How to Treat Deep Smile Lines?

For someone with deep smile lines on their face. Is a facelift or plastic surgery their only option? Are dermal fillers a possible solution?

Doctor Answers 20

Smile Lines On Cheek Hard To Treat With Facelift

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Thank you for your question. By all means keep smiling-a happy face always looks younger regardless of the lines.

I believe that you are referring to the multiple lines that occur out on your cheeks when smiling and not to Nasal Labial Fold lines which run from the nose down to the corner of your mouth.

Nasal Labial Fold Lines can be improved by a Facelift or by adding volume to the cheek with Fat or Fillers like Restylane, Perlane, Radiesse, and Sculptra.

Smile Lines are more accurately described as lines out on the sides of the cheeks when smiling and are usually multiple. These lines tend to recur after a Facelift and trying to treat then with Dermal Fillers can create visible lumps.

Smile lines are permanent creases in the cheek skin caused by repeated muscular contractions during smiling. These skin changes are not corrected with a Facelift or Filler.

In my experience Combine Laser Skin Resurfacing is the most effective treatment, but they will recur with time.

Keep on Smiling - How to Treat Smile Lines

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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

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews

Smile lines: Causes and treatments

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Smile lines are medically referred to as nasolabial folds. The development of these lines represents several of the aging processes acting at once. Depending on the severity and contribution of each problem, different treatments may be best.

The most common treatment involves dermal fillers. These products, such as Restylane, Juvederm, and Radiesse, are used to give extra volume to the area just next to the fold. This causes a smoother transition from the cheek into the upper lip, creating a shallower appearing fold.

One other option besides commercial fillers is fat injection or liposculpting, which requires harvest from another site on the body, such as the stomach or thighs.

I always tell my patients that the fillers should be used to soften the folds, but not get rid of them. Unless the folds are relatively shallow, filling them up completely tends not to look natural. This is because the area of the upper lip you are filling (just inside the fold) is usually flat in younger patients. This problem with dermal fillers is seen even more so when folds are deep.

Although fillers can be used to diminish them, patients usually require extra material (2 or 3 syringes rather than the usual 1), and the central face begins to look swollen and unnatural at the expense of getting rid of the folds.

However, I have noticed that my filler patients often require less material to produce the same result 6-9 months later. This means that I can usually get more correction from the same volume of filling over 2-3 treatments. This approach tends to look more natural than doing it at one shot and is what I usually recommend to patients with deeper folds.

Finally, patients may have deep folds because of a combination of mid-facial aging, skin laxity, and cheek fat loss. Depending on the scope and severity of each problem, other treatments may be required to have a balanced and natural appearing result. These treatments often do not get rid of folds, but soften them enough for the fillers to work better with less volume. Treatments include:

  • Skin resurfacing (laser or chemical peels)
  • Submalar cheek implants
  • Facelifts
  • Endoscopic midface lifts

Discussion of these options is beyond the scope of this response and should be discussed at a formal consultation with your surgeon.

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Improve Deep Smile Lines With a Midface Lift / Cheek Lift

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The primary aging change in the cheek area consists of a combination of deflation and descent of the cheek fat pads, creating a hollowed appearance below the lower lids and deepened nasolabial folds (oblique lines which extend from each side of the nose to the area beside the corners of the mouth). Descent of the midface/cheek fat pad can also contribute to the exaggeration of marionette lines and downturning of the corner of the mouth.

This aging change is significant, but is often not fully appreciated as a feature which can age the face considerably. When I see a person who is in their sixties or older but doesn't 'look their age' (but hasn't had plastic surgery), quite often they will have cheeks which are full and prominent, a feature that the brain immediately associates with youth. Look at an infant!

Cheek area rejuvenation by mean of a mid face lift can be performed as part of a facelift procedure, but is also sometimes performed alone to specifically address deflation and descent of the cheek fat pad. The procedure is performed through two hidden incisions. One is made inside the mouth, at the apex of the space between the gums and the lower cheek. The second incision is hidden behind the hairline of the temple area. Through the intra-oral incision, the cheek fat pad is freed from the cheekbone. A suspension suture is used to grasp the cheek fat pad, and the suture is then passed below the skin to the temple-area incision. Upward traction on the suture elevates the cheek fat pad, and with it the corner of the mouth is elevated slightly. The nasolabial folds soften and in some cases can be almost completely eliminated. The suspension suture is then anchored to the deep soft tissues below the scalp, producing a permanent elevation of the midface.

A technique which does not require incisions or sutures and which I find applicable to more and more patients is structural fat grafting, which involves carefully and painstakingly grafting (by micro-injection) a patient's own fat into areas which benefit from volume restoration. This is an excellent alternative for facelift patients who have flattening of the midface without significant aging changes in the nasolabial folds or oral commissures (corners of the mouth). In selected patients, I have found this to be a powerful but less invasive means of restoring cheek volume and projection.

Structural fat grafting can also be utilized in patients undergoing a midface lift, if additional enhancement of the lateral aspect of the cheekbones is desired. The midface lift and structural fat grafting, alone or in combination, allow me to restore or create youthful cheek and lower lid contours, without the need for cheek implants. Aside from the associated risks of migration, infection, and bone resorption, I feel that cheek implants tend to produce results that are not natural-appearing, and for that reason I do not use them in any facial rejuvenation procedures.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.8 out of 5 stars 123 reviews

How to correct deep smile lines

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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.

Deep smile lines: Filler up please!

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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.

Behrooz Torkian, MD
Beverly Hills Facial Plastic Surgeon
4.3 out of 5 stars 17 reviews

Deep Smile Lines: One Step at a Time

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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...

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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.

Treating deep smile lines

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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.

Laurie Polis, MD
Manhattan Dermatologic Surgeon

Treatment options for deep smile lines

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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.

Patrick S. Carney, MD
Minnesota Dermatologist

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.