Nasolabial Fold Augmentation with Hyaluronic Acid

Injecting hyaluronic acid into the nasolabial fold is the preferred method when it is primarily caused by volume loss. This treatment can restore facial harmony. However, it should not be overcorrected to achieve complete smoothness, as it would compromise the natural three-dimensionality of the face. Overfilling the nasolabial fold would make the face appear flat and swollen, resembling a “moon face” in the worst case.

The wrinkle treatment begins with a comprehensive examination and discussion of risks. The nasolabial fold is one of the high-risk areas in the face where serious complications such as necrosis and blindness can occur after filler injections, although they are rare. The region of the canina fossa, located on the sides of the nostrils, is particularly risky.

Important arteries run through this area, and accidental puncture would have severe consequences. However, it cannot be avoided during the treatment because the shadow cast by the nasolabial fold is often most prominent in this region. Therefore, risks must be explicitly addressed during the informed consent process, and the patient should be able to decide whether the anticipated results are worth taking these risks.

Next, the treatment area is anesthetized, followed by thorough cleansing and disinfection. Infection caused by bacteria introduced into the tissue with the needle is another complication of filler treatments that must be considered and minimized through maximum cleanliness.

Superficial and Deep Correction

The correction with hyaluronic acid filler is performed in two ways: Superficially by injecting it into the skin to camouflage clearly visible and permanent lines with small amounts of filler. And also by injecting it into the muscles to support the actual “fold” and achieve a harmonious lifting effect that gently blends the mouth and cheek regions. This can be done using sharp or blunt cannulas. I, personally, prefer the blunt cannula.

First, a hole is punctured with an injection needle, approximately 1 cm to the side and below the corner of the mouth. Through this hole, the blunt cannula is then inserted beneath the muscle towards the nose. As the cannula is withdrawn, hyaluronic acid filler is gradually deposited, totaling 0.3-1 ml per side. To lift the surrounding tissue as well and create a visually harmonious result, the treatment is not limited to just the nasolabial fold but extends at a sharp angle to it. To minimize pain, the area can be locally anesthetized before the procedure, and the filler products I use also contain lidocaine as a pain reliever.

As mentioned before, the primary cause of the nasolabial fold is often in the cheek region. Therefore, it is recommended to replace the lost volume in the cheek area with filler injections and tighten the skin from the cheeks, creating a “liquid lifting” effect. Ultimately, the nasolabial fold is not only lifted through direct injection, but also “pulled up” by the achieved skin tightening from the cheekbones. The result of such a combined treatment appears more pronounced and natural than simply injecting the nasolabial fold alone.

Additionally, the marionette lines, which run downwards from the corners of the mouth, can also be injected. They are often prominent in cases of pronounced nasolabial folds and extend the nasolabial fold downward, forming a diamond shape with the lips in the center.

As a further complementary treatment, liposuction may be considered if the bulge of the nasolabial fold contains significant amounts of subcutaneous fat. These fat deposits can be significantly reduced in 2–3 sessions with liposuction, which, when combined with filler injection, creates a much more youthful and dynamic facial expression.

Risks and Complications

The region around the nasolabial fold is one of the high-risk areas for facial filler treatments. It is involved in about one-third of the few cases of blindness caused by filler treatments.

This makes it the second most common application with such disastrous consequences, following the injection of the glabella (frown lines), which accounts for approximately half of the globally reported cases of blindness.

While this complication rarely occurs, it is crucial to recognize that not every purpose justifies the means when injecting in such a facial region. If realistic aesthetic improvements cannot be achieved to justify taking such risks, the treatment should not be performed.

A more common complication is swelling, redness, and often bruising, which usually lasts only a few days. However, some individuals are sensitive to hyaluronic acid fillers, and this sensitivity can manifest weeks, months, or even years after the injection.

In cases of delayed allergic reactions, persistent swelling, typically inflammatory and painful, can occur. Treatment involves initially administering corticosteroids and, if unsuccessful, dissolving the injected hyaluronic acid with Hyaluronidase.

How Long Does The Result Last?

Since I exclusively use premium fillers with a long lifespan in my practice in Munich, the expected duration of the result is about 9–12 months. In some of my patients, a noticeable improvement was still visible after 18 months compared to the initial state. However, it should be noted that the longevity of the result is also heavily influenced by individual factors such as facial expression and metabolism. Even in unfavorable cases, I would expect the result to remain visibly significant for at least 8 months and gradually fade thereafter.