Background:  The aging face is marked by many soft tissues changes due to falling tissues. One of those visible aging signs is that of the deepening nasolabial fold. This fold or groove is caused by the sides of the face falling against the fixed tissue of the upper lip. This creates an overhang of facial skin that rolls over toward the lip. As more tissue falls forward, the nasolabial fold gets deeper.

Treatment of the deep nasolabial fold has always been a difficult challenge, particularly at the time of a facelift procedure. No maneuver done underneath a facelift flap has been consistently successful. The pull from the repositioned skin flap during a facelift does not produce a sustained improvement. Even with release of its dermal attachments and the backward pull of the skin flap, nasolabial fold improvement is surprisingly modest.

The only non-surgical treatment, and by far the most common, for nasolabial fold reduction is the use of injectable fillers. This consistently shows that the addition of volume underneath the fold is an effective treatment. The problem with all synthetic fillers is that they are not permanent. Fat injections have been repeatedly tried for more permanent filling of the nasolabial fold but this unfortunately does not work due to fat absorption.

Case Study: This 62 year-old female was to undergo a facial rejuvenation procedure consisting of a facelift, a pretrichial or hairline browlift, bilateral upper and lower blepharoplasties and nasolabial fold reduction by augmentation. Given that she was going to have a hairline browlift, it was decided that her forehead skin would be used as the donor site for the nasolabial fold grafts.  

A browlift was performed using the intial incision that paralleled the hair follicles of her frontal hairline. After the forehead skin flap was raised down to the brow bones and the glabellar muscles partially resected, the forehead flap was elevated and the excess skin removed. This allowed the brows to be elevated but the vertical forehead length not changed. The skin removed was 14cms in length, 8mms wide in the center and 9mms in thickness. The outer layer of skin (epithelium) of the forehead graft was removed and cut into two 7cm long grafts.

Through an incision in the alar crease and another one at the bottom of the nasolabial fold, the forehead dermal-fat grafts was threaded underneath  the nasolabial folds. They were placed with the dermal side of the graft toward the undersurface of the nasolabial fold skin. The reduction in the folds was immediate. The grafts were placed  prior to the facelift being done.

The improvement in the nasolabial fold reduction due to the grafts was both palpable and persistent. At one year after surgery, the fold reduction was still visible.

Case Highlights:

1)      The deep and very visible nasolabial fold is most commonly treated by volume enhancement to soften its appearance.

2)      The most ideal material to put underneath a nasolabial fold is some form of autogenous fat, with a dermal-fat graft being preferable to injected fat.

3)      The tissue normally discarded from a pretrichial (hairline) browlift is ideal in thickness and

4)       length to make for  subdermal grafts to the nasolabial folds.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

Indianapolis, Indiana

Injectable fillers, like Botox, have revolutionized the approaches used for non-surgical facial rejuvenation. While Botox is a paralyzing agent for decreasing expressions, fillers are for adding lost volume or volume that one never had. While each has its own specific facial uses, they are often used in combination for a more significant facial effect.

Injectable fillers are a ‘southern’ facial or perioral treatment method with its major uses being lip augmentation and nasolabial fold reduction. Its use in the nasolabial folds, also known as the facial parentheses, is an actual FDA-approved indication and is so marketed therefore. Lip enhancement is widely done with fillers but is actually not a formally FDA-approved indication.

Injection into the nasolabial folds is a very valuable and effective method of temporarily softening their depth. Deepening nasolabial folds is primarily a female concern and a significant one that is associated with an aging appearance. There often exists, however, a discrepancy in expectation for this injection procedure that is in contrast to that marketed and promoted by the manufacturers.

Promotional advertisements and representative patient results from the various filler manufacturers will usually show a dramatic and near complete (if not complete) elimination of the nasolabial folds. Often the folds are shown to be completely gone. While there are some patient results in which this kind of result can actually be obtained, it does not represent the majority. With the usual use of one syringe per treatment session, which is what most patients are willing to pay, some reduction of the nasolabial folds is always obtained. While this result will satisfy many patients, there are clearly some that it does not. They will either never repeat the experience and will not be seen again…or come back to discuss their dissatisfaction with the results.

