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Treatment of Nasolabial Folds With Fillers
According to the author, injectable dermal fillers can
be used effectively to treat nasolabial folds. He offers
advice on evaluating the depth and classifying the type
of nasolabial fold (crease, fold, or hybrid) and then
selecting an appropriate filling agent. (Aesthetic Surg J
2004;24:489-493)
S
uccessful treatment of the nasolabial fold (NLF)
has presented an ongoing challenge. In addition to
traditional face lifts, other surgical treatments have
included direct excision, elevation of the malar fat pad,
and debulking of the inferior aspect of the malar fat
pad.1-4 However, even with the use of these techniques,
there are still patients who are unhappy with the appearance of their NLF after undergoing surgery. Other
patients are unhappy with the appearance of their NLF
but they are resistant to having surgery. The use of
injectable dermal fillers to improve the NLF can offer a
pleasing alternative.
There are several Food and Drug Administration
(FDA) approved filling agents now available, and it is
anticipated that additional fillers will be approved soon.5
Each dermal filler has its own distinct characteristics with
variations in qualities such as thickness, durability, reactivity, and efficacy. Understanding these characteristics
will enable physicians to choose the appropriate product
for each patient.5,6
Recently, there have been several excellent reviews of
dermal soft tissue fillers, including an article by Dr.
Bergeret-Galley.7 Here, I will explore the products that
work best for different types of patients.
NLF Creases vs Folds
To treat the NLF it is important to identify its
anatomic variations. In addition to varying degrees of
NLF severity, there are 2 separate and distinct anatomic
configurations: (1) nasolabial creases and (2) nasolabial
folds. Nasolabial creases can be a result of repetitive
muscle movement and represent actual creases in the skin
that overlie the anchoring musculofascial attachments.
AESTHETIC
These creases, which are
skin defects rather than contour deformities, appear to
be epidermal and dermal,
not created by overhanging
skin. This type of NLF is
more common in younger
patients and in patients with
Mark G. Rubin, MD, Beverly
thin skin (Figure 1).
Hills, CA, is a board-certified
The second group of
dermatologist.
patients has an actual fold
of skin in the nasolabial
area. Anatomic studies have shown that the actual NLF
position remains unchanged over time, but the downward migration of the malar cheek pads over the
anchored base of the NLF creates the true overhang
defect associated with deep NLFs.8-10 Studies have shown
that a thickening of the inferior aspect of the malar cheek
pad in conjunction with the descent of the overlying skin
creates the true “fold” (Figure 2).9
The NLF can present problems that are not always
easy to classify. Many patients exhibit hybrid characteristics of both creases and folds (Figure 3).These differences
are significant because certain filling agents are better
suited to each category of fold. Therefore, in the hybrid
type of NLF, more than one dermal filler may be needed
to achieve optimal results. Commonly, a base of thick,
deep filler is injected for contour correction. Then a thinner material is injected in a more superficial layer over
the first injection.
Severity of NLF Problem
The NLF has also been classified according to severity
of the problem (Figure 4). This classification has been
validated and used by the FDA in clinical trials assessing
the efficacy of Restylane (Q-Med, Uppsala, Sweden).11
The use of dermal fillers in patients with mild to moderate NLFs (severity rating 2 to 4) is usually quite successful. However, using dermal fillers to treat patients with
deep NLFs (severity rating 5) is usually modestly successful at best. In these patients, with significant cheek ptosis,
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Figure 1. Nasolabial creases resulting from repetitive muscle movement
are epidermal and dermal skin defects rather than contour deformities.
Figure 3. Hybrid NLFs are a combination of a nasolabial crease and
fold problem.
filling the fold actually pushes the redundant skin
upward, creating a more pronounced ridge at the superior aspect of the NLF.
Filling Agents
Classifying the depth and type of NLF is the first step
in successful therapy. The second step is to select an
appropriate filling agent. Consider the type of fold you
are treating. Nasolabial creases (dermal and epidermal
defects) require a dermal filler injected into the upper or
mid dermis for best results. Attempting to fill these creas-
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Figure 2. True nasolabial folds.
es with a deep dermal or subdermal injection may
improve their contour but will not fill in the superficial
dermal defect. Over the years, it has been common practice to treat a patient with NLF creases with Zyplast collagen (INAMED Corp., Santa Barbara, CA). The result is
good, but not great. Treating that same crease with a thinner dermal filler, such as Zyderm 1 (INAMED Corp.),
placed more superficially, will give an excellent result,
superior to that achieved with Zyplast.
