Deep nasolabial folds, marionette lines and malar bags - Facelift? Filler? Threads? What is the right choice. (Photos)

Question

From my teenage years I had developed deep nosolabial fold. Right now I'm 33 and I also developed marionette lines and malar bags. I'm looking for a solution to lift my skin like on the last photo. I tried filler in nl folds many years ago and it wasn't effective. Now I'm hearing that filler in cheek region may help lift the folds but I'm not sure will it be enough for my problem.

Pasha Mostofi, MD, DMD · Answer

Hi there. First off, let me say you look wonderful and I personally don't think you need any kind of intervention at your age. For the sake of answering your question and providing you with some information, this is what I have for you:
What you’re noticing is very common in your early 30s, and your instinct from that last photo is actually the key: when you gently lift your cheek upward, everything improves. That tells us the issue is less about the lines themselves and more about early skin laxity and mild descent of the midface. Since you’ve already tried filler in the nasolabial folds without success, I would not recommend chasing this with more filler in the folds or even aggressively in the cheeks. In many cases like yours, filler can add heaviness or make areas like malar bags (the puffiness under the eyes/upper cheek) look worse rather than better. A more appropriate approach would be to focus on lifting and tightening rather than filling. 
Options include:
- Energy-based treatments (like RF microneedling or ultrasound-based devices) to improve skin firmness and slow progression. These won’t give a dramatic lift, but they can subtly improve contour and quality. This might be the best option for someone your age if you really seek some type of treatment modality. 
- Thread lifting can provide a small, temporary lift and may mimic what you’re doing with your hand, but it’s important to understand results are modest and not long-lasting. I personally do not recommend this treatment.
- If you’re looking for a more noticeable and natural repositioning (closer to what you see in your lifted photo), then a surgical mini-lift or midface lift is the only option that truly repositions tissue rather than just masking the problem. However, I would wait on this for a number of years if I was you. 
Regarding malar bags, these are particularly tricky. They are not well treated with filler and can actually worsen with it. Mild cases may improve with skin tightening treatments, but more defined ones are often best addressed surgically. So in summary, your concern is more about early sagging than volume loss, and in that situation, treatments that lift or tighten are more logical than adding volume. A thoughtful, conservative plan, rather than more filler, will give you a more natural and balanced result. Hope this helps!

Gary M. Horndeski, MD · Answer

Threads do not last and fillers add weight and will not solve your problem. You are too young for a facelift. One thing to consider would be an eccentric lip lift, not a bullhorn lip lift. This does 4 things: shortens the distance between your nose and upper lip, increases the mucosa of the upper lip, increases the incisor show and pulls up the corners. This will help with the nasolabial folds and marionette deformities but will not change the malar contour. This takes 1 hour to perform under local anesthesia and costs $4,000.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Deep nasolabial folds, marionette lines and malar bags - Facelift? Filler? Threads? What is the right choice. (Photos)

Answers (2)

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