Face
Why Do I Look Angry All The Time? (Part 2)
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.
In this episode.
Episode summary
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 this episode answers
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.
🔗 Related information
Explore Botox information, dermal fillers, facial fat grafting, or request a consultation with Dr. Smith in New York City.
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.
Original show notes
Board certified NYC plastic surgeon Dr. Darren Smith draws on his expertise in facial anatomy to describe how plastic surgery can get your friends to stop asking you what's wrong. In Part 1 we focused on the upper facial third. Here in Part 2 we tackle the lower facial third.
Read the conversation.
[00:08] I'm Board Certified New York City Plastic Surgeon Dr. Darren Smith, and this is Plastic Surgery Before and After. Your source for the real deal about plastic surgery procedures, news about trends in aesthetic medicine, and candid sessions with industry insiders. We hope you enjoy today's episode. Why do I look angry all the time? This is part two of a two-part episode. Last time in part one we looked at features of the upper facial third that could cause a angry or tired or aged appearance and in this episode we're going to focus on features of the lower facial third. that can contribute to an angry or tired or aged appearance. And if you're wondering what happened to that middle facial third, we're just not focusing on that here because this tends to be an area that is very critical in the appearance of aging. But at least in my experience, in terms of giving off the impression that one is angry or tired, these are impressions that are most powerfully generated by features of the upper and lower facial thirds.
[01:15] And there are two critical structures or landmarks when we're talking about the lower facial third that can really contribute to this angry look in a very powerful way. And the first one is what we call the oral commissure. And there's one on the left side of your mouth and on the right side of your mouth. And these are essentially the left and right corners of the mouth. And if you think about this intuitively, it makes sense that the vertical position of the commissures, the oral commissures on the face, have a lot to do with conveying your emotion. So when we talk about a smile, we raise the corners of our mouth. And when we talk about a frown to connote an angry appearance, we lower the corners of our mouth. So if your oral commissures adopt a relative downward vertical position at rest. This is going to make you look angry or tired. The other feature that plays a major role in conveying emotion in the lower facial third is the presence of marionette lines. Marionette lines are the lines that can develop from your oral commissures, from the corners, of your mouth that go down to the jawline. And they got this kind of unflattering nickname after old-time marionettes where they had the lower jaw that would open and close. And you could see the seam in the puppet between the lower jaw and the cheek. So those are the marionette lines. And heavy or pronounced marionette lines can definitely contribute to the appearance of angriness or tiredness. So let's look at each of these features one at a time. So first in terms of the position of the corners of the mouth or the oral commissures. So how can we lift the corners of the mouth? Let's take a quick deep dive into the anatomy of this region so that we can kind of answer this question.
[03:31] from a functional perspective. So if we think of the lips and we look at the corners of the lips and we mention that those are called the oral commissures and that's what they're called at the level of the skin. Beneath the oral commissures at the level of the skin, there's another structure called the modiolus. And the modiolus is where a bunch of different muscles come together in the face. And there are essentially two kinds of muscles that come together here. There are muscles that come from above, and these are called lip elevators, and there are muscles that come from below. And these are called lip depressors. So you can imagine that when the, lip elevators contract when those fire, they make the modiolus and therefore the oral commissure go up. When the lip depressors contract or those fire, they make the oral commissure go down. So it's the lip elevators that make you smile and the lip depressors that make you frown.
[04:35] And the position of the corners of the mouth, the position of the commissure at rest, when you're not actively trying to smile or frown, is determined by a balance of the strength of the lip elevators and the lip depressors. So if you can imagine over time as we age, we lose skin and soft tissue elasticity. So our skin and soft tissue becomes lax and everything tends to droop and fall over time with gravity. So the resting position of our oral commisters, of the corners of our lips, Migrates down with time so those lip depressors win out over the lip elevators at rest So then the question of how can we raise? The corners of the mouth at rest to prevent them from being low from giving us this frowning appearance at rest really becomes a question of how can we rebalance the relative strength of the lip elevators and the lip depressors and There are two main ways to do this and it really depends on the severity of the problem For relatively minor issues with the resting position of the oral commissures, if they're just a little bit too low at rest and there's not a severe resting frown present, we can weaken the lip depressors. Specifically, we're aiming at a muscle called the depressor angularis or DAO. And if we weaken this muscle selectively with Botox, we can return the mechanical advantage to the lip elevators so that the oral commissure, the corner of the mouth, rises and it is no longer in a frowning or lowered position at rest.
