Smile lines, or nasolabial folds, are one of the most common things patients point to during consultations at my Livingston, NJ practice.
Usually the conversation starts like this:
“I hate these lines. Can you put filler here?”
Sometimes we can.
But very often, I don’t think we should.
A deeper nasolabial fold is frequently the visible result of changes happening somewhere else in the face. The cheek has lost support. Fat compartments have changed. Bone structure has changed with age. Skin is thinner and doesn’t rebound the way it used to. Usually it’s some combination of these things.
If I simply fill the line without figuring out why it became deeper, I may make the lower face look heavier rather than better.
And that’s exactly the look most of my patients are trying to avoid.
I’m Dr. Carol Eisenstat, a board-certified anesthesiologist and founder of Line Eraser MD in Livingston, New Jersey. I perform all injectable medical treatments in my practice myself. When I’m evaluating smile lines, I’m looking at the entire face and not just the crease someone wants erased.
So let’s talk about what actually causes nasolabial folds, when filler makes sense, when I would consider Sculptra, Radiesse or laser instead, and why sometimes the best treatment for the line doesn’t involve injecting the line at all.
What Are Nasolabial Folds?
Nasolabial folds are the creases that run from either side of the nose toward the corners of the mouth.
Everyone has them.
They’re part of normal facial anatomy, and having a nasolabial fold does not mean your face is aging badly. What changes with age is usually how deep the fold becomes and whether you can see it when your face is at rest.
“Smile lines” is a less precise term because patients use it to describe several different things.
Nasolabial folds run from the nose toward the mouth.
Marionette lines begin around the corners of the mouth and extend toward the jaw.
Perioral lines are the smaller vertical lines around the lips.
Crow’s feet are the expression lines around the eyes.
I make this distinction because these are different anatomical problems. Treating all of them as “wrinkles” and reaching for the same syringe doesn’t make sense.
Why Do Nasolabial Folds Get Deeper With Age?
There isn’t one cause.
Your face changes in layers as you age. Skin changes. Fat changes. Ligaments and other supporting structures change. Even the facial skeleton remodels over time.
The nasolabial fold is simply one of the places where those changes become visible.
Midface Volume and Support
The cheek isn’t made up of one uniform layer of fat. There are multiple superficial and deep fat compartments that contribute to facial shape and projection.
Over time, the distribution and volume of those compartments change.
When the midface has less support than it once did, the relationship between the cheek and the nasolabial fold changes too. The fold can become more prominent even though the actual problem isn’t located inside the crease.
That’s an important distinction.
Sometimes the patient points here:
the fold
while I’m looking here:
the cheek and midface above it.
Collagen, Elastin and Skin Quality
The skin itself is changing too.
Collagen and other components of the extracellular matrix change with age, and cumulative sun exposure accelerates many of those changes.
Younger skin tolerates repetitive movement remarkably well. You smile, the skin folds, and then it rebounds.
As skin becomes thinner and less elastic, a crease that used to appear only with expression may eventually remain visible at rest.
This is also why two patients with similar facial structure can have completely different smile lines. Skin quality matters.
Facial Bone Changes
One of the most overlooked parts of facial aging is the skeleton.
Facial bone isn’t a permanent scaffold that stays exactly the same while everything above it ages. The facial skeleton remodels throughout adulthood.
Changes around the maxilla and the opening surrounding the nose can alter support for the overlying soft tissue.
That means someone can have excellent skincare, never smoke, maintain a stable weight and still notice that the area around the nose and mouth looks different in her 50s than it did in her 30s.
Not every sign of facial aging is something you caused.
Sun Exposure and Smoking
UV exposure contributes to photoaging and collagen breakdown. Smoking also accelerates visible skin aging.
When skin quality deteriorates, folds tend to look more etched because the skin itself is less capable of recovering from repeated movement.
This is the component we can actually influence quite a bit.
Genetics and Facial Anatomy
Some people have noticeable nasolabial folds when they’re 25.
That’s anatomy, not premature aging.
The shape of your cheek, underlying bone structure, fat distribution and ligament anatomy all affect how prominent the fold appears.
This is one reason I don’t believe in treating a photograph or trying to make every patient’s face conform to the same template.
Should You Put Filler Directly Into Nasolabial Folds?
This is where I disagree with a lot of the aesthetic treatment patients have been taught to expect.
A nasolabial fold can be treated directly with filler. Several dermal fillers have FDA-approved indications that include nasolabial folds.
That doesn’t mean directly filling the fold is always the best aesthetic decision.
If a patient’s primary problem is loss of support higher in the midface, adding volume to the crease may camouflage the line without addressing the anatomy that made it more noticeable.
And there is a point where filling a fold makes the area look heavier.
