The Hidden Truth About Nasolabial Folds: Why Most Treatments Fail
Imagine standing in front of the mirror, tracing the lines that frame your smile. Nasolabial folds—those gentle creases running from your nose to the corners of your mouth—are often misunderstood. They are not mere wrinkles; they are the story of your face's architecture, changing with time, gravity, and volume loss. This week, I saw seven patients in my clinic, four of whom needed to dissolve product placed in these very folds. They had fallen into a common trap: thinking that adding filler to the smile line would erase aging, when in fact, it often creates a heavy, unnatural look.
Let's clarify the terms. A smile line is that subtle crease that appears when you smile, often lateral to the nasolabial fold. Accordion lines are those deeper grooves that form at the side of the cheek from loose skin and collagen loss. These are three distinct phenomena, each requiring a unique strategy.
The Beverly Hills Perspective: Dr. Ben Tilly on Nasolabial Folds
Dr. Ben Tilly, a Beverly Hills plastic surgeon known for his natural-looking facelifts, offers a radically different view. He explains that the nasolabial fold is not a "belly fold" that needs to be liposuctioned or removed. Instead, it is a junction between your cheek and upper lip, formed by either descent or deflation of the midface. The cause varies from person to person, and the only way to know is to feel the tissues.
His golden rule: Don't overfill the lower face. Volumetrically, you can place filler into the fold to blunt it, or above it if there is space. But he emphasizes, "It's always better to put above if there's space above." This is because overfilling the lower face creates volume where the face naturally loses support, leading to a heavy, distorted look.
Dr. Tilly identifies three main causes for nasolabial folds: midface volume loss, facial descent, and volume loss within the fold itself. His solutions are multifaceted. For the right candidate, a deep-plane facelift can roll the tissues back up. Volumetric support—like fat grafting above the fold—can dramatically improve shadowing and contour. Radiofrequency treatments, such as Morpheus or Fraxel, can tighten skin without melting fat.
But here is a critical warning: 50% of patients who walk into his clinic are told no. He stresses that nasolabial folds are a natural human feature. "They are not meant to go away," he says. "We try to make them lighter, not eliminate them." Over-treating can make you look odd, just like a nose that draws too much attention. In fact, nasolabial folds are the number one or number two procedure in Hollywood, but also the highest dissatisfaction procedure—because people focus on minutiae that no one else sees.
The Danger of Dumping Filler: What Not to Do
Dr. Tilly is blunt: Do not cut out your nasolabial fold. Do not place an implant there. Do not dump tons of filler onto the bone. The latter is especially risky because the smiling muscles—the elevators and the orbicularis—can become compromised. When filler migrates or crystallizes, it can affect your smile function. He also warns against using Radiesse directly in the soft tissues of the fold, as it can crystallize and hinder muscle movement.
Instead, his recommendation is to use bio-stimulators like Sculptra or hyper-diluted Radiesse that stimulate collagen without adding bulk. "Don't go dumping it into the nasolabial fold," he repeats. "I see this happen all the time."
Dr. Kian Karimi: A Surgeon’s Approach for Younger and Older Patients
Dr. Kian Karimi, a Beverly Hills facial plastic surgeon, offers a complementary perspective. For the younger patient who doesn't need a facelift, he finds thread lifts highly effective. Barbed or lifting threads can soften the nasolabial fold by re-opposing midface tissues, lasting one to two years with no downtime. "You have to be the right candidate," he says.
For older patients with significant sagging, his preferred method is a deep-plane face and neck lift. This procedure shines in the lower face—the hardest area to treat with fillers—because it addresses the melolabial fold (the downturn at the corner of the mouth) and defines the jawline. Results can last 10 to 20 years.
The Art of Filling: Address the Bone First
When filler is appropriate—only for the 50% who truly need it—the approach matters. Dr. Karimi stresses that you must address the piriform aperture first, the area of bone loss around the nose. Injecting here brings the entire midface complex forward, hiding the nasolabial fat pad and creating a natural lift. Next, the mid-cheek and temple need to be supported. He warns, "If your injector doesn't look at you dynamically—moving your face—you're with an inexperienced injector."
Bio-stimulators like Sculptra, PRF (platelet-rich fibrin), or hyper-diluted Radiesse are preferred over fillers for lift. These products stimulate your own collagen, adding gradual structure without bulk. But patience is key: "I'd rather you go to your injector twice and get it right than get it overfilled and unhappy," he says. Overfilled filler can migrate into the nasolabial fat pad, causing a boggy, unnatural look even months or years later.
Smile Lines and Accordion Lines: The Nuances
Now, let's differentiate. The smile line that appears only when you smile is often lateral to the nasolabial fold. This is common in thin females with bone structure and fat loss. Bio-stimulators are ideal here because you don't want to add bulk to the lower face. The goal is to take the edge off—not fully reverse it. If you look at a picture from when you were 20, you likely had a hint of this line even then.
Accordion lines are more lateral, at the side of the cheek. Here, skincare is the number one defense. Alpha hydroxy acids, retinaldehydes, chemical peels, and home wipes with retinol all build collagen. Hyaluronic acid and argirline can plump the skin and decrease movement. Fractionated RF microneedling is excellent for tight, deep results without volume. "You have to get appropriate levels," Dr. Karimi warns, "or you won't see results." Side effects like hyperpigmentation mean you must see an expert.
A Personal Story: Why I Avoid Overfilling
Allow me to share a personal experience. I recently had my own nasolabial folds addressed after seven years of leaving them untouched. I was a training model when a student's patient didn't show. So I let them use me. The method we used was not filler. Instead, we addressed the maxilla (the top bone) and the mandible below. Bone changes create an aging angle, and that is why people go wrong by merely filling the fold. By supporting the bone and using bio-stimulators, we avoided the heavy look.
Those four patients I saw this week? They had filler or diluted filler placed for their smile lines, believing it was an aging feature. But adding volume to the lower face only exacerbated the problem. Their product dissolved, and we started over with a better plan.
Final Wisdom: The Art of Aging Gracefully
The key lesson is this: Patience and precision. Whether you choose a facelift, threads, bio-stimulators, or skincare, understand that nasolabial folds are part of being human. Our goal is to make them lighter, not erase them. Overfilling leads to migration, water absorption, and a boggy look that lasts years. Always consult an expert, ask to see dynamic movements, and trust the process over multiple sessions.
If you're considering treatment, let this guide your path. And if you'd like to hear more from these Beverly Hills surgeons, I can arrange a full webinar. For now, start with a solid skincare routine that builds collagen—it's the foundation for everything.