Cheek volumization and the nasolabial fold

Sir: We have read the article by Mowlds and Lambros1 with great interest and enthusiasm. The findings of their study show that the nasolabial fold does not improve after cheek injection. By analyzing three-dimensional images of the face before and immediately after cheek injection of high- G′ hyaluronic acid, they demonstrate that the perceived nasolabial fold improvement, reported after cheek injections,2,3 is attributable to overall improvement in facial appearance rather than to actual nasolabial fold improvement. As a consequence, it might be ruled out that the nasolabial fold is a consequence of cheek deflating and it is likely attributable predominantly to change in the corner of the mouth and to muscular traction.4 This finding is of paramount importance because cheek overvolumization is frequently performed in an attempt to achieve something that will not occur: correction of the nasolabial folds. This practice is responsible for the bloated, overfilled appearance of the cheeks. Cheek overfilling gives a bulging, unnatural result, especially on animation. Increasing cheek volume and enhancing malar projection, by injecting the deep medial cheek fat compartment, is part of the treatment because lost volumes should be replaced.5 It is overfilling in an attempt to improve nasolabial and nasojugal folds that causes unnatural results. In fact, we see more and more patients asking to avoid that overfilled appearance. We also strongly agree with the authors’ statement that “young faces benefit from filling prominences and older faces benefit from filling hollows.” We would like to emphasize how important it is to fill the nasolabial fold and nasojugal crease directly in the subdermal plane as they become hollow with age. The benefit of treating these areas is clearly shown by the case presented (Figs. 1 and 2). The result is obtained progressively (in two sessions separated by 10 days) using LP–nonanimal stabilized hyaluronic acid gel (Restylane Perlane, now Lyft, Restylane; Q-Med, Uppsala, Sweden). The result is long lasting and can be maintained by yearly repeated injections (Fig. 2). Treating the nasolabial and nasojugal creases directly allows not only elimination of the crease but also maintenance of a natural result by avoiding overfilling of the cheek. We aim at supporting the breakthrough findings of Mowlds and Lambros that volumizing the cheek does not improve the nasolabial fold. Filling of the cheek must be performed judiciously to reshape the cheek, and any attempt at treating the nasolabial fold by volumizing the cheek will fail. To flatten the nasolabial fold, it should be directly injected.