Wrinkles should only show where smiles have been.
This common saying is especially true for the nasolabial folds. Deepening of these creases is one of the signs of aging in the midface. Conversely, softening these lines through various interventions results in a rejuvenated appearance.
There are many techniques available for reducing the prominence of nasolabial folds. As with so many other problems in dermatology, the existence of multiple therapeutic options implies that the perfect treatment has yet to be discovered. However, while each treatment has its own limitations, with care and practice you, the dermatologic surgeon, can lessen the effects of an aged appearance due to deep nasolabial folds.
In this article, we’ll review several treatment options for prominent nasolabial folds.
Anatomy of the Nasolabial Fold
With any surgical problem an understanding of the anatomy is the basis of effective treatment.
The anatomy of the nasolabial fold has been investigated through the study of living subjects and through cadaveric dissection.1,2,3
The fold occurs at the junction of the upper lip and the cheek. The crease is accentuated by smiling because the muscles of facial expression that draw the upper lip in a superolateral direction, primarily the zygomaticus major, the zygomaticus minor, and the levator labii superioris, have dermal insertions on the upper lip. The skin of the upper lip is characterized by a very thin layer of fat between the reticular dermis and the underlying orbicularis oris muscle. In contrast, the cheek has the malar fat pad as a defining anatomic feature. Smiling draws the upper lip under the malar fat pad as the pad bulges forward.
At birth and in early childhood the nasolabial fold is absent while the face is at rest. With aging, the fold becomes visible even when the face is in repose. This change is due to multiple age-related factors including ptosis of the malar fat pad, atrophy of dermal collagen and increased skin laxity. The presence of the nasolabial fold is also dependent on some baseline tonic activity of the muscles of facial expression. This is best evidenced by the disappearance of the fold in patients with paresis of the facial nerve.
Rejuvenation techniques for the aging nasolabial fold address some of these underlying causes.
Filling Agents
A common approach taken to reduce prominent nasolabial folds is to use a filler substance. This method addresses the dermal atrophy associated with aging that contributes to the development of the nasolabial fold. When using a filler substance, consider the quality of the skin, the depth of the fold, the patient’s goals regarding degree and longevity of correction and the patient’s risk tolerance.
Collagen has been the prototypical filler. When using collagen, you can currently choose between bovine and human varieties, as well as the viscosity and degree of cross linking of the product. Human collagen is associated with a much lower occurrence of allergic reactions as compared with bovine collagen. There are many collagen products to choose from, including Zyderm, Zyplast, CosmoDerm and CosmoPlast.
To diminish nasolabial folds, collagen is placed in the mid- to upper-dermis just medial to the fold. Due to the anesthetic solution present in the product a slight overcorrection of the fold is the end point of treatment. As the anesthetic solution is absorbed the collagen remains and provides support to the skin that reduces the visibility of the fold. (See Photos 1A and 1B.) Collagen has a supple and natural feel in the nasolabial fold. However, the collagen is metabolized fairly quickly and the duration of the effect is typically 2 to 6 months.
Hyaluronic acid is another filler option to treat the nasolabial folds. Many competing products, such as Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and more, are available that vary in terms of source, processing and duration of effect.
Hyaluronic acid is a natural component of connective tissue that shares a uniform structure among species. There is no potential for allergic reaction to hyaluronic acid. However, reactions to other components of injectable hyaluronic acid gel can occur, albeit rarely.
As with collagen, the hyaluronic acid gel is injected just medial to the nasolabial fold but in the mid- to deep-dermal layer. None of the currently available hyaluronic acid gel products in the United States incorporate anesthetic solutions, so anesthesia can be obtained with topical application, regional nerve block or dermal infiltration.
Hyaluronic acid generally is smoothly incorporated into the ground substance of the dermis. (See photos 2A and 2B.) Occasionally lumpiness can occur, but usually resolves within several days with gentle massage. Hyaluronic acid can last for 6 to 12 months, sometimes longer.
