fold, also known as the marionette line. All these changes in the perioral area can give an impression of sadness and aging that is unpleasant for the patient.1 In many cases their correction is insufficient or inadequate due to the presence of creases, lines, wrinkles, skin irregularities, and muscle hyperactivity. The Happy Face technique provides a better solution for these problems.ObjectiveThe diverse irregularities of the perioral area, the marionette lines and the downward corner of the mouth are the main problems. Thus, the two main objectives of the happy face treatment are: (1) Turn the corner of the mouth upward or as minimum horizontal oral commissures. (2) Homogenize the amount of volume of both sides of the labiomandibular fold in order to achieve uniformity and evenness.Anatomical BasisConventionally, in the upper half of the face, the main problem is wrinkles secondary to muscle hyperactivity, which can be treated with botulinum toxin type A.2 In the lower half of the face, there are lines and folds secondary to skin laxity and loss of volume. The proper treatment is to restore this volume with dermal fillers. However, how should one address the dynamic component of lines and wrinkles in the lower third of the face due to muscle hyperactivity without the frequent unpleasant paresis associated with neuromodulator use?There are more muscles involved in the regulation of movement of the aperture of the mouth than muscles in the upper and midface combined. There are ten muscles around the perioral area and at least seven of them have the same fixation point called the modiolus, located about 1cm lateral to the oral commissure.3The depressor anguli oris (DAO) is one muscle particularly responsible for the downward pulling of the oral commissure. The most medial border of the DAO has cutaneous insertions forming the labiomandibular ligament. The superior limit of the labiomandibular ligament is the oral commissure. The inferior limit of the labiomandicular ligament is the mandibular ligament. The labiomandibular ligament is not a true osteocutaneous ligament,4 but defines an anatomically distinct area and creates the labiomandibular fold. The ligament also impedes further medial and inferior displacement of the jowl fat compartment, creating greater volume compared to the scarce superficial fat found between the two labiomandibular folds.5,6