Patients are understandably misled by showing results that demonstrate the best case scenario. While doing so has obvious marketing advantages for the manufacturer and provider alike, it could be construed as misleading. One’s best results are not average results. This is where time spent on patient education and expectations is important. Better results can always be obtained by more volume or ¾ to one full syringe per side. But this may be too costly for most patients for a treatment that will not last a year. Letting the patient know that the results are based on volume injected and that the initial treatment will involve only one syringe is important. More volume at increased cost can always be done later if the results are not enough.

There are other options for nasolabial fold augmentation including autogenous and synthetic implants and even excision in the rare patient. Having a patient discussion about the range of treatment options and choosing a value-oriented approach for the long-term is a useful patient service.

Nasolabial fold injections are not a magic eraser or will not usually result in complete elimination of their presence. Until more permanent injectable fillers that have safety profiles comparable to the more temporary ones are developed, patients need to be willing to accept a temporary mild to moderate reduction in their depth.   

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

As one ages, much of the face falls downward. This is well known but, what is not obvious, is that the central part of the face falls much less than the side. The nose and the upper lip fall only slightly, being held up by the projecting structure of the  nasal and upper jaw bones. This is actually good from a functional standpoint, because if the nose and upper lip fell like the rest of the face, we would have trouble breathing and eating as we age!

Because the face falls against a more fixed or stable mouth area, a ‘fold’ develops at the junction of the two. Known as the nasolabial fold, melolabial crease, or facial parentheses, this area is a classic sign of aging that does bother a lot of people. The deepening of the nasolabial is one of the most common areas for injectable fillers. In my Indianapolis plastic surgery practice, it is injected more than that of the lips.

But there are other treatment options than injectable fillers to help soften the aging nasolabial folds. A different type of injectable filler is your own fat. Liposuctioning some fat, purifying it, and then injecting into the nasolabial folds is a natural injectable filler. But particulated fat can be unpredictable and its survival is not assured. For this reason, most plastic surgeons will overfill the injection site in anticipation of some resorption afterwards. This is a very logical approach if you are in the operating room anyway and are already having some liposuction done.

Another more effective fat approach, in my experience, is the dermal-fat or fat strip graft. By taking a strip of skin and fat from somewhere else in the body (the outer layer of skin, epithelium, is removed first), the strip graft is thread into the nasolabial folds through a small nick incision at the top and bottom of the fold. This acts like placing an implant although it is not synthetic. It is well known that dermal-fat grafts typically have better survival rates than free injected fat as the attached dermis provides  a conduit for early capillary ingrowth. Establishing an early blood supply is the key for optimizing fat graft take.

To use a strip fat graft, however, requires two things; a harvest site and usually an operating room experience. Strip fat grafts will result in a scar and that is a significant consideration. For this reason, I usually like to take it from where one already has a scar, usually on the abdominal area. Previous  tummy tucks, c-sections, or vertical abdominal incisions are ideal. The other uncommon option is from an open hairline browlift where a long strip of upper forehead skin is removed in the lifting process. No matter where it is harvested from, the strip fat graft is not an office procedure.

The deep nasolabial fold can be filled with a variety of materials, both synthetic or natural. Fat can be placed through either injection or as a threaded implant. When a favorable donor site exists as part of an operative procedure, the strip fat is a good option to consider for longer-lasting results.    

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Deepening of the nasolabial fold area is a common cosmetic concern. Known as the parentheses (by advertising) or the cheek-lip grooves, they appear and deepen with age. They develop has the cheek tissue above the lip loosens and sags with aging, falling over its junction with the more fixed upper lip. Their level of cosmetic concern is evidenced by the nasolabial folds being one of the two main facial areas in which injectable fillers are used. In my practice, the lips and the nasolabial folds are about even in terms of requested injectable improvement.

