How can I treat deep smile lines?

The primary aging change in the cheek area consists of a combination of deflation and descent of the cheek fat pads, creating a hollowed appearance below the lower lids and deepened nasolabial folds (oblique lines which extend from each side of the nose to the area beside the corners of the mouth). Descent of the midface/cheek fat pad can also contribute to the exaggeration of marionette lines and downturning of the corner of the mouth.

This aging change is significant, but is often not fully appreciated as a feature which can age the face considerably. When I see a person who is in their sixties or older but doesn't 'look their age' (but hasn't had plastic surgery), quite often they will have cheeks which are full and prominent, a feature that the brain immediately associates with youth. Look at an infant!

Cheek area rejuvenation by mean of a mid face lift can be performed as part of a facelift procedure, but is also sometimes performed alone to specifically address deflation and descent of the cheek fat pad. The procedure is performed through two hidden incisions. One is made inside the mouth, at the apex of the space between the gums and the lower cheek. The second incision is hidden behind the hairline of the temple area. Through the intra-oral incision, the cheek fat pad is freed from the cheekbone. A suspension suture is used to grasp the cheek fat pad, and the suture is then passed below the skin to the temple-area incision. Upward traction on the suture elevates the cheek fat pad, and with it the corner of the mouth is elevated slightly. The nasolabial folds soften and in some cases can be almost completely eliminated. The suspension suture is then anchored to the deep soft tissues below the scalp, producing a permanent elevation of the midface.

A technique which does not require incisions or sutures and which I find applicable to more and more patients is structural fat grafting, which involves carefully and painstakingly grafting (by micro-injection) a patient's own fat into areas which benefit from volume restoration. This is an excellent alternative for facelift patients who have flattening of the midface without significant aging changes in the nasolabial folds or oral commissures (corners of the mouth). In selected patients, I have found this to be a powerful but less invasive means of restoring cheek volume and projection.

Structural fat grafting can also be utilized in patients undergoing a midface lift, if additional enhancement of the lateral aspect of the cheekbones is desired. The midface lift and structural fat grafting, alone or in combination, allow me to restore or create youthful cheek and lower lid contours, without the need for cheek implants. Aside from the associated risks of migration, infection, and bone resorption, I feel that cheek implants tend to produce results that are not natural-appearing, and for that reason I do not use them in any facial rejuvenation procedures.

Patients are choosing less invasive options for correction of nasolabial (smile or laugh lines) folds.  The options are numerious and include Radiesse, Juvederm, Restylane, Perlane, and Fat Grafting.  Plastic surgeons and dermatologists each have their preferences so a full discussion should be made with your practitioner.

Your discussion should focus on the risks of each particular filler, method of injection, technique of injection, quantity of injection, and postprocedural follow-up.

There are several treatment options depending on where the smile lines are:

• For smile lines around the eyes, Botox or even laser resurfacing can be a good option.

• For smile lines in other parts of the face, dermal fillers such as hyaluronic acid or even Sculptra can be used to soften the lines. Again, laser resurfacing may help if the lines are rather superficial.

For a more permanent solution for some smile lines, consider fat injection. In this procedure, fat is taken from the person's abdomen or thighs and transferred to the face. This is considered a permanent procedure.

Remember though - having some smiles lines is natural. You don't want to get rid of them completely or you would look like you have a frozen face.

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.

For patients with deep smile lines, a variety of factors will determine the proper treatment approach.  Younger patients with isolated smile lines or "nasolabial folds" most often benefit from an injectable filler.  The most popular of these fillers are the hyaluronic acid (HA) products and their varients, such as Restylane, Juvederm, Prevelle, etc.  In the nasolabial fold area, the cross-linked forms of these fillers (Perlane, Juvederm Ultra) are longer-lasting and generally preferred.

Patients who are somewhat older, or who have substantial signs of sun damage or loss of skin elasticity due to smoking or other environmental factors, or who have signs of facial atrophy, may benefit from autologous fat injections, or deeper fillers such as Sculptra or Radiesse, which are designed to augment the facial volume.  Fat transfer involves a surgical procedure to harvest and prepare the fat for injection, and because of the size of the injecting needles required, usually necessitates sedation or general anesthesia.  Sculptra (L-Polylactic Acid) and Radiesse (Calcium HydroxyApatite) are walk-in office treatments that do not require sedation or general anesthesia.  Patients with significant fine wrinkles and sun damage in addition to deep nasolabial folds and smile lines may also benefit from laser resurfacing or chemical peel of the face.

Finally, patients with significant facial laxity in addition to a component of deep smile lines, are the best candidates for facial rejuvenation surgery.  Face lift, either combined with autologous fat injections, or staged before or after fillers or resurfacing, can correct sagging neck, cheek, and jowl skin that cannot be corrected by any form of filler or resurfacing procedure in isolation.

Your plastic surgeon should be able to give you an honest opinion regarding which procedure is best for you, depending on the factors outlined above.  In some cases, a simple paint and patch is all that is required, while in other cases, a more comprehensive surgical approach is required.