Injectable calcium hydroxylapatite (Radiance) is a long-lasting filler that can be used in the treatment of nasolabial folds. Calcium hydroxylapatite is the primary mineral component of bone and teeth. The injectable filler is a suspension of 25 to 45 micron-sized calcium hydroxylapatite particles in water and glycerin.4 Placement is in the deep dermis just medial to the nasolabial fold. The calcium hydroxylapatite particles are permanently incorporated into the tissues and augment the dermis, resulting in long-lasting correction as the calcium hydroxylapatite crystals are very slowly metabolized.
As with all long-lasting fillers be careful not to overcorrect when using calcium hydroxylapatite. Adequate support is usually achieved in three to six treatment sessions at monthly intervals. The effect can last for several years.
Autologous Fat Transfer
Autologous fat transfer is another treatment option for the rejuvenation of the nasolabial folds. This technique is best suited for patients with deep, prominent folds.
Fat is harvested from a suitable donor site with low metabolic activity.5
The fluid component is separated and discarded and then the fat is injected just beneath the dermis medial to the nasolabial fold.
Typically, 2 to 4 mm of injected fat is adequate to treat the nasolabial fold. The duration of full effect is commonly 6 to 12 months. (See photos 3A and 3B.) Up to 20% of patients may attain long-lasting correction.
Rhytidectomy
Various face lifting procedures can have a positive effect on the deepening nasolabial fold. Resuspension of the superficial muscular aponeurotic system and redraping of skin in a superolateral direction can reposition the ptotic malar fat pad and thereby reduce the appearance of the nasolabial fold.6
While rhytidectomy can benefit the nasolabial fold, be sure to tell the patient that complete ablation of this anatomic feature cannot be attained through face lifting. However, in appropriately selected patients positive, durable results can be achieved. (See Photos 4A and 4B.)
Combining face lifting with fat transfer or filling agents can have synergistic effects.
Miscellaneous Surgical Procedures
A variety of surgical interventions to address the nasolabial fold have been described and promoted. While some of these show promise or are useful in a small subset of patients, none has clearly demonstrated superiority to the others in terms of efficacy, safety and durability.
These procedures include rhytidectomy with undermining of the flap medial to the nasolabial fold,7 direct excision of the nasolabial fold,8 suture resuspension of the malar fat pad,9 placement of expanded polytetrafluoroethylene (PTFE) strips,10 liposuction of the malar fat pad,11 and placement of dermal or fascial grafts beneath the nasolabial fold.12 Exercise caution and sound medical judgment if you decide to implement one of these less often employed treatments.
Restoring a Youthful Appearance
Deepening of the nasolabial folds is one of the common signs of aging in the midface. This process is multifactorial in its cause. With careful consideration and application of available techniques, you can mitigate the effects of aging in the nasolabial fold and restore a youthful appearance for your patients.
Wrinkles should only show where smiles have been.
This common saying is especially true for the nasolabial folds. Deepening of these creases is one of the signs of aging in the midface. Conversely, softening these lines through various interventions results in a rejuvenated appearance.
There are many techniques available for reducing the prominence of nasolabial folds. As with so many other problems in dermatology, the existence of multiple therapeutic options implies that the perfect treatment has yet to be discovered. However, while each treatment has its own limitations, with care and practice you, the dermatologic surgeon, can lessen the effects of an aged appearance due to deep nasolabial folds.
In this article, we’ll review several treatment options for prominent nasolabial folds.
Anatomy of the Nasolabial Fold
With any surgical problem an understanding of the anatomy is the basis of effective treatment.
The anatomy of the nasolabial fold has been investigated through the study of living subjects and through cadaveric dissection.1,2,3
The fold occurs at the junction of the upper lip and the cheek. The crease is accentuated by smiling because the muscles of facial expression that draw the upper lip in a superolateral direction, primarily the zygomaticus major, the zygomaticus minor, and the levator labii superioris, have dermal insertions on the upper lip. The skin of the upper lip is characterized by a very thin layer of fat between the reticular dermis and the underlying orbicularis oris muscle. In contrast, the cheek has the malar fat pad as a defining anatomic feature. Smiling draws the upper lip under the malar fat pad as the pad bulges forward.