The main treatment method for deepening nasolabial folds is to soften them by pushing them out with injectable fillers. The type or name brand of injectable filler used does not make a difference in the cosmetic outcome. The folds are softened and made less deep by the ‘push’ of the injectable fillers. The result from fillers is instantaneous albeit temporary.

There are some nasolabial fold problems, however, that I do not think do well with injectable fillers. Very deep folds or inverted nasolabial folds do not usually get very satisfying results with injection methods alone. The inversion or v-shape of the fold makes any push from underneath less significant and not very long lasting. In these folds, excision produces the best result (most flattening) but the scar is not usually a good aesthetic trade-off.

An interesting approach to the inverted nasolabial fold is surgical release. Detaching the dermal attachments from the depth of the fold produces a release as a result of loosening the fixed part of the fold. This can clearly be done with surgical instruments but the entrance incision for access results in a bigger scar that is aesthetically acceptable. A special cutting wire has been developed for this application so the nasolabial folds can have a ‘wire release’. Placed through two separate stab entrances, the wire does a good job of a wide release of the overlying nasolabial fold. The immediate results are quite impressive and it is a procedure which can be done in the office under local anesthesia.

This is the best method that I have seen yet for these difficult inverted nasolabial folds. Whether long-term results bear out that it is better than injectable fillers remains to be seen. But the early results are promising.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Cenetr, Avon, Indiana

Indianapolis

One of the most common facial areas that bothers many patients is the development of the nasolabial folds, also referred to as the lip-cheek groove, or in a recent television commercial known as the parentheses. You can argue whether it is a fold or a groove but it is probably closer to a fold. It develops as the cheek tissue from above ages and begins to sag….falling over its border with the upper lip. The upper lip is ‘fixed’ so the overhanging cheek tissue creates the appearance of a deepening fold. With time, aging, and the anatomy of one’s face, this nasolabial fold extends south past the corner of the mouth and sometimes nearing the lower border of the jaw in extreme cases of skin laxity.This area is commonly treated by injectable fillers and in my practice as many patients wants their nasolabial folds treated as they want their lips enlarged.

 
The most common method for nasolabial fold reduction is with injectable fillers. Like all filling procedures by injection, the results from nasolabial fold reduction is quick, easy to do, and the results are immediate. I usually perform them under a local anesthetic block so the treatment is as comfortable as possible. While all of the injectable fillers will work, I think some are better for this area than others. And the ones that I think are best are those that last the longest and have the greatest ‘push’.

 
While all of the hyaluronic acid fillers such as Restylane or Juvaderm will work, they do not last as long as any of the particulated injectable fillers. Currently Radiesse (ceramic beads) and Artefill (plastic beads) are the only two particulated fillers currently available. The evidence is clear, not surprisingly because of their solid bead component, that they consistently last longer than any of the hyaluronic acid fillers. While beaded injections can cause lumpiness and irregularities, this is not a significant cosmetic issue (nor can it usually be seen) in the forgiving area of the nasolabial fold. Conversely, in the lips this is a different matter. Also, because the bead composition makes the injectable material more thick and viscous, I think it provides more push as it goes in resulting in a better cosmetic effect and having to use less injectable filler. Because of particulated fillers longevity and thicker volume, it is my preferred injectable approach to the nasolabial folds. This injectable treatment will give a 9 to 12 month result.

 
There are other treatment options for the nasolabial fold as well. The best way to eliminate them is the one way which is almost never done….cut them out. That gets rid of the fold immediately but also leaves a fine line scar which may only be acceptable in an older patient. The other more commonly done alternative is to use an implant. I specifically use an Advanta implant for those patients that want a permanent volume solution. A very small incision is made in the nose crease and at the end of the lower fold line. The implant is slide into place from one end to the other. This is a procedure that can be done in the office under local anesthesia. An implant approach to the nasolabial fold is a good solution for someone who no longer wants to do injections, doesn’t mind the concept of an implant in their face, or has very deep nasolabial folds which would take a lot of injectable filler volume. My experience with an implant in this area has been quite good but it is not a first line approach for most patients.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis