How can I treat deep smile lines?

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.

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.

Injectables are a great temporary solution, lasting up to 9 months, but fat Injections are even a better solution and last longer, up to 7 years.

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.

Smile lines, or nasolabial folds, are present even in children. As we age and loose volume in the cheeks and mid-face, they become more prominent.

Restoring the apple of the cheek is one way to soften nasolabial folds. This can be done with a temporary filler such as Radiesse or a more permanent treatment with fat injections.

Another option is to treat the line or fold itself. I prefer hyaluronic acid fillers for this area, such as Juvederm, Restylane and Perlane.

Smile lines, also called Nasolabial folds, can be treated with a number of different products.

Hyaluronic acid fillers: Restylane, Juvederm, and Perlane

The most popular products (in the USA) in the Hyaluronic Acid family include Restylane, Juvederm, and  Perlane.

These fillers are injected underneath the smile lines. The goal is to correct the contour of the skin (the deep folds) and make them more shallow. Just by changing the shape of the grooves,  from a "V" shape to a "U" shape, you will have less of a shadow which will reduce the appearance of the smile lines.

Fractional resurfacing lasers

Many times, there is a crease or wrinkle at the bottom of the nasolabial fold. Although the fillers may make this wrinkle or crease look a little better, the fillers are not intended to make it go away. If the injector tries to make this wrinkle or crease disappear by injecting the filler directly underneath the crease, the material may leave a bluish discoloration (called the Tyndall effect).

A much better way to treat this crease would be to use a fractional resurfacing laser. My favorite fractional resurfacing laser is the Lux 2940 made by Palomar Medical.

Radiesse

Another option for treating the smile lines is a product called Radiesse. Radiesse does not contain Hyaluronic Acid. Instead it contains a very fine powder called calcium hydroxylapatite (CaHA). This powder stimulates the production of collagen.

As the gel carrier that holds the CaHA dissolves, it is partially replaced by your own collagen. This new collagen may last for years. That is why some injectors call Radiesse a semi-permanent filler. The first treatment with Radiesse may last for about 3-6 months. The second treatment may last between 12 and 18 months. With each treatment, you are adding more of the CaHA which will stimulate more of your own collagen.

One advantage of Radiesse is that it comes in a slightly larger syringe (1.3 cc vs 1.0 cc for Restylane and 0.8 cc for Juvederm). One disadvantage of Radiesse is that we do not have any chemicals to dissolve it. Going to an experienced injector should minimize the risk of any problems.

You should also be aware that these same fillers can be used to enhance other areas such as the hands, hide bumps on the nose and enhance cheek bones.

Michael Sinclair, MD

Smile lines or peri-oral lines are some of the most challenging to treat on the face.  There are several options depending on the amount of result you want, the money you want to spend and downtime you are undergo. 

Lasers

Probably the most effective treatment is CO2 laser. The fractionated version (Active FX and Deep FX) are a nice combination of very good results while limiting downtime.  This procedure uses a laser to remove the damaged skin and heat to stimulate skin repair and new collagen growth. 

Procedures run around $3000-$4500, count on downtime of about 1-2 weeks but the results will be very good for a single treatment and will likely last several years. 

Dermal Fillers

Another option is a filler like Juvederm.  Depending on the amount of Juvederm is needed, you may spend anywhere from $500-$1500.  If injections are done with proper anesthesia, they are almost completely painless. 

Swelling will likely last  from a few days up to a week and results will last about 6-9 month.

It has been said that the best form of plastic surgery is smiling, so by all means keep on smiling.

Smile lines are usually the result of the loss of volume in the face that occurs along with the aging process. I believe that replacement of your facial volume is the best treatment for smile lines (naso-labial folds).

Radiesse, used to build up the submalar (cheek) area, is excellent at restoring volume to the face in a safe and dependable fashion when injected by an experienced physician. It should last for 12-18 months.

For those who desire a long term correction, fat transfer to the face is best (again, find an experienced physician with an aesthetic sense). When performed properly, fat transfer has been shown to be permanent.

Midface implants can restore volume, but appear unnatural to me. I am shy of Sculptra because of serious adverse granuloma reactions that I have seen from other physicians. Once the volume is restored, then the superficial facial fillers can be used to complete the treatment.

It has also been said that when you laugh the world laughs with you; but when you cry, you cry alone. So keep on laughing and smiling :-)

Be well.
Dr. P

Smile lines, commonly called nasolabial folds and marionette lines, vary in depth and appearance.

Dermal fillers (Collagen, Juvederm, Restylane, Radiesse, Silikon, and Artefill) offer softening and filling of these lines and wrinkles. All dermal fillers are available at Skin Speaks Spa M.D because the characteristics of these fillers vary and what may be best for one patient may not be the best choice for the next.

• Juvederm, Restylane, Radiesse, and Collagen products offer temporary correction, while Artefill and Silikon 1000 are long-term (categorized as permanent) options.

• Correction is immediate with all temporary dermal fillers, while long-term fillers may require a second or third treatment for optimal results.

• A patient who has never attempted treatment is strongly advised to use a temporary filler first to ensure a satisfactory outcome.

Smile lines may be softened and improved with ThermaFrax, a combination treatment using skin tightening (collagen stimulation) and fractional resurfacing as well. This treatment may provide overall improvement to the skin's appearance, however a dermal filler may be unavoidable for maximum result.

At Skin Speaks Spa M.D., Dr. Carney also provides chemical peels that will reduce deep lines and folds, as well as his Local Lift, if there are persistent problems with lax skin elsewhere on the face. This is often a "bonus" in a local lift, leaving less depth and prominence to the once deep smile lines.

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.

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.

Smile lines (nasolabial folds) are a natural consequence of facial movement - particularly the most pleasant animation, smiling.

The changes that occur under the skin and within the skin result from numerous factors. These factors include the condition and/or thickness of the dermis (deep layer of skin), the epidermis (superficial layer of skin), and the subcutaneous tissue (layers of fat, muscle and connective tissue under the skin). The compound effects of repetitive folding of the skin during facial animation, photodamage, and aging of the skin and subcutaneous tissues result in a deepening of the nasolabial folds, and a thinning of the dermis and epidermis.

Historically, the lines were excised surgically, placing the scar within the natural position of the folds for camouflage - sounds pretty drastic, but results were acceptable greater forty years ago. The recent concepts of treatment involve filling of the defect or depressed area with injectable fillers that can be employed in the office setting.

The choices of the fillers in order of longevity are:

1. Collagen
2. Hyaluronic acid (HA)
3. Calcium hydroxyapatite (CaHA)
4. Polymethyl-methacrylate (PMMA)
5. Fat graft

In my practice, I commonly use CaHA (Radiesse) for the treatment of deep lines. I have found that the results look natural, are safe, and tend to be long lasting in my patients. There has also been evidence showing a thickening of the dermis layer of the skin resulting from collagen production stimulated by the CaHA.

HA (common forms: Restylane and Juvederm) are also great for the treatment of nasolabial folds. Theoretically, they do not last as long, however variations exist between patients and the longevity of these products. Some of my colleagues who have used HA exclusively have observed that different injection techniques may result in longer-lasting results.

Fat is also a wonderful option for nasolabial fold filling. Generally, it is more expensive and labor-intensive, as fat has to be "grafted" (moved from one part of the body to another) using liposuction technique. Evidence also exists that fat grafting may also transfer stem cells that may result in favorable effects on the dermis and epidermis. The tricky part of fat grafting is interpersonal variablility in the success of the fat relocation.