The Misconception About Nasolabial Folds
There’s a common mistake taught to injectors worldwide about treating nasolabial folds, and it may be holding you back from achieving your true potential. Many have learned that treating the cheek supports the fold, and while there is a connection, this simplistic view rarely suffices. A perfect example is a patient who presents with a nasolabial fold, but looking closely, you see volume loss under the eye and in the lateral cheek. These areas provide some support, but what’s often missed is the three-dimensional contour of the cheek—a ripple that causes the fold to protrude. The lost volume directly beneath the eye, more medial than typical cheek treatments, is deeply connected to this fold.
Rethinking the Cheek and Fold Connection
Adding volume where it’s been depleted in the upper half of the cheek—more medial—directly impacts the indentation that makes the fold visible. The order of restoration is crucial: replace volume here, then here, then here. But this is seldom enough. You must usually treat the nasolabial fold itself because volume loss occurs here, and even bone loss can be present. Replacing volume underneath and, if there’s a crease, treating the crease itself is the full approach.
The key insight is to stop thinking of the nasolabial fold as an isolated issue. Instead, frame it as midface rejuvenation. The nasolabial fold retaining ligament creates a shadow, but by treating the entire middle third—a little bit in many places—you achieve natural, beautiful results. Patients love hearing that you’ll treat a little bit in lots of places, not a ball of filler in the cheek or fold. It’s about linking all surfaces together to simplify the lines and planes reflecting light, creating a cleaner, softer fold.
The Balanced Approach: Leaving a Natural Shadow
Nasolabial folds are part of the defining inverted lines of the face. Everyone has a slight shadow here. Deleting it completely looks strange—a bit monkey-like. Leaving a little shadow is intentional and recommended for all patients. This wisdom guides a holistic treatment plan.
Step-by-Step Injection Strategy
For restoring the midface in this patient, begin with the lateral part of the cheek. Use a needle on bone for the lateral cheek, though a cannula can work. Restore volume on the upper half of the zygoma before adding too much laterally. Then, treat the medial part—more risky due to the infraorbital and facial arteries. Anything medial to the midpupillary line, always use a cannula. Enter with the cannula, re-volumize the area, and smooth it with your supporting hand to create a continuous, round curve blending the lower lid.
Three Techniques for Direct Nasolabial Fold Treatment
Restoring volume in the fold itself requires precision. Three techniques are used based on what’s observed:
Periosteal Needle Injection: For a depleted shadow where the lip projects outward, place 0.2 to 0.3 ml of filler on the periosteum using a needle. This is stable and long-lasting, often not needing retreatment for years. Safety is paramount—being beneath the arterial level makes artery presence unlikely. Always aspirate and oscillate to improve sensitivity. Add small amounts, see the response, then add more until the aesthetic result is achieved.
Cannula for the Fold Length: For the bulk of the procedure, a cannula is safer. Insert it into the fatty layer, gently revolumize as you go in and out. Vascular occlusion is still possible, so aspirate patiently, work to the alar base, and trickle product slowly. Use a medium-density product. The volume should form an inverted triangle—more at the top, tapering off like the fold, not an equal slug along its length.
Intradermal Injection for Creases: For a crease on the surface, use an intradermal injection with low viscosity products like skin boosters. Inject superficial to the dermis, aspirate, and apply linear threads along the crease. Safety requires being superficial—above the artery.
The Ultimate Solution
These three techniques together form the ultimate solution: a needle on bone for stability and volume, a cannula for the fold length, and a superficial needle for creases. Remember one thing: treat the nasolabial fold as a midface treatment. Guide your patient to a holistic, beautiful result. Understanding these three layers puts you on a different level compared with most injectors.