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

Figure4Figure5Finally, direct volume restoration is done over the premarked jowl sulcus supraperiosteally with a 29 G needle. Results are assessed and the contralateral side is done following the same in steps 2-4, attempting to achieve symmetry (See Figures 2-5; Also, see video at two main advantages of the Happy Face treatment are: (1) The subcision of the dermal attachments to the labiomandibular ligament allows normal muscular mobility without the formation of deeper commissures, grooves or wrinkles. (2) The subcision “creates” the space necessary for the insertion of the HA filler.Side effects of the technique are minor. The patient may have discomfort around the oral commissure for 2-3 days and bruising secondary to the cannula subscision.


The Happy Face technique is an individualized treatment that subsizes the area to be filled in order to achieve smoothness all around the perioral area, eliminate the marionette lines, and provide better lift of the corner of the mouth. This technique is novel and safe because it is done with a cannula. There are no vascular or nerve structures that can be harmed with a cannula in the subsized area.The Happy Face treatment is a good option to return youthfulness to the lower third of the face. Once the technique is understood, it is easy to perform with minimum pain. The results will be superior to simple injection techniques that do not involve any subscision.The cornerstone of a good result in dynamic motion is the thorough knowledge of the facial anatomy, including the perioral muscles, to obtain a youthful Mona Lisa smile without compromising function nor aesthetics in the perioral area. A Happy Face is a happy patient.


The authors have no financial interest to declare in relation to the content of this article.


  1. Brandt F, Cazzaniga A. Hyaluronic acid gel fillers in the management of facial aging. Clin Interven Aging. 2008;3(1) 153–159.
  2. Ascher B, Talarico S, Cassuto D, Escobar S, Hexsel D, Jae´n P, Monheit GD, Rzany B, Viel M. International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit) – part I: upper facial wrinkles. J Eur Acad Dermatol Venereol. 2010;24(11):1285-95.
  3. Hutto JR, Vattoth S. A practical review of the muscles of facial mimicry with special emphasis on the superficial musculoaponeurotic system. AJR. 2015; 204:W19–W26.
  4. Pessa JE, Garza PA, Love VM, Zadoo VP, Garza JR. The anatomy of the labiomandibular fold. Plast Reconstr Surg.1998;101(2):482-6.
  5. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesth Plast Surg. 2008;32:185–195.
  6. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219- 27; discussion 2228-31.
  7. Kablik J, Monheit Gd, Yu L, Chang G, Gershkovich J. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35 Suppl 1:302-12.


Elizabeth Jasso-Ramírez