Smile lines, laugh lines, parentheses—we’ve yet to find a euphemism that can make our nasolabial folds feel cute. They exist, in some form, on virtually every unaltered human face. Even babies have nasolabial folds, doctors assure us. “There’s supposed to be a line there—it’s actually a natural feature,” says Dr. Sinehan Bayrak, a board-certified facial plastic surgeon in Philadelphia. Yet “we seem to have adopted this idea that there shouldn’t be a concavity or even a hint of shadow there.” She speculates that our cultural reliance on filters and fillers may be skewing our perception of textbook anatomy—what is normal. The irony is, she adds, “it’s when you obliterate that concavity that things start looking very weird.”
Flanking the corners of the mouth, the nasolabial folds are more complex than the average wrinkle, their heft—that defining skin fold—giving them a sort of 3D quality that intensifies over time, due to inevitable volume shifts and bone loss. “In many people, the fat pads that sit at the nasolabial fold expand with age,” says Dr. Amelia K. Hausauer, a board-certified dermatologist in Campbell, California. Meanwhile, the fat pads just above them, in the cheeks, are deflating and descending, and the upper jaw bone is shrinking—all of which makes the nasolabial folds look heavier and their accompanying creases deeper.
These changes—and the shadows they cast—tend to draw the eye, causing a great many of us to fixate on this area. Nasolabial folds are, in fact, one of the biggest gripes driving women and men to seek filler, our experts tell us. Surprisingly, though, there really isn’t a simple—or even standard—way to correct them. Some dermatologists and plastic surgeons are actually moving away from injecting them directly, since they’re so unforgiving. “I haven’t threaded [lightly injected] a nasolabial fold with hyaluronic acid [HA] in at least five years,” notes Dr. Papri Sarkar, a board-certified dermatologist in Brookline, Massachusetts. When aiming to blur and brighten this area, even the best injector risks overtreating and creating “that bulldog, Simian, central-face heaviness” that makes nasolabial folds look worse after filler, adds Dr. Hausauer. She too is treating these folds far less frequently than she used to, she says.
The illusion of improvement
Instead of reflexively filling every fold they encounter, many injectors are honing the art of distraction. “Much of what we do with filler is illusion and redirecting attention,” Dr. Sarkar tells us. She finds that oftentimes, if she “reshapes the face” by enhancing its perimeter—defining the chin, sharpening the jawline, restoring the temples and cheeks—“it automatically makes everything in the middle of the face look so much better.”
Dr. Sarkar likens her technique to the approach one might take with a coloring book—outlining an object first to make it pop before shading it in. “Especially for people with more years behind them, balancing the perimeter of the face often means they don’t need the central areas injected—or they need just a sprinkling of filler there—which keeps them looking more like themselves over time, because we’re preserving the natural dimensionality of the face,” she explains. Strengthening the bony frame of the face with filler also “causes the skin to be stretched a little more taut,” she adds, which allows more light to hit the midface, further minimizing the look of shadows and creases.
Nasolabial fold filler, before and after
When patients ask Dr. Hausauer for nasolabial fold treatment, she too looks peripherally, typically employing a cheeks-first strategy. By rebuilding the cheeks, she explains, you can make the surrounding tissue lie more appropriately—in a more organic position—which has the effect of “displacing some of the nasolabial fold,” she says. This isn’t to say that a teaspoon of gel spread across the cheeks is going to lift your lower face and erase folds completely, however. The doctors we interviewed were all very clear on this point and are careful to manage patients’ expectations when attempting to improve nasolabial folds by augmenting other parts of the face.
“I strongly believe that fillers do not lift,” Dr. Bayrak says. “I do surgical lifting, so I know how much elbow grease and actual physical labor it takes to truly lift and redrape those tissues—there is no way a gel does that.” But filler can sometimes aid in the pursuit of a more lifted look. “It’s an optical illusion, a magic trick,” she adds. “You’re pulling the eye upward by adding a little volume to the outer cheek—it’s all light and shadows.” Dr. Bayrak does not recommend plumping the medial cheek (the fleshy part closer to the nose) in these patients, since adding volume there can exacerbate neighboring folds.
