Which treatment is best for improving nasolabial folds? From causes to treatment selection

If you've started to worry about the deep lines grooving on both sides of your mouth when looking in the mirror, there is one thing you must know first. Nasolabial folds are not simple 'skin wrinkles', but rather folds created by sagging and sunken cheeks.

That is why the formula "fillers are a must for nasolabial folds" is half right and half wrong. If the folds are caused by a loss of volume, filler is close to the correct answer. However, if sagging is the cause, filling only with filler will make the mouth area look heavy. Identifying the cause first is the starting point for all treatment choices.

🔍 Nasolabial Folds, What Exactly is the Problem?

The medical term for nasolabial folds is **nasolabial fold**. These are the lines that run from the side of the nose down towards the corners of the mouth. What is important to note is that these are not 'wrinkles' caused by facial muscles folding, but rather 'folds' caused by soft tissue sagging downwards.

There is more than one cause. A combination of changes occurs simultaneously: the cheek fat pads of the midface atrophy and descend, bones like the maxilla resorb, and collagen and elastic fibers decrease. On top of this, repetitive facial expressions, UV rays, smoking, genetics, and weight changes also contribute.

Therefore, an approach that focuses only on "filling the nasolabial line" has its limits. The place that is actually sunken is the front cheek and under the cheekbone. Rather than just the nasolabial line itself, supporting the supporting structures of the midface together produces natural results.

📌 Key Summary: Nasolabial folds are structural changes where volume loss + midface sagging + loss of elasticity overlap, and identifying the cause is a prerequisite for treatment selection.

🪞 Are My Nasolabial Folds Due to Sagging or Lack of Volume?

There is a simple way to estimate this at home. Stand in front of a mirror and gently pull your cheek skin below the cheekbone upwards with your fingers.

• If the folds visibly fade → It is closer to the sagging type. Lifting is the priority.

• If there is little change → It is likely to be the lack-of-volume type. Volume-filling treatments are the priority.

Of course, most people have a mix of both. Therefore, for moderate to severe cases, rather than finishing with a single treatment, a combined approach that blends lifting + volume replenishment + skin elasticity improvement is the standard. Accurate judgment is ultimately up to the medical staff who see and touch in person, but knowing just this much will change the quality of your consultation.

📌 Key Summary: If the folds decrease when pulling the cheek skin up, it's the sagging type; if they don't, it's the lack-of-volume type. For moderate to severe cases, a combined approach is standard.

📊 Comparison of Nasolabial Fold Treatments at a Glance

💉 From Fillers to Surgery, Examining Each Treatment

Filler — The Most Commonly Used Primary Choice

Hyaluronic acid filler is the number one choice for nasolabial fold treatment due to its immediate volume effect and reversibility. A major advantage is that if a problem occurs, it can be dissolved with hyaluronidase. The maintenance period is typically 6 to 18 months, depending on the product and individual metabolism. A combined total of about 2cc (1cc on each side) is a common standard.

However, if too much filler is injected into a sagging type, the area around the mouth will look protruding, creating a so-called **'monkey face'**. Filling more does not make it look more natural.

**Calcium Hydroxylapatite (CaHA, Onblossem, Radiesse)** adds collagen-stimulating effects to immediate volume, so it lasts longer. However, you must keep in mind that it cannot be dissolved.

Sculptra — Slow and Natural

With Poly-L-lactic acid (PLLA) as the main ingredient, it is a method that stimulates your own collagen production. It slowly fills in starting from 4 to 6 weeks after the procedure and lasts for about 2 years. To prevent nodules, the '5-5-5 rule', which is massaging 5 times a day for 5 minutes each for 5 days after the procedure, is recommended.

Thread Lifting — Directly Pulling Up the Sagging

Threads made of PDO, PLLA, PCL, etc., physically lift the skin while also inducing collagen. It is suitable for nasolabial folds accompanied by sagging, and depending on the type and number of threads, it lasts for 6 to 18 months. There is a common misconception that "the more threads inserted, the better," but putting in too many can make facial expressions look unnatural and delay recovery.

Ultherapy/Thermage/Needle RF — Non-invasive Elasticity Improvement

Ultherapy (HIFU) is a representative non-invasive lifting treatment that uses ultrasound to stimulate the SMAS layer. Thermage uses high-frequency to shrink and regenerate dermal collagen, and needle RF like InMode directly stimulates the dermis with microneedles. The effects of all three appear gradually over 1 to 3 months and last for 6 to 12 months. It is realistic to view them as supporting roles to maintain elasticity rather than eliminating nasolabial folds on their own.

