The Nasolabial Fold
The nasolabial fold is the groove going from the nose to the corner of the mouth. The underlying muscles of the face with contraction carve in this fold overtime. As skin loses elasticity it sags over the fold making it deeper. Fillers can be injected to fill in the fold. Surgical face lift, skin resurfacing and tightening with a laser, and muscle relaxation with Botox also help.
Before and after treatment of the nasolabial fold
Patient selection
Patients need to have realistic expectations. Several treatments will be required. Wrinkles will require Botox, fillers for deeper folds, and facelift for drooping skin. Single procedures with much quicker recovery are usually done first followed by more invasive treatments. The best filler patient has a moderate NLF with realistic expectations. If they want more improvement than possible with a filler, because of over hanging skin, they will need a face lift. Patients with aging skin and fine wrinkles may also need laser resurfacing. Treatment of the NLF addresses the four major causes. Botox will treat wrinkles from muscular contraction. It can be injected into the muscle that lowers the lip to raise the corner of the mouth in addition to filler injection into the lower NLF and drool lines. The sagging cheek will often require a face lift. There is a technique of Sulamanidze-Aptos where hooks and threads are used to hold up the cheek and combined with fillers for severe NLF’s. Lasers can be used with fillers to treat sun damaged skin as well as deeper folds.
Different fillers can be used in combination to address all the problems of the NLF. Thinner fillers treat the fine wrinkles around the NLF and thicker fillers for the deeper fold. If filler is injected too superficially, nodules will develop. Injecting too deep into the fat under the skin instead of into the skin itself will result in the appearance of no improvement.
Patient Interview
A complete medical history and physical exam should be done including history of collagen vascular diseases and allergies. Skin tests should be done if necessary. Bleeding problems and blood thinning drugs should be noted. The patient should go through a series of facial expressions like looking up, smiling, and grimacing, and all of the patient’s facial defects should be noted and photos taken. The patient should make a list of the five things they want improved in their face. The list is reviewed and a mirror used to make sure everyone understands what is desired. Treatment options are discussed. More temporary treatments are used first so the patient has a chance to decide if a more permanent fix is actually desired. Also as the patient ages one implant may look unnatural later as the face changes. The costs are reviewed and patients given literature.
Treatment
Patients need to sign informed consent. Make up is removed and areas cleaned with alcohol. Photos are taken from the front, sides, and 45 degree angles.
Collagen
Bovine (cow) collagen has a long safety record and is used commonly in the NLF. It comes in 3 forms, Zyderm I, Zyderm II, and Zyplast. They all need skin tests. Zyderm I is for shallow defects and Zyderm II and Zyplast are for deeper defects. Zyplast may be used to fill the nasolabial groove and Zyderm I to fill the left over wrinkles. Two or more sessions may be required to complete the work, 2 or more weeks apart. To maintain the result, injections are repeated every 4-12 months. Best results are from using Zyplast deeper and layering Zyderm I on top to fill the fold. More filler is used at the top of the fold where it is more depressed. Massaging after injection helps avoid nodule formation and makes the implant look smoother. The disadvantages of Zyderm is the need for skin tests, its short duration of effect, and the possibility of blood vessel occlusion with tissue ulceration.
Before and after treatment of the nasolabial fold
The nasolabial fold is the groove going from the nose to the corner of the mouth. The underlying muscles of the face with contraction carve in this fold overtime. As skin loses elasticity it sags over the fold making it deeper. Fillers can be injected to fill in the fold. Surgical face lift, skin resurfacing and tightening with a laser, and muscle relaxation with Botox also help.
Before and after treatment of the nasolabial fold
Patient selectionPatients need to have realistic expectations. Several treatments will be required. Wrinkles will require Botox, fillers for deeper folds, and facelift for drooping skin. Single procedures with much quicker recovery are usually done first followed by more invasive treatments. The best filler patient has a moderate NLF with realistic expectations. If they want more improvement than possible with a filler, because of over hanging skin, they will need a face lift. Patients with aging skin and fine wrinkles may also need laser resurfacing. Treatment of the NLF addresses the four major causes. Botox will treat wrinkles from muscular contraction. It can be injected into the muscle that lowers the lip to raise the corner of the mouth in addition to filler injection into the lower NLF and drool lines. The sagging cheek will often require a face lift. There is a technique of Sulamanidze-Aptos where hooks and threads are used to hold up the cheek and combined with fillers for severe NLF’s. Lasers can be used with fillers to treat sun damaged skin as well as deeper folds.
Different fillers can be used in combination to address all the problems of the NLF. Thinner fillers treat the fine wrinkles around the NLF and thicker fillers for the deeper fold. If filler is injected too superficially, nodules will develop. Injecting too deep into the fat under the skin instead of into the skin itself will result in the appearance of no improvement.