That’s when you start seeing the “filler face” patients are afraid of, not necessarily because filler itself looks unnatural, but because volume was added where the face didn’t need more volume.
My goal isn’t to make every line disappear.
My goal is to make the face look better.
Those are not always the same thing.
Can Cheek Filler Improve Nasolabial Folds?
Sometimes.
If loss of midface projection or support is contributing to the fold, strategically restoring volume in the cheek may soften the transition into the nasolabial fold without placing much, or sometimes any, filler directly into the crease.
But I want to be careful with the word “lift.”
Filler isn’t a facelift. It doesn’t literally reposition descended facial tissue the way surgery can.
What appropriately placed filler can do is restore selected areas of lost volume and improve contour and structural support. In the right patient, the nasolabial fold may look softer as a result.
The amount matters.
More cheek filler is not automatically more lift.
What Does Overfilled Nasolabial Fold Filler Look Like?
This is one reason I evaluate patients from the front, profile and three-quarter view.
A fold may look smoother straight on after it’s filled aggressively, while the profile tells a completely different story.
Too much volume around the nasolabial fold can make the area beside the nose and upper lip look bulky or projected. Instead of light reflecting naturally from the cheek, the lower midface starts to look heavy.
If you’ve ever looked at someone and thought, “I can tell she has filler, but I can’t figure out exactly where,” this type of misplaced volume can be part of the reason.
Good injectable treatment has to work from more than one camera angle.
Your face exists in three dimensions.
What Is the Best Treatment for Nasolabial Folds?
There isn’t one.
The best treatment depends on why your fold is prominent.
For some patients, it’s primarily structural volume loss.
For others, skin laxity and texture are a bigger component.
Some need collagen support.
Some don’t need treatment at all.
Here’s how I think about the main options.
Hyaluronic Acid Filler for Nasolabial Folds
Hyaluronic acid, or HA, fillers are commonly used to restore facial volume and soften wrinkles and folds.
One of their biggest advantages is immediacy. You see a change at the appointment, although swelling means you shouldn’t judge the final result that day.
Another important advantage is reversibility. HA filler can be broken down with hyaluronidase if medically necessary or if a correction needs to be reversed.
Who is a good candidate?
I consider HA filler when I want precise structural correction and control over where volume is being added.
That might mean treating the cheek or another area contributing to the fold rather than automatically injecting the nasolabial fold itself.
In selected patients, a conservative amount of filler directly in the fold can also be appropriate.
It isn’t an all-or-nothing rule.
How long does filler last?
There isn’t one honest number.
Longevity varies by product, location, amount injected, anatomy and individual patient factors.
Depending on the filler and treatment area, results can persist for many months and, with some products and locations, longer than a year.
I would rather give a patient a realistic range based on the actual product and placement we’re considering than promise that “filler lasts X months.”
Sculptra for Smile Lines
Sculptra is made with poly-L-lactic acid, or PLLA. It is an injectable biostimulatory product that is used to improve facial wrinkles and volume by stimulating collagen formation over time.
It behaves very differently from an HA filler.
You don’t choose Sculptra because you want me to precisely fill one little line today.
I think of it when the problem is broader.
A patient may have generalized facial volume loss, thinning tissue or a gradual change in facial support and wants improvement that develops over time.
Treatment is typically performed as a series rather than a single “one and done” appointment.
And patience is part of the treatment.
Results develop gradually over the following months and can persist for up to approximately two years in appropriate patients.
When do I prefer Sculptra?
I like Sculptra when the conversation is less:
“Fill this one line.”
And more:
“My entire face looks like it lost something.”
Those are very different requests.
Sculptra is not dissolved with hyaluronidase the way HA filler can be, which is something patients should understand before choosing it.
Radiesse for Nasolabial Folds
Radiesse is a calcium hydroxylapatite, or CaHA, injectable.
It is FDA approved for correction of moderate to severe facial wrinkles and folds, including nasolabial folds.
It provides an initial volumizing effect from its carrier gel and also has biostimulatory properties.
Like Sculptra, Radiesse is not an HA filler and isn’t reversed with hyaluronidase.
That distinction matters.
I may consider Radiesse when I’m looking for structural support or when its particular characteristics make sense for the patient’s treatment plan.
But I don’t select an injectable because one product is universally “better.”
I select it based on the tissue, anatomy, treatment goal and where I’m planning to put it.
Laser Resurfacing for Smile Lines
Laser treats a completely different part of this problem.
If the fold is primarily structural, laser isn’t going to replace lost facial volume.
But many patients don’t just have a fold. They also have fine lines, sun damage, uneven pigmentation or changes in skin texture.
That’s where resurfacing becomes useful.