True NLFs are not skin defects; in addition to skin
redundancy they represent loss of support and an apparent loss of volume. These folds are best treated with volume correction using either deep dermal or subdermal
injectables. Another method may be to augment the
cheek itself, which creates a lifting effect in the NLF.
Certainly, in patients with deep NLFs, filling agents alone
are not sufficient and work best when used as a followup to surgery.
There are multiple injectable materials on the market for
use in treating NLFs. These products may be divided into 4
groups: (1) permanent, (2) temporary, (3) dermal fillers,
and (4) subdermal fillers. Additionally, these materials can
also be subdivided into true space-occupying dermal fillers
and bioactivators, which correct not only by providing temporary volume, but also by stimulating collagen deposition
leading to long-term increasing correction. Products in the
true space-occupying category include liquid silicone, and
Artefill (Artes Medical, San Diego, CA). Sculptra (Dermik
Laboratories, Aventis Pharmaceutical, Bridgewater, NJ) is
considered a bioactivator. Although these products are
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A
B
C
D
Figure 4. Wrinkle severity scale. Three examples (horizontally) of: A, Score 2. B, Score 3. C, Score 4. D, Score 5. (Photos courtesy of Q-Med and
MEDICI, manufacturer and US distributor of Restylane).
promising, they are currently not approved by the FDA as
facial fillers, except for Sculptra, which was approved
August 3, 2004, for treatment of facial wasting in HIV
patients.
Recently, there has been a trend to use temporary or
semipermanent fillers rather than those that are permanent. This may be attributed to a desire to avoid long-term
complications that can arise from permanent materials.6
Any physician who has been confronted by a patient who
is unhappy with some lumps or bumps from collagen or
fat injections is grateful that the problem will self-correct
Treatment of Nasolabial Folds With Fillers
AESTHETIC
when the material degrades. With permanent fillers, problems are permanent. Also, full permanent correction of the
NLF with a dermal filler may create problems after facial
surgery. When the skin is tightened and the malar fat pad
repositioned, the previously injected material may be
pulled closer to the surface where it may appear nodular
or ropelike. This is not a problem in all patients, but certainly needs to be considered when selecting a filling agent.
Currently available FDA approved materials include
(1) bovine collagen (Zyderm, Zyplast, INAMED); (2)
bioengineered human collagen (Cosmoderm,
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Cosmoplast, INAMED); (3) nonanimal stabilized
hyaluronic acid (Restylane, Q-Med, Uppsala, Sweden);
(4) calcium hydroxylapatite (Radiance, Bioform Medical,
Franksville, WI); (5) mycelized acellular freeze dried
human fascia (Cymetra, LifeCell, Branchburg, NJ); (6)
Fascian (Fascia Biosystems, Beverly Hills, CA), (7) avianderived stabilized hyaluronic acid (Hylaform, INAMED),
and autologous fat. Intradermal fillers include Zyderm,
Zyplast, Cosmoderm, Cosmoplast and Restylane.
Subdermal fillers include autologous fat, Radiance,
Fascian, and Cymetra.
When selecting an appropriate injectable, the following factors should be kept in mind: safety, persistence,
and the number of treatments needed for optimum correction. Homologous human fascia-derived materials
(Fascian, Cymetra) produce inflammation involving several days of posttreatment swelling and erythema.
Usually, more than one injection is necessary to achieve
acceptable correction. Longevity of these materials has
been reported as 4 to 12 months but neither product is
highly popular.12,13
Autologous fat grafting has a more than 100-year clinical history, yet has still failed to yield the predictable,
long lasting results desired.14 Certainly, it has a role in
patients with deep NLFs who need significant volume
and are willing to accept the downtime (similar to posttreatment morbidity when using human fascia-derived
materials) associated with fat grafting.
Both collagen-based products, bovine and human bioengineered, have similar effects. They generally create
minimal inflammation with minimal posttreatment morbidity. In most cases, one treatment is sufficient for
acceptable correction. The greatest limitation is the
longevity of these products, which is generally 3 to 6
months.7 Although there are no published studies comparing the longevity of Cosmoderm with Zyderm, my
personal experience has been that it is quite similar.