Patient Interview
A complete medical history and physical exam should be done including history of collagen vascular diseases and allergies. Skin tests should be done if necessary. Bleeding problems and blood thinning drugs should be noted. The patient should go through a series of facial expressions like looking up, smiling, and grimacing, and all of the patient’s facial defects should be noted and photos taken. The patient should make a list of the five things they want improved in their face. The list is reviewed and a mirror used to make sure everyone understands what is desired. Treatment options are discussed. More temporary treatments are used first so the patient has a chance to decide if a more permanent fix is actually desired. Also as the patient ages one implant may look unnatural later as the face changes. The costs are reviewed and patients given literature.
Treatment
Patients need to sign informed consent. Make up is removed and areas cleaned with alcohol. Photos are taken from the front, sides, and 45 degree angles.
Collagen
Bovine (cow) collagen has a long safety record and is used commonly in the NLF. It comes in 3 forms, Zyderm I, Zyderm II, and Zyplast. They all need skin tests. Zyderm I is for shallow defects and Zyderm II and Zyplast are for deeper defects. Zyplast may be used to fill the nasolabial groove and Zyderm I to fill the left over wrinkles. Two or more sessions may be required to complete the work, 2 or more weeks apart. To maintain the result, injections are repeated every 4-12 months. Best results are from using Zyplast deeper and layering Zyderm I on top to fill the fold. More filler is used at the top of the fold where it is more depressed. Massaging after injection helps avoid nodule formation and makes the implant look smoother. The disadvantages of Zyderm is the need for skin tests, its short duration of effect, and the possibility of blood vessel occlusion with tissue ulceration.
Before and after treatment of the nasolabial fold
Cosmoderm and Cosmoplast are human collagen fillers. They are used like Zyderm and Zyplast. No skin tests are deeded and they may last longer. It causes less swelling and bruising than any other filler. The most recent collagen released is Evolence or Dermical P-30. This porcine (pig) product can last up to a year. It is injected with a little bigger needle and therefore needs a nerve block for better anesthesia.
Hyaluronic acid
These are the most recently approved fillers. Restylane comes from bacteria and Hyalaform is from chicken combs. Juvederm is another hyaluronic acid that may last up to 6 months. Hyaluronic acids cause few side effects with rare allergic or inflammatory reactions. Granulomas rarely occur.
Calcium hydroxylapatite (Radiesse in the US) are microspheres carried in a gel. As the gel dissolves away, collagen forms around the spheres adding to the filling effect. Effects can last up to 2-5 years. It is injected through slightly larger needles and needs a nerve block for anesthesia. The defects are usually under treated and supplemental treatment done 2-4 weeks later. After injection it can be molded by massage to prevent lumpiness.
Sculptra can be injected deep into the skin. Because it stimulates collagen growth, there will be a gradual increase in filling over a few months. Nodules can occur as well as bruising, swelling, abscess formation, and allergic reactions. Treatments are spread over 2-3 sessions. The effects may last 2-4 years.
Permanent fillers include silicone and Artefill. Silicone has tiny droplets that stimulate collagen formation around them to grow the filler. Repeat injections are done every 6 months until the desired effect is achieved. Complications include implant movement and beading. Adatosil and Silikon are products being used.
Artefill is a permanent filler placed deep in the skin. Facial movement must be limited to prevent pushing the product deeper. The injection site can be taped to remind patients not to move. Complications include allergy and rarely granuloma formation.
Hyaluronic acid
These are the most recently approved fillers. Restylane comes from bacteria and Hyalaform is from chicken combs. Juvederm is another hyaluronic acid that may last up to 6 months. Hyaluronic acids cause few side effects with rare allergic or inflammatory reactions. Granulomas rarely occur.
Calcium hydroxylapatite (Radiesse in the US) are microspheres carried in a gel. As the gel dissolves away, collagen forms around the spheres adding to the filling effect. Effects can last up to 2-5 years. It is injected through slightly larger needles and needs a nerve block for anesthesia. The defects are usually under treated and supplemental treatment done 2-4 weeks later. After injection it can be molded by massage to prevent lumpiness.
Sculptra can be injected deep into the skin. Because it stimulates collagen growth, there will be a gradual increase in filling over a few months. Nodules can occur as well as bruising, swelling, abscess formation, and allergic reactions. Treatments are spread over 2-3 sessions. The effects may last 2-4 years.
Permanent fillers include silicone and Artefill. Silicone has tiny droplets that stimulate collagen formation around them to grow the filler. Repeat injections are done every 6 months until the desired effect is achieved. Complications include implant movement and beading. Adatosil and Silikon are products being used.
Artefill is a permanent filler placed deep in the skin. Facial movement must be limited to prevent pushing the product deeper. The injection site can be taped to remind patients not to move. Complications include allergy and rarely granuloma formation.
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