At birth and in early childhood the nasolabial fold is absent while the face is at rest. With aging, the fold becomes visible even when the face is in repose. This change is due to multiple age-related factors including ptosis of the malar fat pad, atrophy of dermal collagen and increased skin laxity. The presence of the nasolabial fold is also dependent on some baseline tonic activity of the muscles of facial expression. This is best evidenced by the disappearance of the fold in patients with paresis of the facial nerve.
Rejuvenation techniques for the aging nasolabial fold address some of these underlying causes.
Filling Agents
A common approach taken to reduce prominent nasolabial folds is to use a filler substance. This method addresses the dermal atrophy associated with aging that contributes to the development of the nasolabial fold. When using a filler substance, consider the quality of the skin, the depth of the fold, the patient’s goals regarding degree and longevity of correction and the patient’s risk tolerance.
Collagen has been the prototypical filler. When using collagen, you can currently choose between bovine and human varieties, as well as the viscosity and degree of cross linking of the product. Human collagen is associated with a much lower occurrence of allergic reactions as compared with bovine collagen. There are many collagen products to choose from, including Zyderm, Zyplast, CosmoDerm and CosmoPlast.
To diminish nasolabial folds, collagen is placed in the mid- to upper-dermis just medial to the fold. Due to the anesthetic solution present in the product a slight overcorrection of the fold is the end point of treatment. As the anesthetic solution is absorbed the collagen remains and provides support to the skin that reduces the visibility of the fold. (See Photos 1A and 1B.) Collagen has a supple and natural feel in the nasolabial fold. However, the collagen is metabolized fairly quickly and the duration of the effect is typically 2 to 6 months.
Hyaluronic acid is another filler option to treat the nasolabial folds. Many competing products, such as Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and more, are available that vary in terms of source, processing and duration of effect.
Hyaluronic acid is a natural component of connective tissue that shares a uniform structure among species. There is no potential for allergic reaction to hyaluronic acid. However, reactions to other components of injectable hyaluronic acid gel can occur, albeit rarely.
As with collagen, the hyaluronic acid gel is injected just medial to the nasolabial fold but in the mid- to deep-dermal layer. None of the currently available hyaluronic acid gel products in the United States incorporate anesthetic solutions, so anesthesia can be obtained with topical application, regional nerve block or dermal infiltration.
Hyaluronic acid generally is smoothly incorporated into the ground substance of the dermis. (See photos 2A and 2B.) Occasionally lumpiness can occur, but usually resolves within several days with gentle massage. Hyaluronic acid can last for 6 to 12 months, sometimes longer.
Injectable calcium hydroxylapatite (Radiance) is a long-lasting filler that can be used in the treatment of nasolabial folds. Calcium hydroxylapatite is the primary mineral component of bone and teeth. The injectable filler is a suspension of 25 to 45 micron-sized calcium hydroxylapatite particles in water and glycerin.4 Placement is in the deep dermis just medial to the nasolabial fold. The calcium hydroxylapatite particles are permanently incorporated into the tissues and augment the dermis, resulting in long-lasting correction as the calcium hydroxylapatite crystals are very slowly metabolized.
As with all long-lasting fillers be careful not to overcorrect when using calcium hydroxylapatite. Adequate support is usually achieved in three to six treatment sessions at monthly intervals. The effect can last for several years.
Autologous Fat Transfer
Autologous fat transfer is another treatment option for the rejuvenation of the nasolabial folds. This technique is best suited for patients with deep, prominent folds.
Fat is harvested from a suitable donor site with low metabolic activity.5
The fluid component is separated and discarded and then the fat is injected just beneath the dermis medial to the nasolabial fold.
Typically, 2 to 4 mm of injected fat is adequate to treat the nasolabial fold. The duration of full effect is commonly 6 to 12 months. (See photos 3A and 3B.) Up to 20% of patients may attain long-lasting correction.
