A Validated Grading Scale for Marionette Lines

ALASTAIR CARRUTHERS, MD, JEAN CARRUTHERS, MD,y BHUSHAN HARDAS, MD,z

MANDEEP KAUR MD, MS,z ROMAN GOERTELMEYER, PHD,z DEREK JONES, MD,y
BERTHOLD RZANY, MD, PHD,z JOEL COHEN, MD,J MARTINA KERSCHER, MD, PHD,#
TIMOTHY CORCORAN FLYNN, MD, COREY MAAS, MD,yy GERHARD SATTLER, MD,zz
ALEXANDER GEBAUER, MD,z RAINER POOTH, MD,z KATHLEEN MCCLURE, RN,z
ULLI SIMONE-KORBEL,z AND LARRY BUCHNERyy

BACKGROUND Melomental folds, or marionette lines, are one of the consequences of facial aging. The
curvilinear wrinkles formed because of facial movements and the aging process extend downward from
the oral commissures.
OBJECTIVES To develop the Marionette Lines Grading Scale for objective quantification of the severity
of melomental folds and to establish the reliability of this photonumeric scale for clinical research and
practice.
MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify
the severity of melomental folds. Nine experts rated photographs of 35 subjects, twice, with regard to
marionette lines in comparison with morphed images. Inter- and intrarater variability was assessed by
computing intraclass correlation coefficients.
RESULTS The agreement between the experts was high. Bubble plots (bivariate scatter plots) demon-
strated linearity in judgment by the experts.
CONCLUSION The 5-point photonumeric scale generated spans the severity of marionette lines for
which patients commonly seek correction. The scale is well stratified for consistent rating.
Drs. Alastair Carruthers, Jean Carruthers, Derek Jones, Berthold Rzany, Joel Cohen, Martina Kerscher,
Timothy Corcoran Flynn, Corey Maas, and Gerhard Sattler are paid consultants to Merz Pharmaceuticals.
Dr. Bhushan Hardas, Dr. Mandeep Kaur, Dr. Roman Goertelmeyer, Dr. Alexander Gebauer, Dr. Rainer Pooth,
Kathleen McClure, and Ulli Simone-Korbel are employees of Merz Pharmaceuticals. Larry Buchner is an
employee of Canfield Scientific.

quence of facial aging and form as curvilinear

Background
wrinkles extending downward from the oral com-

R epairing the effects of aging on facial skin is a

common objective of cosmetic procedures.
Melomental folds, or marionette lines, are a conse-
missures. The etiology of marionette lines is unclear,
but they are probably related to repetitive facial
expressions and the effects of gravity on increasingly

Department of Dermatology and Skin Sciences, University of British Columbia, Vancouver, British Columbia, Canada;
y
Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia,
Canada; zResearch and Development, Merz Pharmaceuticals, Greensboro, North Carolina; yDepartment of
Dermatology, University of California at Los Angeles, California; zCharitéFUniversitätsmedizin Berlin, Klinik für
Dermatologie, Division of Evidence Based Medicine (dEBM), Berlin, Germany; JAboutSkin Dermatology and
DermSurgery, Englewood, and Department of Dermatology, University of Colorado, Denver, Colorado;
#
Division of Cosmetic Sciences University of Hamburg, Germany; Department of Dermatology, University of North
Carolina at Chapel Hill, and Cary Skin Center, Cary, North Carolina; yyDivision of Facial Plastic and Reconstructive
Surgery, University of California at San Francisco, California; zzRosenparkklinik GmbH, Darmstadt, Germany;
yy
Canfield Scientific, Fairfield, NJ

& 2008 by the American Society for Dermatologic Surgery, Inc.
Published by Wiley Periodicals, Inc.

ISSN: 1076-0512
Dermatol Surg 2008;34:S167–S172
DOI: 10.1111/j.1524-4725.2008.34366.x

