Nasolabial folds guide: what causes them and the best treatments

Nasolabial folds — the lines running from the sides of the nose to the corners of the mouth — are one of the most common aesthetic concerns patients bring to med spas. They're also one of the areas most frequently mistreated. Here's what actually causes them and what works best.

What causes nasolabial folds

Nasolabial folds deepen for two distinct reasons — and the treatment depends on which is dominant.

Volume loss in the midface

The most common cause in patients over 35. As the fat compartments of the cheeks and midface lose volume with age, the overlying skin has less support and descends. This descent pushes the nasolabial fold forward and deepens it.

The analogy: When a tent pole shortens, the tent fabric droops. The "tent pole" of the midface is the fat and bone that supports the overlying skin. As it deflates, the fold deepens — not because something is happening at the fold itself, but because the support above it has diminished.

Skin laxity and descent

As skin loses collagen and elasticity, the tissue above the fold descends under gravity. This compounds the volume-loss effect.

Intrinsic fold anatomy

Nasolabial folds have a structural muscular component — the fold itself is partly an anatomical feature, not purely a volume/aging issue. Very prominent folds at a young age often reflect anatomy as much as aging.

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Why direct filler is often the wrong approach

The instinct is to inject filler directly into the fold — fill the groove, it goes away. This works to a limited extent, but has significant downsides:

The problems with direct NLF filler:

• Filler in the fold itself is in a high-movement area — it metabolizes quickly
• Heavy direct filler in the fold can create a "sausage-like" appearance on either side of the line
• It doesn't address the underlying cause — if midface volume loss is the driver, filling the fold only treats the symptom

The better approach for most patients: Restore midface volume first. By restoring volume to the cheeks and lateral midface, the fold often significantly improves without placing any filler directly into it — the tissue is supported from above rather than filled from below.

This is one of the clearest examples in aesthetics where treating the cause (midface deflation) produces better results than treating the symptom (fold depth).

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Treatment options

Midface filler (cheeks / lateral midface)

Best for: Patients where midface volume loss is the primary driver of fold deepening. The single most effective treatment for most NLF patients over 35.

Product choices:

• Voluma XC (Juvéderm) — FDA-cleared for cheeks; high G-prime; lasts up to 2 years
• Restylane Lyft — equivalent lifting product; similar longevity

Amount: 1–3 mL per side for moderate-to-significant volume restoration.

Result on folds: When cheeks are restored to a youthful position, nasolabial folds typically improve significantly without direct fold injection.

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Direct NLF filler (fold injection)

Best for: Residual fold depth after midface restoration, or mild NLF in patients without significant cheek volume loss.

Product choices:

• Juvéderm Vollure XC — FDA-cleared for NLF; lasts 18 months in studies
• Restylane Defyne — flexible gel; FDA-cleared for NLF and marionette lines

Technique: Linear threading or serial puncture along the fold; small aliquots; avoid overcorrection

Amount: 0.5–1.5 mL per side depending on fold depth

Important: Use sparingly — the NLF area accepts filler but overcorrection looks unnatural quickly

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Biostimulators (Sculptra, Radiesse)

For patients with diffuse volume loss across the midface and NLF area, Sculptra (PLLA) or dilute Radiesse can stimulate collagen broadly rather than placing specific HA deposits.

Sculptra approach: 3 vials per session × 2–3 sessions over 3 months; results build over 6 months; lasts 2+ years.

Best for: Patients who want gradual, natural-looking results over time rather than immediate correction.

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Ultherapy / Sofwave (skin lifting)

For patients where tissue descent is a significant component, ultrasound skin tightening can provide mild lifting that reduces fold prominence from above.

Realistic expectation: Modest fold improvement; most effective in younger patients (35–45) with early descent rather than significant volume loss.

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Thread lift

PDO threads can provide mechanical lifting of the lateral face, which can reduce NLF prominence by lifting tissue off the fold.

Realistic expectation: Mild improvement; threads work best combined with volume restoration. Not a standalone NLF solution for most patients.

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The assessment sequence

A thorough assessment before treating NLF should include:

1. Evaluate midface volume: Is there significant deflation of the lateral cheek and midface? If yes, midface filler is the primary treatment.
2. Evaluate fold depth at rest vs. smiling: A fold that's only deep during animation has more of an anatomical/muscular component — direct filler is less transformative here.
3. Evaluate skin quality: Is there a significant skin laxity component? If so, skin tightening may help.
4. Evaluate marionette lines: Often co-present; treated similarly with filler at the jawline/chin area.

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What doesn't work

• Botox: There is no Botox injection that effectively treats nasolabial folds. Botox relaxes muscles; the NLF doesn't have a muscle that, when relaxed, eliminates the fold.
• Superficial facials/peels: No surface treatment improves NLF depth. These treat the skin surface, not the structural cause.
• Exercises: No facial exercise effectively reverses NLF — the fold has a structural basis, not a muscle weakness basis.

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Questions to ask at your consultation

1. In your assessment, is my fold primarily caused by midface volume loss or skin descent?
2. Do you recommend cheek volume restoration before or instead of direct fold filler?
3. If we do midface filler, how much improvement in the fold do you realistically expect without touching the fold itself?
4. For my anatomy, what product in what plane do you use for NLF correction?
5. What does overcorrection look like in this area and how do you avoid it?

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