Nasolabial folds: understand before you fill

A normal fold that deepens with time

The nasolabial fold is not a flaw: it marks the boundary between the cheek and the upper lip, and it appears every time you smile. What bothers people is when it stays marked at rest and makes the face look tired or sad.

Why nasolabial folds deepen

Several mechanisms add up:

• The fat compartments slide. The fat of the midface is not one continuous layer: it is divided into separate compartments. With age, they move down and their volume shifts downwards.
• Deep support decreases. A deep fat compartment, in the inner part of the cheek, loses volume. The cheek is then less supported near the fold.
• The bone changes too. Over the years, the upper jaw bone recedes and the bony opening around the nose widens. The soft tissues lose part of their support.
• The tissues descend: this is what is called ptosis.

In other words, a deep fold often reflects a loss of support in the middle third of the face, not just a problem with the fold itself.

Why I look at the cheek first

A group of experts recommended starting by restoring volume in the midface, then assessing the effect on the folds, which may soften, and treating the fold directly only when needed.

We need to be precise about the mechanism, though. You often hear that a little product in the cheekbone "lifts" the fold. A three-dimensional study in 77 people, 37 of whom were analysed by direct comparison, found no such pull. Improvement was only visible when the gel had been placed in the transition zone between the cheek and the fold.

So I look at the cheek first, not to pull on the fold, but to restore support where it is missing, often just beside the fold. Sometimes a small amount in the fold itself remains the right answer. The computer analysis of the face helps decide this on measurements rather than by eye.

What hyaluronic acid can do, and what it does not do

Well placed, hyaluronic acid restores support and softens the fold. It also has clear limits:

• It does not erase the fold, and that is not the goal: a fold that disappears completely makes a smile look unnatural.
• It does not replace a facelift when sagging is significant. That calls for a different approach.
• It does not improve skin texture: that is the role of medical peels or facial PRP, available from November.
• It does not correct an asymmetry of bony or dental origin.

Finally, adding product session after session can weigh down the lower face, as I explain in the article on perceptual drift. So the first time, I always do less.

Safety: the facial artery runs close by

The facial artery runs up alongside the nose, where it becomes the angular artery. In an anatomical study of 60 half-faces, branches of the facial artery ran close to the fold in 93% of cases. The artery crossed the fold in about a third of cases, and ran within 5 mm of it in 43%.

A misplaced injection can block a blood vessel, with serious consequences. That is why the injection depth, the needle or cannula and the quantity are chosen according to this course, injecting slowly. No technique removes this risk. Hyaluronidase and an emergency protocol are always at the practice. The signs that should make you call immediately are explained in the article on the reversibility of hyaluronic acid.

How long does it last?

The effect is immediate, and the product contains a local anaesthetic. The result is assessed around day fifteen, at the check-up, on the same photographs.

In a meta-analysis of randomised trials on nasolabial folds, all fillers combined, the improvement was clear after one month, largely maintained at six months, then gradually faded by twelve months, without returning to the starting point. The most frequent side effects were small palpable irregularities, tenderness, swelling and bruising. At the practice, we expect six to eighteen months depending on the area, the gel and the person.

How I work

We look at your face at rest and when you smile, from the front and in profile, with the computer analysis. I tell you what seems useful to me, and sometimes that it is better to do nothing. You receive written information and a quote; the treatment can take place the same day if you wish, or on another date. We treat one area at a time, then meet again around day fifteen, with the same photographs, to decide on any touch-up.