Rhytidectomy
Various face lifting procedures can have a positive effect on the deepening nasolabial fold. Resuspension of the superficial muscular aponeurotic system and redraping of skin in a superolateral direction can reposition the ptotic malar fat pad and thereby reduce the appearance of the nasolabial fold.6
While rhytidectomy can benefit the nasolabial fold, be sure to tell the patient that complete ablation of this anatomic feature cannot be attained through face lifting. However, in appropriately selected patients positive, durable results can be achieved. (See Photos 4A and 4B.)
Combining face lifting with fat transfer or filling agents can have synergistic effects.
Miscellaneous Surgical Procedures
A variety of surgical interventions to address the nasolabial fold have been described and promoted. While some of these show promise or are useful in a small subset of patients, none has clearly demonstrated superiority to the others in terms of efficacy, safety and durability.
These procedures include rhytidectomy with undermining of the flap medial to the nasolabial fold,7 direct excision of the nasolabial fold,8 suture resuspension of the malar fat pad,9 placement of expanded polytetrafluoroethylene (PTFE) strips,10 liposuction of the malar fat pad,11 and placement of dermal or fascial grafts beneath the nasolabial fold.12 Exercise caution and sound medical judgment if you decide to implement one of these less often employed treatments.
Restoring a Youthful Appearance
Deepening of the nasolabial folds is one of the common signs of aging in the midface. This process is multifactorial in its cause. With careful consideration and application of available techniques, you can mitigate the effects of aging in the nasolabial fold and restore a youthful appearance for your patients.
Wrinkles should only show where smiles have been.
This common saying is especially true for the nasolabial folds. Deepening of these creases is one of the signs of aging in the midface. Conversely, softening these lines through various interventions results in a rejuvenated appearance.
There are many techniques available for reducing the prominence of nasolabial folds. As with so many other problems in dermatology, the existence of multiple therapeutic options implies that the perfect treatment has yet to be discovered. However, while each treatment has its own limitations, with care and practice you, the dermatologic surgeon, can lessen the effects of an aged appearance due to deep nasolabial folds.
In this article, we’ll review several treatment options for prominent nasolabial folds.
Anatomy of the Nasolabial Fold
With any surgical problem an understanding of the anatomy is the basis of effective treatment.
The anatomy of the nasolabial fold has been investigated through the study of living subjects and through cadaveric dissection.1,2,3
The fold occurs at the junction of the upper lip and the cheek. The crease is accentuated by smiling because the muscles of facial expression that draw the upper lip in a superolateral direction, primarily the zygomaticus major, the zygomaticus minor, and the levator labii superioris, have dermal insertions on the upper lip. The skin of the upper lip is characterized by a very thin layer of fat between the reticular dermis and the underlying orbicularis oris muscle. In contrast, the cheek has the malar fat pad as a defining anatomic feature. Smiling draws the upper lip under the malar fat pad as the pad bulges forward.
At birth and in early childhood the nasolabial fold is absent while the face is at rest. With aging, the fold becomes visible even when the face is in repose. This change is due to multiple age-related factors including ptosis of the malar fat pad, atrophy of dermal collagen and increased skin laxity. The presence of the nasolabial fold is also dependent on some baseline tonic activity of the muscles of facial expression. This is best evidenced by the disappearance of the fold in patients with paresis of the facial nerve.
Rejuvenation techniques for the aging nasolabial fold address some of these underlying causes.
Filling Agents
A common approach taken to reduce prominent nasolabial folds is to use a filler substance. This method addresses the dermal atrophy associated with aging that contributes to the development of the nasolabial fold. When using a filler substance, consider the quality of the skin, the depth of the fold, the patient’s goals regarding degree and longevity of correction and the patient’s risk tolerance.
Collagen has been the prototypical filler. When using collagen, you can currently choose between bovine and human varieties, as well as the viscosity and degree of cross linking of the product. Human collagen is associated with a much lower occurrence of allergic reactions as compared with bovine collagen. There are many collagen products to choose from, including Zyderm, Zyplast, CosmoDerm and CosmoPlast.