Restylane has a similar postinjection adverse event profile
to the collagen-based products, however, its longevity has
been shown to be significantly greater—generally, 6 to 12
months. In most patients, one injection provides acceptable results.11
Radiance (calcium hydroxylapatite crystals in a gel
base) is a subdermal injection product unlike collagen
and hyaluronic acid gel. This material, like autologous
fat, is used as a volume filler to change contour rather
than to fill in a crease. Use of this product as a facial filler
is fairly new, with about 2 years follow-up. Longevity
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appears to be variable, with patients having from 30% to
100% correction after 2 years.12
Treatment
Patients with nasolabial creases respond best to the
intradermal injectables. The most superficial creases
require the thinnest dermal filler, such as Zyderm 1 and
Cosmoderm. 1 Deeper creases may be treated with
Zyderm 2 or with small amounts of Restylane placed
deeper in the dermis, which must be massaged to assure a
smooth contour. Attempting to fill finer creases with
superficial placement of a thick product will result in
lumpiness and an unacceptable result. Deep dermal placement of a subdermal filler in these patients will give some
degree of improvement, but will fail to adequately fill the
superficial aspect of the crease.
In treating true NLFs, volume is necessary; placing
thicker material deeply can restore the contour needed.
Superficial placement of a thin material will give minimal
results with almost no longevity. (Remember that
longevity is due to the inherent durability of the
injectable, the patient’s metabolism, and the degree of
correction achieved with the final injection). A patient
who is only 50% improved with the dermal filler injection will be disappointed with the longevity of their correction much sooner than if they had achieved 80%
correction with the initial injections.
As treatment options for the aging face multiply,
patient evaluation becomes ever more critical. By carefully
considering the NLF type, as well as the patient’s expectations regarding degree of correction and longevity, you
can effectively deliver an acceptable cosmetic result in
most patients. ■
Note: The author conducted an FDA trial of Restylane
funded by Q-Med, manufacturer of Restylane. He is also a
member of the Speaker’s Bureau for Medicis, distributor of
Restylane.
References
1. Netcher DT. Ancillary excisions in the periorbital and nasolabial
regions for facial rejuvenation revisited. Aesthetic Plast Surg
1995;19:193-196.
2. Owsley JQ. Elevation of the malar fat pad superficial to the orbicularis
oculi muscle for correction of prominent nasolabial folds. Clin Plast
Surg 1995;22:279-293.
3. De Cordier BC, De La Torre JI, Al-Hakeem MS. Rejuvenation of the
midface by elevating the malar fat pad: Review of the techniques,
cases and complications. Plast Reconstr Surg 2002;110:1526-1536.
4. Owsley JQ. Lifting the malar fat pad for correction of prominent
nasolabial folds. Plast Reconstr Surg 1993;9:463-474. Discussion
475-476.
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5. Rohrich R, Rios JL, Fagien S. Role of new fillers in facial rejuvenation:
A cautious outlook. Plast Reconstr Surg 2003;112:1899-1902.
6. Saylan Z. Facial fillers and their complications. Aesthetic Plast Surg
2003;23:221-224.
7. Bergeret-Galley C. Comparison of resorbable soft tissue fillers.
Aesthetic Plast Surg 2004;24:33-46.
8. Yousif NJ, Gosain A, Sanger JR, Larson DL, Matloub HS. The nasolabial fold: A photogrammetric analysis. Plast Reconstr Surg 1994;93:7077.
9. Gosain AK, Amarante MT, Hyde JS, Yousif NJ. A dynamic analysis of
changes in the nasolabial fold using magnetic resonance imaging:
implications for facial rejuvenation and facial animation surgery. Plast
Reconstr Surg 1996;98:622-635.
10. Hoefflin SM. The ligamentous facial fence: The cause of nasolabial
folds and jowling. Plast Reconstr Surg 1998;101:1148.
11. Narins RS, Brandt F, Leyden J, Lorenc ZP, Rubin M, Smith S. A randomized, double blind, multicenter comparison of the efficacy and tolerability of Restylane versus Zyplast for the correction of nasolabial
folds. Dermatol Surg 2003;29:588-595.
Treatment of Nasolabial Folds with Fillers
AESTHETIC
12. Sclafani AP, Romo T, Jacono AA .Rejuvenation of the aging lip with
an injectable acellular graft (Cymetra). Arch Facial Plast Surg
2002;4:252-257.
13. Burres S. Preserved particulate Fascia Lata for Injection: A New
Alternative. Dermatol Surg 1999;25:790-794.
14 Eremia S, Newman N. Long-term follow-up after autologous fat grafting: Analysis of results from 116 patients followed at least 12
months after receiving the last of a minimum of 2 treatments.
Dermatolog Surg 2000;26:1150-1158.
15. Graivier M. Personal Communication. April 2004.
Accepted for publication June 16, 2003.
Reprint requests: Mark G. Rubin, MD, 153 S. Lasky Drive, Suite 1, Beverly
Hills, CA 90212.
Copyright © 2004 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$30
doi:10.1016/j.asj.2004.06.004
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