Options for Treating Smile Lines.

You may have deep smile lines around the eyes or around the mouth, and the treatment for each is quite different.

Smile lines around the eyes, which are also called crow's feet, are very effectively treated with Botox injections. The Botox relaxes the orbicularis muscle which causes the skin to crease into the smile lines. When the muscle is relaxed, the surface of the skin becomes smoother. The results of Botox treatment of the crow's feet typically last for four months.

Laugh lines or smile lines around the mouth are most effectively treated with injectable fillers. For superficial lines, we use Restylane, and for deep lines we use Juvederm Ultra Plus. Both of these products are hyaluronic acid gels but they have different properties. Restylane is more appropriate for superficial lines, and typically lasts 5 or 6 months. Juvederm is more extensively cross-linked and is more effective for deep lines and folds, and Juvederm has been shown to last for one year.

Smile lines are medically referred to as nasolabial folds. The development of these lines represents several of the aging processes acting at once. Depending on the severity and contribution of each problem, different treatments may be best.

The most common treatment involves dermal fillers. These products, such as Restylane, Juvederm, and Radiesse, are used to give extra volume to the area just next to the fold. This causes a smoother transition from the cheek into the upper lip, creating a shallower appearing fold.

One other option besides commercial fillers is fat injection or liposculpting, which requires harvest from another site on the body, such as the stomach or thighs.

I always tell my patients that the fillers should be used to soften the folds, but not get rid of them. Unless the folds are relatively shallow, filling them up completely tends not to look natural. This is because the area of the upper lip you are filling (just inside the fold) is usually flat in younger patients. This problem with dermal fillers is seen even more so when folds are deep.

Although fillers can be used to diminish them, patients usually require extra material (2 or 3 syringes rather than the usual 1), and the central face begins to look swollen and unnatural at the expense of getting rid of the folds.

However, I have noticed that my filler patients often require less material to produce the same result 6-9 months later. This means that I can usually get more correction from the same volume of filling over 2-3 treatments. This approach tends to look more natural than doing it at one shot and is what I usually recommend to patients with deeper folds.

Finally, patients may have deep folds because of a combination of mid-facial aging, skin laxity, and cheek fat loss. Depending on the scope and severity of each problem, other treatments may be required to have a balanced and natural appearing result. These treatments often do not get rid of folds, but soften them enough for the fillers to work better with less volume. Treatments include:

• Skin resurfacing (laser or chemical peels)
• Submalar cheek implants
• Facelifts
• Endoscopic midface lifts

Discussion of these options is beyond the scope of this response and should be discussed at a formal consultation with your surgeon.

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The deep smile lines appear for several reasons.

• One, as we age and lose collagen and soft tissue, the face gets flatter and sags with gravity. This sagging and loss of volume emphasizes the lines that run from the nose to the corners of the mouth.
• The fat pads that give the "apple" of the cheek soften and sag.
• Fine lines also appear around the mouth and lips from years of repetitive movements.

To reduce these lines I use injectable fillers, like Restylane, Perlane, Juvederm, and Radiesse, to replace volume and fill in the lines and grooves.

I also use fillers in the mid cheek and along the cheekbones to re-volumize the cheeks. Filling the cheek will raise the skin, reduce the downward sagging, and decrease the deep lines between the nose and the mouth. In some people with very early signs of jowls, filling the cheeks can reduce this as well.

There are some lasers that will also tighten the skin. The amount of downtime and the number of treatments required varies depending on the laser used. These lasers can tighten the skin and treat fine wrinkles and lead to a subtle overall skin tightening.

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Although fillers are the most common solution to deep smile lines, many times we can boost the volume of the UPPER face by restoring contour, cheekbone definition and upper cheeks, which in turn diminishes the look of deep smile lines without even directly injecting into them!!

Patients are usually surprised and pleased with this approach.

You see, as we age, the cheek fat pad descends due to gravity, and when we replace the 'fallen' area with new volume, you can see a more youthful and rejuvenated appearance. We can accomplish this with the new 'volumizers," such as Radiesse, Sculptra and Artefill for long-lasting correction. 

In some patients, full face laser resurfacing can diminish some of the depth of the smile lines, but usually not sufficient to alleviate the need for fillers completely. 

Then, of course, there is always surgery......some of the newer more moderate mini surgeries or even a standard mid face lift are always available for those who want a more lengthy solution.

Fillers are usually the easiest way to treat smile lines.  Sometimes surgical excisions can be performed in very specific cases to remove these lines.  Of course, face lift surgery may improve some "smile lines" as well.

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There are many different ways to treat deep smile lines.

• Injectable filler materials (e.g., Restylane, Juvederm) may be used to temporarily fill the smile lines
• BOTOX Cosmetic may be used to prevent a wrinkle caused by repetitive muscle movement from getting deeper
• Lasers (e.g., carbon dioxide, erbium:YAG) and chemical peels may be used to resurface the skin

An evaluation by a physician is necessary to determine which treatments are best for a given patient.