Laser treatment can improve the surface and dermal component of facial aging while injectables address volume or structure.
In my Livingston practice, this is why I sometimes recommend a combination approach rather than putting more and more filler into a face that actually needs better skin.
You can’t volumize your way out of poor skin quality.
What About Microneedling?
Microneedling creates controlled micro-injury in the skin to stimulate a wound-healing and collagen-remodeling response.
It can be helpful for overall skin quality and fine lines.
It is not, however, going to replace missing structural volume or make a significant nasolabial fold disappear.
I think this distinction matters because patients are often sold treatments based on what the device can improve without being told what it cannot improve.
If the problem is skin, treat skin.
If the problem is structure, treat structure.
If it’s both, we may need both.
Filler vs. Sculptra vs. Radiesse vs. Laser: Which Should You Choose?
Here is the simplest way I explain it:
HA filler: precise volume correction with an immediate visible change and the benefit of being reversible with hyaluronidase.
Sculptra: gradual collagen stimulation for patients who need broader correction rather than precise filling of one crease.
Radiesse: a calcium hydroxylapatite injectable that can provide volume and biostimulatory effects and is FDA approved for moderate to severe facial folds, including nasolabial folds.
Laser resurfacing: addresses skin quality, texture, pigmentation and fine lines rather than replacing structural volume.
And sometimes the answer is a combination.
A patient with volume loss and photodamaged skin doesn’t necessarily need twice as much filler.
She may need less filler and a completely different treatment for the skin.
That’s a much more interesting and usually more useful conversation.
Is Nasolabial Fold Filler Safe?
Dermal filler is a medical procedure.
Bruising, swelling, tenderness and redness are among the more common temporary effects.
The complication I care most about as a physician is inadvertent injection into a blood vessel, also called vascular occlusion.
Although uncommon, intravascular filler injection can cause tissue injury and, in rare cases, serious complications including visual impairment, blindness or stroke.
This is why I don’t think the conversation around filler should begin and end with how much a syringe costs.
Before someone injects your face, I think it’s reasonable to ask:
- What is your medical training?
- What product are you using and why?
- How do you recognize a vascular occlusion?
- What happens if I have a problem after I leave?
- Do you have an emergency protocol?
- Do you use ultrasound, and how is it incorporated into your practice?
At Line Eraser MD, I use ultrasound as an additional tool when clinically appropriate for vascular mapping, evaluating previously placed filler and managing certain filler-related concerns.
Ultrasound doesn’t make filler risk-free.
Nothing does.
It gives me additional information when I need it.
What Symptoms After Filler Require Immediate Attention?
Your treating medical provider should give you specific post-procedure instructions.
Symptoms that can indicate a serious complication and require immediate medical assessment include unusual or severe pain, blanching or marked changes in skin color, or any visual symptoms.
Visual changes after filler are an emergency.
Do not wait for a routine follow-up appointment.
How Much Does Nasolabial Fold Treatment Cost?
This is impossible to answer responsibly without seeing the face.
And I know that’s not the answer people searching Google want.
The cost depends on what we’re actually treating.
If your fold is primarily related to midface volume loss, I may recommend treating the midface rather than purchasing “one syringe for smile lines.”
Another patient may be better suited for a biostimulator.
Another may benefit more from investing in resurfacing.
That’s why comparing the price of one syringe with the price of one Sculptra vial or one laser session doesn’t tell you very much.
The better question is:
What are we trying to correct, and what will it realistically take to maintain that result?
I would rather build the smallest treatment plan that makes anatomical sense than sell someone more syringes because a line is still visible.
What Happens at a Smile Line Consultation?
I want to see your face before I decide what belongs in it.
During a consultation, I evaluate your face at rest and in motion. I look from the front, profile and three-quarter view.
I’m assessing things like:
- midface projection
- cheek volume
- the depth and location of the fold
- facial symmetry
- skin quality
- lower-face structure
- previous filler
- how your face changes when you smile
I also want to know what has been injected previously, where it was placed and approximately when.
Sometimes a patient who thinks she needs more filler actually has old filler that needs to be evaluated first.
The treatment plan comes after the exam, not before it.
What Is Recovery Like After Filler?
Swelling and bruising vary considerably between patients and treatment areas.
Some people have very little. Others swell or bruise enough that they don’t want photographs taken for several days.
This is why I tell patients not to schedule filler immediately before a wedding, major event or important photographs.
You also shouldn’t judge your result while you’re still swollen.
For HA filler, I generally want the initial swelling to resolve before deciding whether anything needs to be adjusted.
Biostimulatory treatments such as Sculptra are different because the desired result develops gradually rather than being judged primarily by the immediate post-treatment appearance.
Your specific aftercare should always be based on the product and procedure you actually received.
