When a skin booster goes into a nasolabial fold instead of filler

A patient once turned her phone around during a nasolabial consultation to show me her search screen. The phrase was "regret after nasolabial filler". She had put the idea off because she worried her smile would look off and because filler felt hard to undo.

Listening further, there is usually something left to check before any product is chosen. Two folds of the same depth can need different material in a different place once you know why each one deepened.

Three reasons a nasolabial fold looks deeper

There are days when I look at two similar folds and suggest filling for one person and lifting for the other. What differs is not the depth on the surface but what created it.

First, volume beside the nose and around the fold has dropped and a shadow has formed. Filling is the right approach here.

Second, the cheek has descended and now sits on top of the fold. Lifting comes first in this case.

Third, a shallow line from smiling has stayed in the skin. This one is handled as a question of skin texture.

If only filling is done on a fold created by a descended cheek, the mouth corner can end up looking heavier. So before filling anything I check whether the cheek has come down. What follows is about the first case, the fold created by volume loss.

Why filler packed along the line shows when you smile

When someone tells me they regret nasolabial filler, it almost always turns out the filler was packed along the line itself. Filler is firm and settles as a mass. That works well for pushing up a single line, but the treated spot can stand out on a smile and the mouth corner can look blunt.

That does not make filler a poor material. For a deeply carved groove, filler is the right choice. In a randomised split-face study of people with moderate to severe folds, wrinkle severity was still about one grade lower 24 weeks after a single injection of hyaluronic acid filler.

What that study treated was folds in the moderate to severe range. A fold that is only shallowly sunken and mostly casting a shadow is a different conversation.

How Hyraura spreads differently from filler

I often hear that filler feels like too much but the shadow along the fold is still bothersome. Hyraura is what I suggest to those patients.

Hyraura is a hyaluronic acid skin booster made by CHA Meditech. Rather than packing the line, it is placed so that it spreads thinly across the whole sunken plane. Because no mass forms in one spot, it shows less than filler and disturbs expression less.

The product itself is built with a dual rheology, so it spreads softly on injection and then stays where it was placed. It contains lidocaine and is injected through a fine 33G needle.

So it goes to people who do not want a visible increase in volume, and to people whose dryness makes the area around the fold read as deeper than it is.

How the amount differs beside the nose and at the mouth corner

A fold is rarely sunken to the same depth from one end to the other, so the material is not laid evenly along the line.

The triangle beside the nose is the deepest part, so it takes a little more.

The upper part of the fold runs into the cheek, so it is spread thin to avoid a step against the surrounding surface.

The mouth corner takes very little. Too much there makes the corner look heavy.

Many people are deeper on one side than the other. The deeper side gets its own amount.

The fold a booster will not fill

Some patients come in having researched Hyraura and I end up not raising it at all. That is when the groove is carved deeply enough to feel with a finger.

A skin booster supports a plane thinly and will not fill a deep groove. Filler is right there, and I say which of the two fits before anything else.

The same goes for a fold created by a descended cheek. Starting with volume makes the mouth corner heavy, so lifting is looked at first.

There is one thing I say in advance even to patients we do go ahead with. Hyraura does not erase the line itself. Expecting the shadow to lighten, so that the fold is less visible at rest, is closer to what happens.

Where water injections and PN fit alongside

Some patients still see the shade after the area has been filled. Usually the skin there is dry and fine lines remain. In those cases the fold work is combined with skin hydration injections and PN.

Hydrating injections place hyaluronic acid in the shallow layer of the skin for moisture and gloss. PN, a polynucleotide preparation known for being derived from salmon, is used to support skin recovery.

PN is still at the stage where only small studies exist. In a randomised study of twenty women with moderate to severe acne scars, split into two groups of ten, only the group given highly purified PN improved at one and three months against the saline group. With twenty participants in a preliminary study, the result cannot be carried straight over to nasolabial folds, so I read it as a direction rather than a number.

Hyraura supports the sunken plane and the texture above it is handled with hydration and PN. If the texture is already fine, Hyraura goes in on its own.

Why the smiling face is checked before injecting

The fold at rest is not enough to decide on. From the front I look at how deep the shadow is, and at forty-five degrees at how far the area beside the nose has sunk and how far the cheek has come down.

On a smile I watch where the fold starts and how far it creases. The smiling face is the one a patient will look at most after treatment.

Pain and the days that follow

With lidocaine in the product the procedure is not especially painful, though the needle is still felt going in.

Bruising and swelling can follow, and the injected area may feel palpable for several days. People who bruise easily hold it longer.

Hyaluronic acid injections carry a rare risk of vascular complications. This is explained beforehand and the area is reviewed afterwards.

For anyone flying home or with an event booked, the date is set with those days of recovery in mind. Coming in early in a trip rather than the day before departure leaves room for bruising to settle and for a review visit.

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