Christopher Wenzel, MD

You have an excellent question and RHA fillers are indeed one of the few fillers indicated for dynamic lines. They can certainly help even when the lines are not visible at rest and by reducing the depth of the fold they may even help prevent deeper lines to some degree over time. For the nasolabial folds, we have to be careful not to add too much volume if you don't have depression in these areas at rest, as this can make the face in this area look "puffy" or unnatural.

If you were to choose a facelift I think a minilift or short incision facelift would be a good choice if you are looking to improve the jowl area. If you chose to extend the incision behind the ear (it is more hidden than the minilift incision in front of the ear anyway) you would be able to see more results in the anterior neck area as well. In the view from the right you can see some vertical wrinkles in the middle of the neck and these may not be treated very well without extending the incision behind the ear as well. In a few years you may end up disappointed and wish you would have gone with a little larger procedure. Both of these could be done in the office setting under local anesthesia depending on the surgeon.

The Marionette lines along the corners of the mouth are problematic in that they attract moisture from the corners of the mouth and the deep folds retain that moisture making a perfect environment for yeast. Treatments include fillers injected into the subdermal and superficial subcutaneous plane to fill them in. Given the depth of the folds in your case, facelift would help to treat the jowl area and help to retract some of the excess skin in that area as well. The best treatment would be a combination of the two.

Options to consider would be Intense Pulsed Light therapy which is relatively inexpensive and can help with small uneven blood vessels and pigmentation changes. Radiofrequency microneedling treatments would help improve skin fullness and decrease fine wrinkling by increasing collagen production, etc. Injections of filler material like Sculptra may help but it is a large area and would be more painful and possible uneven depending on the injection pattern.

It appears that the filler in your lips is very adequate in the upper lip but proportionately I would add more filler to the lower lip to achieve more balance. I would be very careful when placing filler or fat grafting to the lower lids as this can result in excessive swelling and puffiness. I would first be sure that the lower lid changes are not resulting from allergies or underlying medical issues. I think you should consider some additional filler in the cheekbone areas to accent this part of your face but I would be fairly conservative adding volume here.