To diminish nasolabial folds, collagen is placed in the mid- to upper-dermis just medial to the fold. Due to the anesthetic solution present in the product a slight overcorrection of the fold is the end point of treatment. As the anesthetic solution is absorbed the collagen remains and provides support to the skin that reduces the visibility of the fold. (See Photos 1A and 1B.) Collagen has a supple and natural feel in the nasolabial fold. However, the collagen is metabolized fairly quickly and the duration of the effect is typically 2 to 6 months.
Hyaluronic acid is another filler option to treat the nasolabial folds. Many competing products, such as Hylaform, Hylaform Plus, Restylane, Perlane, Captique, Juvéderm and more, are available that vary in terms of source, processing and duration of effect.
Hyaluronic acid is a natural component of connective tissue that shares a uniform structure among species. There is no potential for allergic reaction to hyaluronic acid. However, reactions to other components of injectable hyaluronic acid gel can occur, albeit rarely.
As with collagen, the hyaluronic acid gel is injected just medial to the nasolabial fold but in the mid- to deep-dermal layer. None of the currently available hyaluronic acid gel products in the United States incorporate anesthetic solutions, so anesthesia can be obtained with topical application, regional nerve block or dermal infiltration.
Hyaluronic acid generally is smoothly incorporated into the ground substance of the dermis. (See photos 2A and 2B.) Occasionally lumpiness can occur, but usually resolves within several days with gentle massage. Hyaluronic acid can last for 6 to 12 months, sometimes longer.
Injectable calcium hydroxylapatite (Radiance) is a long-lasting filler that can be used in the treatment of nasolabial folds. Calcium hydroxylapatite is the primary mineral component of bone and teeth. The injectable filler is a suspension of 25 to 45 micron-sized calcium hydroxylapatite particles in water and glycerin.4 Placement is in the deep dermis just medial to the nasolabial fold. The calcium hydroxylapatite particles are permanently incorporated into the tissues and augment the dermis, resulting in long-lasting correction as the calcium hydroxylapatite crystals are very slowly metabolized.
As with all long-lasting fillers be careful not to overcorrect when using calcium hydroxylapatite. Adequate support is usually achieved in three to six treatment sessions at monthly intervals. The effect can last for several years.
Autologous Fat Transfer
Autologous fat transfer is another treatment option for the rejuvenation of the nasolabial folds. This technique is best suited for patients with deep, prominent folds.
Fat is harvested from a suitable donor site with low metabolic activity.5
The fluid component is separated and discarded and then the fat is injected just beneath the dermis medial to the nasolabial fold.
Typically, 2 to 4 mm of injected fat is adequate to treat the nasolabial fold. The duration of full effect is commonly 6 to 12 months. (See photos 3A and 3B.) Up to 20% of patients may attain long-lasting correction.
Rhytidectomy
Various face lifting procedures can have a positive effect on the deepening nasolabial fold. Resuspension of the superficial muscular aponeurotic system and redraping of skin in a superolateral direction can reposition the ptotic malar fat pad and thereby reduce the appearance of the nasolabial fold.6
While rhytidectomy can benefit the nasolabial fold, be sure to tell the patient that complete ablation of this anatomic feature cannot be attained through face lifting. However, in appropriately selected patients positive, durable results can be achieved. (See Photos 4A and 4B.)
Combining face lifting with fat transfer or filling agents can have synergistic effects.
Miscellaneous Surgical Procedures
A variety of surgical interventions to address the nasolabial fold have been described and promoted. While some of these show promise or are useful in a small subset of patients, none has clearly demonstrated superiority to the others in terms of efficacy, safety and durability.
These procedures include rhytidectomy with undermining of the flap medial to the nasolabial fold,7 direct excision of the nasolabial fold,8 suture resuspension of the malar fat pad,9 placement of expanded polytetrafluoroethylene (PTFE) strips,10 liposuction of the malar fat pad,11 and placement of dermal or fascial grafts beneath the nasolabial fold.12 Exercise caution and sound medical judgment if you decide to implement one of these less often employed treatments.
Restoring a Youthful Appearance
Deepening of the nasolabial folds is one of the common signs of aging in the midface. This process is multifactorial in its cause. With careful consideration and application of available techniques, you can mitigate the effects of aging in the nasolabial fold and restore a youthful appearance for your patients.