When Is Filler Not Enough?
There is a point where adding more injectable product is not the answer.
If significant tissue laxity or descent is driving the lower-face changes a patient wants corrected, nonsurgical treatment has limitations.
Filler can restore volume.
It cannot reproduce what a surgical facelift does.
I think one of the responsibilities of a good aesthetic physician is knowing when to say that.
If I don’t think six syringes of filler will give you what you’re asking for, I’d rather tell you than put six syringes into your face.
Can You Prevent Nasolabial Folds?
You can’t prevent facial anatomy from existing, and you can’t stop aging.
You can protect skin quality.
Daily broad-spectrum sunscreen is probably the least exciting recommendation in this entire article and one of the most important.
Consistent retinoid use may also be appropriate for many patients, depending on the individual and product.
Avoid smoking.
Treat sun damage.
Maintain your skin before you’re asking a procedure to undo decades of accumulated change.
I don’t think everyone needs to start injecting their face in their 20s to “prevent aging.”
I do think everyone benefits from taking care of the skin they already have.
How I Treat Nasolabial Folds at Line Eraser MD
My approach is not to erase every visible line.
Faces are supposed to move. They’re supposed to have transitions. They’re supposed to look like faces.
When someone comes to Line Eraser MD concerned about smile lines, I first determine what is creating the appearance she doesn’t like.
If it’s predominantly structural, we discuss structure.
If it’s skin quality, we discuss skin.
If there is generalized volume loss, a collagen-stimulating treatment may make more sense than chasing individual folds with HA filler.
And if the fold itself really does need a small amount of filler, then we can treat the fold.
There is no rule that says you can never inject a nasolabial fold.
The point is that the diagnosis should come before the syringe.
Nasolabial Fold and Smile Line Treatment in Livingston, NJ
Line Eraser MD is a physician-led aesthetic medical practice in Livingston, New Jersey.
I perform the injectable medical treatments in my practice myself, and I approach facial rejuvenation from an anatomy-first perspective.
That means I don’t decide how to treat a nasolabial fold by looking at the fold alone.
I evaluate the entire face, previous treatment history, skin quality and the patient’s actual goal before recommending filler, Sculptra, Radiesse, laser resurfacing or a combination approach.
There isn’t one “best filler for smile lines.”
There is a treatment plan that makes sense for your anatomy.
And sometimes that means leaving the line alone.
Frequently Asked Questions About Nasolabial Folds
Does filler get rid of nasolabial folds?
Filler can soften the appearance of nasolabial folds, but completely eliminating the fold isn’t necessarily a desirable or realistic goal. Nasolabial folds are part of normal facial anatomy. The treatment plan should depend on why the fold has become more prominent.
Should filler be injected directly into smile lines?
Sometimes, but not automatically. In certain patients, treating volume loss or support elsewhere in the face may improve the appearance of the fold without aggressively filling the crease itself.
Can cheek filler help smile lines?
It can in appropriately selected patients when midface volume loss is contributing to the appearance of the nasolabial fold. Cheek filler isn’t a universal treatment for smile lines and shouldn’t be used simply to create “lift.”
Is Sculptra better than filler for nasolabial folds?
Neither is universally better. HA filler allows precise volume correction and can be dissolved with hyaluronidase. Sculptra produces a more gradual change through collagen stimulation and may make more sense when facial volume loss is broader rather than confined to one area.
Is Radiesse good for nasolabial folds?
Radiesse is FDA approved for correction of moderate to severe facial wrinkles and folds, including nasolabial folds. Whether I would choose it depends on the patient’s anatomy, treatment goals and the area being treated.
Can laser treatment remove smile lines?
Laser resurfacing can improve skin texture, fine lines and other aspects of skin quality, but it does not replace structural volume. If a deep nasolabial fold is primarily related to facial volume or structural changes, laser alone is unlikely to correct it.
How long does nasolabial fold filler last?
It depends on the specific filler, treatment location, amount used and individual patient factors. Rather than choosing a treatment based on a generic longevity claim, I recommend discussing the expected duration of the specific product being considered.
How do I know which smile line treatment I need?
Start with an examination rather than choosing a product.
The same nasolabial fold can have very different causes in two different faces. A consultation should determine whether the dominant issue is volume, structure, skin quality, laxity or a combination before a treatment is recommended.
Dr. Carol Eisenstat, MD is a board-certified anesthesiologist and founder of Line Eraser MD, a physician-led aesthetic medical practice in Livingston, New Jersey. Injectable medical treatments at Line Eraser MD are performed by Dr. Eisenstat.
This article is for educational purposes and does not replace an individualized medical evaluation. Treatment recommendations, risks, contraindications and expected results vary by patient and by product.