Autologous Fat Grafting, Facelift, Noble Surgery — More Fundamental Solutions

Autologous fat grafting transfers your own fat to the midface, which has semi-permanent potential, but the survival rate fluctuates between 30% and 70%, so overcorrection to account for some absorption is common.

For middle-aged and older adults with severe sagging, a facelift is the most powerful option. The effect lasts for more than 5 to 10 years, but it comes with the burden of incision, recovery period, and scarring. Noble surgery is a method of inserting an implant into the depressed area next to the nose, which can be a permanent solution for naturally deep nasolabial folds, but carries the risk of a foreign body sensation and displacement.

For reference, Botulinum Toxin is not the main treatment for nasolabial folds alone. This is because nasolabial folds are structural sagging problems, not muscular wrinkles. It is used only in a limited auxiliary capacity, such as adjusting the depressor anguli oris muscle.

📌 Key Summary: Fillers, fat grafting, and Sculptra for lack of volume; threads, Ultherapy, and facelifts for sagging; high-frequency for lost elasticity. Botox is not the main treatment.

⚠️ Why Safety is Crucial

The nasolabial area is located close to where the facial artery and superior labial artery pass. Therefore, if filler enters a blood vessel, vascular occlusion can occur, and in rare cases, skin necrosis or vision loss have been reported. It is not common, but it is a risk that should never be taken lightly.

So, what you need to check is whether an emergency response system, like having hyaluronidase on hand, is in place. However, keep in mind that even this medication cannot perfectly reverse all situations.

If any of the following signs appear after the procedure, you must contact the clinic immediately.

• The skin turning white or patchy

• Blurred vision or vision changes

• Pain that worsens over time

Ultimately, the biggest variables that determine results and safety are the practitioner's understanding of anatomy and experience. During your consultation, make sure to ask "Is it a hyaluronic acid filler?" and "Is there an emergency response system for vascular occlusion?"

📌 Key Summary: Since nasolabial fillers carry a risk of vascular complications, checking the emergency response system and the experience of the medical staff is essential.

🎯 Realistic Treatment Sequence by Age Group

The right answer varies for everyone, but the general flow is as follows.

• Early 30s/Early Stage: Sagging is still mild. It is highly cost-effective to start with a small amount of filler or collagen-stimulating treatments, and combine them with lifestyle habits like UV protection and smoking cessation.

• 40s/Moderate Stage: Sagging and volume loss occur together. A combined approach of supporting with thread lifting or Ultherapy first, and then finishing with filler, looks natural.

• 50s and older/Severe Sagging: There is a limit to filler. It is time to consider more fundamental treatments like a facelift.

When combining treatments, the sequence of setting the foundation with lifting and then filling the volume is usually safe. However, the interval between treatments varies depending on the equipment and individual condition, so coordinate with your medical provider.

One more thing. The realistic goal for nasolabial folds is 'alleviation and improvement', not perfect elimination. The fold that appears when you smile is a normal anatomical structure. Trying to erase even that will make you look unnatural.

📌 Key Summary: Prevention and small amounts for the 30s, a combined approach for the 40s, and surgery consideration for the 50s and older. The goal is 'improvement', not 'removal'.

💬 Frequently Asked Questions

How do I tell if my nasolabial folds are due to sagging or a lack of volume?

Stand in front of a mirror and gently pull your cheek skin upwards with your fingers. If the folds fade, it is closer to the sagging type; if there is no change, it is closer to the lack-of-volume type. However, most people have a mix of both causes, so accurate judgment requires a diagnosis from medical staff.

Can Botox eliminate nasolabial folds?

It is difficult. This is because nasolabial folds are not muscular wrinkles, but are primarily caused by structural sagging and volume loss. Botox is used only in a limited auxiliary capacity, such as correcting the corners of the mouth.

Can I receive filler and thread lifting at the same time?

It is possible. However, if there is sagging, it is usually natural to set the foundation with lifting first and then fill the volume. Whether concurrent treatment is possible and the intervals between them depend on individual conditions, so please consult with your medical provider.

What should I do if my skin turns white after a nasolabial filler procedure?

This could be a sign of vascular occlusion and is an emergency. If your skin turns pale, pain worsens, or your vision becomes blurry, you must contact the clinic immediately. Emergency treatment to dissolve the filler with hyaluronidase may be required.

Can nasolabial folds be completely removed?

Alleviation and improvement are realistic goals rather than complete removal. Folds that form when smiling are a normal anatomical feature, so trying to erase them forcefully will make you look unnatural.