Filler for the smile lines: now the lines come back again. (Photo)

Thank you for your question. You describe having fillers done for your smile lines two weeks prior, and had initial improvement, but now the smile lines came back. In addition, you had filler placed in your cheeks to add more tension to help improve the smile lines, and are frustrated you spent money, but the smile lines have come back. You’re trying to have some understanding of what is happening.
I can share with you my approach to this area, and the consultation process I have with my patients who have similar concerns. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. Injectable fillers are very big part of my practice for every area you can think of for facial volume, whether it’s for cheek volume, nasolabial folds, chin, lips, and the under eye area, so this is something we do a lot in our practice. It’s very important for you to have some guidance with your doctor on the expectation of the degree of improvement.
When I talk to patients about this particular area that is commonly a high concern, people feel this area makes them look much older. This is something I address particularly on people who have facial aging changes in contrast to people who are relatively young. This area is frequently discussed in our field. The anatomy is that particular line is an area where several facial muscles are attached. Further, at the deeper level, there are important connections and blood vessels, so it’s an area that doesn't just pop away.
I would also ask you to think about what this area looked like before the procedure, which is important to review with your doctor. Oftentimes, people want to see something disappear completely, but when you review the photos, you might see that there was some improvement.
This area draws a wide range of opinions about the best way to treat it. A lot of my colleagues don’t treat this area because it’s a frustrating area to manage. When I look at this from a facial aging perspective, I look at the global facial aging process where you did address some of that with cheek volume, so you are on the right track.
When I look at someone with this type of concern, I often employ a technique called Structural Volumizing. I place volume at the bone level of the cheek area to restore harmony, and makes the nasolabial fold look better. It is pretty common for me to combine the placement of filler in the cheek with some filler at the nasolabial fold level, which depends on what I perceive as a relative hollow in bone volume. Without getting into the details of the particular anatomic structures, I would say, as you go higher on the nasolabial fold, there is a potential space more amenable to volume correction. I think a lot of my colleagues get frustrated, and their patients get frustrated because the filler is placed just under the skin where movement of the facial muscles moves and shifts the material. When it’s placed at the skin level or intradermally, it kind of looks like a narrow band.
That said, I think the best candidates for this type of filler are people with either a genetic volume deficit, or a significant amount of age-related volume loss. I think it’s important you review your photos with your doctor. Look at the big picture and at your facial anatomy. I’m confident that with the cheek volume improved, you may see that the contrast of the cheek to the nasolabial fold, and the harmony of the facial balance have probably improved. I think it’s less realistic to expect those lines to be completely gone. You may initially have had a better correction because there was volume with an element of swelling, and in my practice I routinely see my patients two weeks after an injectable filler to see how they look, and learn about their particular response to that filler. We get to review what they look like before, and after to see how successful the result was. It’s important to have that kind of dialogue and relationship with the doctor you have chosen to do your fillers. I think it’s important for the doctor to learn what is right and optimal for you. If it turns out this is not the best way to allocate resources, it may be better to look at the whole face, and see what other things you can do to help you look your best.  I hope that was helpful, I wish you the best of luck, and thank you for your question.

A combination approach will give the most improvement. I recommend fillers for the lines themselves but also lifting around the mouth and cheeks to build underlying anatomical support. In our practice we combine sculptra with other fillers "layered" on top and lasers, rf treatments, J Plasma and peels to get the most conservative natural look. Please see a facial sculpting expert. Best, Dr. Emer

 I would follow up with your injecting physician regarding your treatment and results. This will give you an opportunity to determine how to best correct this issue.