Where to fill: cheeks to lift nasolabial folds or just nasolabial folds? (Photo)

For the past few years, the emphasis in nonsurgical facial rejuvenation with injectable fillers and volumizing agents is "deep support volumetry" to contour the face in three dimensions. Aging of the face involves the loss of fat from various fat compartments, including the cheeks, temples, lips, and chin, along with loss of bone and cartilage--all of which lead to sagging and jowl formation. Loss of cheek fat and cheek bone recession, particularly in the mid-facial region leads secondarily to the development of nasolabial folds. Since loss of volume in the cheeks is the primary cause of the development of the smile folds, directly replenishing the volume to the cheeks can not only restore the proper projection and light reflection to the cheeks themselves, but can secondarily help to soften the smile lines themselves, often without the need for directly injecting them (something that was common practice when I first began treating wrinkles over thirty years ago with the original Zyderm and Zyplast collagen fillers). In my Upper East Side Manhattan office I would opt to use Voluma XC and Radiesse for this purpose. In my Israel satellite facility, where a far greater number of regulatory agency approved fillers and volumizers are available I would opt for Stylage XXL and Emervel Volume.Nowadays experienced, expert physician injectors do not simply chase after wrinkles by filling them. Like sculptors, they must instead attempt to balance and contour the face by restoring the lost volume to the places where that volume existed earlier in life. In fact, when it comes to the smile lines, filling them directly and erasing them can give rise to an unnatural look--to what has been referred to as the "simian look," the flat-faced central face of a monkey. Once the appropriate 3D contouring has been achieved by volumization, individual etched-in wrinkle lines, such as may occur in the nasolabial folds after years of emoting, can be smoothed, if so desired, through the use of a superficial filler (rather than a more robust volumizing filler). 

The goal of restoring midface beauty is accomplished in many different ways. As we get older we loose bone in all of our body. The same happens to facial skeleton as well. As the cheek bones get smaller they sink into the face and cannot hold up the soft tissues that used to make a beautiful apple cheek in our younger years. It is obviously exacerbated by the loss of elasticity in the soft tissues. As the tissues descend towards the lower jaw and lips they end up creating a fold called 'Nasolabial Fold' also known as 'Nasolabial Groove' or Smile lines. So this makes it very clear that the loss of cheek volume comes first and then the nasolabial fold. Hence the chicken came first or the egg mystery has been solved. Next the issue is how to treat it. I always leave it to the patient to decide. If they want nasolabial folds to be softened only then any filler will achieve that. However a better or more aesthetic approach is try restoring the structure of the face to what it used to be. To achieve that a filler should be used to rebuild the cheek bones to lift the tissues back up from the nasolabial folds to the apple cheek area where they belong. This works very well in the early aging years. With time it can be quite advanced and you need to approach the nasolabial fold directly as well. This issue has been addressed by mid face lift as well. RegardsDr. J

Thanks for the photos!  You've had some loss of volume of your cheeks and filling that in will give you a more natural look - so long as it's done by someone experienced.I do this often and find that it reduces the amount of filler needed for the nasolabial area with a more natural result.

As we age, we lose bone and fat in our face. This volume loss happens first in the outer/upper cheek area.  Our skin also thins and loses elasticity.  The fat pad next to the nose and mouth is the last to go. These aging effects commonly result in a flatter outer-upper cheek area and the appearance of jowls and nasolabial folds.  If warranted, I always recommend filler in the upper cheek before treating the nasolabial folds directly. The photos you have provided indicate that filling the upper cheek region would help restore lost volume and soften the nasolabial folds. Additionally, you would experience a natural but subtle lift.  In my opinion, this approach provides a more aesthetically pleasing response.  If needed, a small amount of filler in the nasolabial folds can be done, but only after achieving the lift in the lateral face first.  I would also recommend adding a collagen stimulating/tightening treatment to help build and tighten the collagen.  The combination of volume restoration and skin tigtening/lifting will offer the best, most natural result.
Hope this helps!
Sheila Surdu, RN - Gerrish MedEsthetics

I love to fill cheeks /mid face/temporal before lower face. Where I inject depends on patient, age and their budget. Young patients who haven't had the volume loss in cheeks and mid face, can get away with just naso labial folds. The average cost depending on which filler you use, $600-$4000, depending on the amount of syringes, and which kind of filler. We offer anwhere from $550 filler to $1000 per syringe. I offer a free consultation, then we come up with a treatment plan.

If your only concern is the appearance of your nasolabial folds, then you should just have your nasolabial folds injected. The major benefit of injecting your nasolabial folds directly is that you will require much less product then if you were to have your cheeks injected. Also, you will have less swelling and less risk of bruising. The exception to this is when there is a significant amount of cheek volume loss. In this situation, if you fill the nasolabial folds it creates an unbalanced appearance and you look like you have a muzzle.Now, if you are concerned about the appearance of your cheeks and nasolabial folds, then I would recommend addressing your cheeks first. Framing your eyes with cheeks that have a gentle youthful convexity has a much greater aesthetic impact then filling the nasolabial folds alone. Once the cheeks are corrected most patients do not see the nasolabial folds as much of an aesthetic concern. Therefore, a small percentage of patients will go on to have their nasolabial folds injected after their cheeks are corrected.

Thanks for your question.I find it amusing that you have the answer and the two doctors did not. This just reinforces the theory that one needs to have an aesthetic eye first and the ability to inject second!!I totally agree with you, you need cheek fillers first before NL folds, for the reason that you have mentioned.I do all the cosmetic injecting in my practice and this is the approach I take.All the best

Everyone is correct. You are right that filling the cheeks can lift the soft tissues a bit, but also injecting the nasolabial folds directly will help as well.  I commonly treat both areas.

I would recommend a more global approach that includes tightening and then filler to add volume in the appropriate areas to create a balanced and beautiful face.  You are absolutely correct to ask "Why not my cheeks?"  For the past 20 years I have been saying, "Youth is in the mid-face."  I think it is aesthetically accurate to address the face for balance, light and curves or arcs and this is impossible to accomplish by treating only one area of the face.  See an experienced, artistic and expert injector.  All the best, Alexis Parker MD

Filling your upper cheeks will restore needed volume to your cheeks and help give you face more of a Vshape.  Filling the nasolabial folds will soften them.  Generally filler in the cheeks has little affect on the nasolabial folds.  From you photos, I would probably recommend both areas.