S167
 VA L I D AT E D G R A D I N G S C A L E F O R M A R I O N E T T E L I N E S
inelastic tissue.1 The rate of the normal aging process
is genetically determined1 but can be accelerated by
exposure to environmental toxins such as ultraviolet
light2 and cigarette smoking.3
Cosmetic treatment of well-established marionette
lines has been difficult. There seems to be a trend
away from the use of more invasive forms of
rhytidectomy, or facelift, to resolve marionette lines,
because less invasive procedures appear to be
more effective. Improvement in the appearance of
marionette lines can be achieved with injectable
fillers such as collagen, polymethylmethacrylate,
calcium hydroxylapatite, hyaluronic acid, and
autologous fat transfers.4,5 These fillers can elevate
the lip corners and melomental folds, providing a
three-dimensional treatment that results in a more
pleasing, youthful appearance.6 In the past,
botulinum toxin-A injections were not used to
minimize marionette lines, but more recently,
lower-dose botulinum toxin-A injections have
been used for the treatment of wrinkles in the mid
and lower face.7
There is no validated standard for objectively
quantifying the severity of facial wrinkles in the
clinical setting. There is a subjective rating scale that
evaluates general changes in facial skin.8 Another
photonumeric rating scale was developed to objec-
tively quantify improvement of facial wrinkles with
injectable filler by correlating observer judgment
with optical assessments of skin replicas.9 Numerous
objective, quantitative rating scales that measure
three-dimensional details of the skin surface also use
skin replicas10,11 and optical12,13 or computer-
assisted analyses.14 The significant equipment
requirements for these objective scales limit their
utility in clinical practice.
No publications were found from MEDLINE
searches using the non-Medical Subject Heading
terms melomental folds, marionette lines, rhytides or
wrinkles; perioral or oral commissures; pre-jowl
sulcus; and validated scale. There is a need for an
objective, quantitative rating scale for evaluating the
S168 D E R M AT O L O G I C S U R G E RY
severity of marionette lines and monitoring response
to treatment. Such a scale could establish guidelines
in the clinical setting and provide a standard, ob-
jective evaluation of clinical trial outcomes. In this
article, we present the Marionette Lines Grading
Scale for objective quantification of melomental
folds and the clinimetric evaluation that establishes
the validity, reliability, and responsiveness of this
photonumeric scale.
Methods
Assessment Scale
The Marionette Line Grading Scale is a 5-point
photonumeric rating scale that was developed to
objectively quantify the severity of melomental folds,
as can be seen in Figure 1A. The scale ratings are 0
for no visible fold, continuous skin line; 1 for
shallow but visible fold with slight indentation; 2 for
moderately deep folds with clear feature at normal
appearance but not when stretched; 3 for very long
and deep folds, prominent facial feature; and 4 for
extremely long and deep folds detrimental to facial
appearance. A clinician was involved in the
development of morphing methodology and the
description of the scales. Approximately 50 images
(per scale validation set) were selected from the
photographic database of 100 subjects based on
quality and equal distribution across each
representative scale. Using a standardized php-based
computer randomization program, 35 images per
target area or validation set were randomly
selected from the 50 for final inclusion in
the pool.
Validation of Assessment Scale by Experts
Nine experts in the field of aesthetic medicine rated
35 cases presented as photographs of real persons
(Figure 1B) with regard to the aspect ‘‘marionette
lines’’ in comparison with morphed images. The
morphed images showed a step-wise variation of the
defined aspect. After an initial training session and
discussion of the practice cases, each expert performed
 CARRUTHERS ET AL

Figure 1. Marionette Lines Grading Scale. Scoring of the photonumeric scale for the severity of melomental folds: (A)
morphed images, (B) untouched validation images.

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 VA L I D AT E D G R A D I N G S C A L E F O R M A R I O N E T T E L I N E S
TABLE 1. Descriptive Statistics
Day 1 2
Mean 2.63 2.54
Median 3 3
STD 1.17 1.20
Min 0 0
Max 4 4
the assessment of the 35 cases independently from
each other on 2 consecutive days. The data were
double entered into a database and checked for
correctness.
Statistical Analyses
Descriptive statistics (standard deviation, mean,
median, maximum, and minimum) were calculated
for the ratings per day (Table 1). The stability
of ratings is visualized as bivariate scatter plots
(bubble plots). A bubble plot is a way of representing
the relationship between variables on a scatter
plot. Observations on two variables are plotted in
the usual way, using circles as symbols; the radii
of the circles are made proportional to the
associated values for the third variable. The
frequency of the given scores determines the size
of the bubbles, which are ideally located along the
diagonal.
Validity and Reliability
For each time point, intraclass correlation coeffi-
cients (ICCs) were calculated according to the model
of random selection of cases and raters.15,16
The appropriate ICCs under these assumptions
will be the Shrout-Fleiss random set reliability
coefficient, which is used when the same raters
rate all cases and the raters are regarded to be a
random set of all possible raters. The Pearson
correlation coefficient was calculated as a test–retest
reliability estimator for stability of rating per
expert after an overnight interval over all cases
for each rater.
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Results
The results from the training session are not included
in the evaluation.
The ICCs (first rating 0.873, second rating 0.891)
were calculated based on 35 cases rated by nine
experts. As can be seen from the ICCs, the
agreement between the experts was high.
Furthermore, the test–retest correlation coefficients
(minimal 0.845, maximal 0.966) were high
for each judge after an overnight interval. Bubble
plots for each expert are given in Figure 2 for
comparing the bivariate frequencies of scores
between the experts. The frequency of the given
scores determines the size of the bubbles. As can
be seen from Figure 2, good intraindividual
correlation was observed.
Discussion
The results from this scale validation exercise in
aesthetic medicine for comparative judgment of real-
life photographs against morphed images associated
with 5-point scale resulted in moderately high ICCs.
The statistical model used for these estimates
assumes a random subset of raters from a population
of experts in the aesthetic medicine field. The
coefficients can therefore be regarded as conservative
estimates of interrater reliability. Test–retest
reliability coefficients were high, indicating suffi-
ciently high stability of the ratings after an overnight
interval. The expert raters used the morphed
images to judge photographs of live patients.
Morphed images, although standardized to a site-
specific area, do not translate clinically to the
multiple physical changes that occur in an aging face.
At later stages of severity, marionette lines connect
to the nasolabial folds. Photographic evaluation
and live patient evaluation are distinct, and thus
should a clinical trial use this validated scale, the
evaluations in the clinical trial should be performed
on standardized photographs, not (live) physical
examination.
 CARRUTHERS ET AL

Figure 2. Bubble plots of all experts.

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