If budget allows, injectors might highlight other areas too, with the goal of downplaying nasolabial folds. Spotlighting the lips—making them just a touch fuller—can imbue a youthful vibe, notes Dr. Bayrak, distracting from lines around the mouth. According to Dr. Sarkar, smoothing the marionette lines and the crease between the bottom lip and the chin generally “makes people look happier—and then the nasolabial folds appear completely different.”
Yeah, but… what about these lines?
What if you’re still irked by your smile lines, despite the overall refresh? Or you simply don’t have the funds to fill multiple parts of the face?
“In my experience, patients typically feel a little disappointed, or like you haven’t heard them, when you don’t directly address the thing that they see when they look in the mirror,” Dr. Bayrak says. In such situations, our experts find that injecting just the topmost portion of the fold, at the outer corner of the nostril—what doctors call the nasal alar groove or the pyriform aperture—can work wonders. “That upper part of the fold is usually the deepest—and oftentimes, it’s the area that’s most bothersome,” says Dr. Hausauer. Filling that hollow is almost like “restoring the bone, pulling it forward,” she says. Dr. Sarkar agrees that it’s a powerful maneuver: “Putting just a small amount in there makes the entire line look less deep while allowing everything to move naturally and helping the nose to sit up a bit straighter too.”
@injectorbunny My favorite ❤️❤️❤️ #fyp #viral #foryourpage ♬ original sound – Erika Barry NP-C
If the full length of an etched smile line truly requires tweaking, some doctors may inject a thin, soft HA filler very superficially along the fold, “just to airbrush it,” says Dr. Hausauer. “We’re not volumizing—we don’t want to make the line look heavy or like a worm of filler—we’re just trying to get everything to blend better.”
Again, this is rarely a starting point for injectors, as zeroing in on the fold alone can create some odd effects. It’s important to remember, notes Dr. Bayrak, that “our faces are not singular, individual components that have been pasted together haphazardly—they all relate to each other in a harmonious way. So I don’t think the right way to address any part of the face is to focus solely on just that one part.”
Underscoring her point, Dr. Sakar shares that the only time she routinely injects the nasolabial folds is when treating Sculptra patients who have dramatic, full-face volume loss. “When they’re getting collagen formation in all these other areas—the temples, cheeks, below the cheekbones, the marionettes, the chin, et cetera—I can’t leave the nasolabial fold as is,” she says, because it’ll look out of proportion. Since people frequently need three sessions of Sculptra, she usually leaves the folds for a later round in order to give the rest of the face a chance to fill out first.
Danger zone: nasolabial filler gone wrong
Type “nasolabial filler” into the search bar, and Google will quickly add: “gone wrong.” Because yes, it happens—and not just when it gives you a funny sort of monkey face if overdone.
While less talked about than, say, the nose or the glabella, “the nasolabial folds are one of the top four areas for vascular occlusion,” says Dr. Hausauer. “It’s actually a really high-risk area for filler,” because the angular artery, a critical facial vessel that covers a lot of ground, courses right through the nasolabial fold. Accidentally injecting into this vessel can block blood flow to various parts of the face, potentially causing widespread tissue death and irreversible blindness.
It’s important for your injector to know precisely where this artery is at each point along the fold and to take measures to avoid it, like injecting nasolabial fold filler only at the proper depth and possibly using a cannula in certain spots. Your injector should also have HA-dissolving hyaluronidase on hand and know how to manage filler emergencies. (For the record, Sculptra is not reversible, like HA, but some doctors hypothesize that it may be less likely to cause occlusions, especially at low doses, since it’s a watery suspension as opposed to a thick gel. Like any injectable, however, it still has the potential to block vessels and do damage—and should be injected only by highly experienced providers.)
Whatever approach your injector takes, communication is everything. “It’s all about setting realistic expectations,” stresses Dr. Hausauer. “If I’m going to start by filling your cheeks, then I have to explain to you why I’m doing that and what I’m expecting it to do—or not do—for your nasolabial folds.” Your doctor should be able to offer two or three personalized treatment options based on your anatomy and budget, Dr. Bayrak adds—and they should ultimately treat this area cautiously and conservatively “so you don’t end up looking cartoonish or artificial,” she says.