[06:25] Sometimes we can also help in these mild cases by carefully placing a little filler or by doing some fat grafting to provide a bit of a platform for the oral commissure so that it doesn't drift as far down at rest. So between Botox and filler or fat grafting, we can often make a nice difference for mild cases of a depressed oral commissure that's giving us a tired or angry look. For more severe cases we can actually address this problem surgically and we can reset the position of the oral commissure at rest by performing some soft tissue manipulation with carefully hidden incisions. Now this is a relatively extreme procedure that we don't undertake lightly and this is reserved for really the very most severe cases of a resting frown and it's something that should not be undertaken without a thorough conversation with your surgeon to understand the risks and benefits and to make sure this is a procedure that your surgeon has a lot of experience with and has good results with.
[07:40] In terms of the other structure that can be contributing to the appearance of tiredness or angriness at rest, we'll address the marionette lines. As a reminder, the marionette lines are the lines that span from the corners of the mouth to the jawline. Again, we treat these based on their severity or their depth, and we divide this severity into three categories. First, we can talk about superficial marionette lines, and then there are intermediate marionette lines, and then there are these really deep, severe marionette lines. So superficial marionette lines can be addressed pretty effectively with things like a chemical peel, and I really like a nice TCA peel for this purpose, or with laser resurfacing. The gold standard here is probably a carbon dioxide laser.
[08:33] or even with radio frequency microneedling, such as with the Morpheus 8 device. And this is something we've addressed in depth in an earlier episode. So this is going to provide kind of any of these three things will provide some superficial resurfacing, which will decrease the prominence of superficial marionette lines. When we start talking about lines that are a little bit deeper, these intermediate marionette lines, we need to actually alter their topography. We need to change how deep they are and this is something that we can achieve with fillers and I like the hyaluronic acid based fillers for these procedures. or for people that want a more permanent approach we can also treat this with fat grafting and we've talked about fat grafting at length in earlier episodes but just as a brief review to perform fat grafting we perform a little bit of liposuction under local anesthesia and we harvest fat from one part of the body we then process those fat cells to get rid of any extra lipids or blood products or other things that can damage take of the fat graft and then gently inject the fat graft as a biological filler into the area that we're trying to treat. And in this case, it will work very nicely for marionette lines. And it can also improve the overlying skin quality in the region due to the presence of the adipose drive stem cells.
[09:58] in the fat graft. So for these intermediate marionette lines, fillers or fat grafting are both very reasonable. approaches. When we start to talk about truly deep marionette lines, when we start seeing kind of soft tissue folding over itself and causing real ridges in this region that are often associated with jowling or the descent of soft tissue along the jawline itself, then we're talking about truly invasive surgery that would be most beneficial in addressing these kind of deep marionette lines and these are things like face lifts or extended neck lifts that we could use in this kind of case. So between this episode and the previous episode we've tried to cover the various anatomical features that could be making you look angry even when you're not and discussing the different procedures that we can perform to correct these issues. And as always, we encourage you to rate and review the podcast and to reach out to us at darrensmithmd.com with any other questions or comments that you might have. Thanks for listening and don't forget to subscribe, share the show, and head over to darrensmithmd.com for more real world plastic surgery talk.
Sources and context.
Original Captivate episode. Original release date: 2020-08-14. The recording is the source for the transcript and episode discussion. Later context in the written summary is identified separately.
Behind the conversation.
Darren M. Smith, MD, FACS