Nasolabial folds are the lines that run from the sides of the nose to the corners of the mouth. They are one of the most commonly searched facial ageing concerns in the UK and one of the most consistently mishandled treatments in non-surgical aesthetics. Not because the treatments available are inadequate, but because the approach most often applied to them is not the one the anatomy actually calls for.
Understanding why nasolabial folds form, what is actually creating the crease, and how the approach to treating them should differ depending on the cause is the starting point for any result that looks genuinely natural and that does not worsen the problem it was meant to address.
What Nasolabial Folds Actually Are
A nasolabial fold is not simply a line on the skin surface. It is a visible groove created by the intersection of several anatomical structures that meet in this specific zone of the face.
The fold marks the boundary between two distinct fat compartments. The malar fat pad, which provides the fullness of the cheek and sits above the fold, and the nasolabial fat, which sits immediately adjacent to the fold on the medial side. These compartments are separated by a fibromuscular layer that creates a natural transition zone in the young face, visible as a gentle shadow even in youthful skin but not as a significant crease.
As the face ages, the malar fat pad descends. This fat compartment was once positioned over the cheekbone, giving the midface its fullness and projection. With age and the weakening of the retaining ligaments that hold it in place, it gradually moves inferiorly. As it descends, it piles onto and above the nasolabial fold rather than sitting over the cheek. The fold deepens not because something new has formed but because the tissue above it has migrated downward and created a bulge that emphasises the boundary between the compartments.
Volume loss in the midface accelerates this process. When the deep medial cheek fat and the overlying malar fat deflate, the cheek projection that was holding the tissue in position reduces. The tissue descends more readily as its volumetric support from below disappears. The nasolabial fold deepens as a consequence of the structural changes above it rather than as an isolated local event.
The orbicularis oris, which is the circular muscle of the mouth, and the levator labii superioris, which elevates the upper lip, both insert into the nasolabial zone. Their activity during smiling, speaking, and expression creates repeated dynamic folding in this area throughout life. This repeated mechanical movement contributes to the tissue changes at the fold over decades.
Why Treating the Nasolabial Fold Directly Often Disappoints
The most common patient request for nasolabial fold treatment is straightforward. Fill the crease. Smooth it out. Make it less visible.
The impulse makes sense. The crease is the visible problem. Putting filler into the crease should address it directly. In practice, this approach frequently produces results that neither the patient nor the practitioner is satisfied with, and the reason comes back to the anatomy.
If the nasolabial fold is primarily caused by descended malar fat piling onto and above the fold rather than by a volume deficit in the fold itself, filling the fold adds volume to the wrong location. The descended tissue above the fold already creates a bulge. Adding filler to the fold itself adds another mass immediately below that bulge. The result can be an area that looks heavier and more full rather than smoother, because both the descended tissue and the added filler are now occupying the same zone simultaneously.
For patients where this is the dominant anatomy, placing filler directly into the nasolabial fold worsens the appearance of heaviness in the lower midface even while technically smoothing the groove itself.
The appropriate structural approach for this anatomy is to address the cause rather than the visible consequence. Restoring volume to the midface and the malar fat pad region supports the descended tissue from above, reducing how far it has descended and therefore reducing the depth of the fold it is creating below. This approach treats the nasolabial fold by treating the anatomy that caused it to deepen, which is consistently more effective and more natural-looking than filling the fold in isolation.
When Direct Nasolabial Filler Is Appropriate
Direct filler in the nasolabial groove is appropriate for a specific presentation that is less common than the descended malar fat pattern but genuinely exists in some patients.
Where the fold reflects a true volume deficit in the fold itself, meaning there is a hollow or depression at the fold rather than descended tissue piling above it, direct filler addresses the actual anatomical situation. This presentation is more common in younger patients, in patients with naturally deep nasolabial anatomy, and in patients where significant weight loss has depleted the tissue in this specific zone without the broader pattern of descended midface fat.
A practitioner assessing whether direct fold filler is appropriate can evaluate this by gently supporting the tissue above the fold with a finger. If the fold significantly reduces when the midface tissue is manually supported upward, the dominant cause is descended tissue rather than a local volume deficit, and midface restoration is the more appropriate treatment. If the fold remains pronounced even when the overlying tissue is supported, a local volume deficit is more likely and direct fold filler has a clearer clinical rationale.
Even where direct fold filler is appropriate, the amount used matters enormously. Overfilling the nasolabial groove is one of the most common causes of the slightly bloated or indistinct lower face appearance that some patients carry from previous filler treatments. Small amounts of appropriately soft filler placed precisely along the fold produce a subtle improvement. Larger amounts produce a result that draws attention to itself rather than improving the natural appearance of the face.
The Midface First Principle
The most important clinical concept in treating nasolabial folds is that the midface should almost always be assessed and addressed before the fold itself.
Restoring malar fat pad volume and deep medial cheek fat volume lifts the descended tissue above the fold back toward its more anatomically youthful position. This reduces how much descended tissue is piling above the fold and therefore reduces the depth of the fold as a consequence. The improvement in the nasolabial fold from restoring midface volume is often significant without any product being placed in the fold at all.
This approach produces a result that looks natural because it restores the face to the shape it had before the descent rather than adding material at the symptomatic location of the descent. Patients who have midface volume restored often comment that they look like themselves again rather than looking like they have had treatment. The three-dimensional lift of the face that restored malar projection produces is consistently more satisfying than the flattening effect of filler placed directly in the fold.
After midface restoration, if a residual fold remains that warrants further attention, a small amount of direct fold filler placed conservatively completes the treatment. In many cases, the residual fold after midface restoration is mild enough that patients are satisfied without additional fold filler.
Thread Lifting and Nasolabial Folds
Where the dominant cause of nasolabial deepening is the physical descent of the malar fat pad rather than volume deflation alone, thread lifting offers a mechanical alternative to volume replacement.
Threads placed at the lateral midface can reposition the descended malar fat pad upward toward its more youthful anatomical position. This physical repositioning reduces the tissue that is piling above the fold and directly addresses the cause of fold deepening rather than compensating for it with added volume.
Thread lifting is particularly relevant in patients where the malar fat pad has descended significantly and where adding filler to replace the projection of the original pad position would require large volumes that produce a heavy or overfilled appearance. For these patients, repositioning the tissue that has descended is anatomically more appropriate than trying to replace it with injected product from below.
The combination of thread lifting to reposition descended tissue and conservative midface filler to address residual volume deficit is increasingly used by practitioners who understand both treatments and plan lower face programmes to address both the descent and the volume components in a coordinated way.
Profhilo and Skin Quality in the Nasolabial Zone
The skin quality dimension of nasolabial folds, particularly the fine surface texture of the skin overlying the fold and the skin quality on either side of it, is addressed by Profhilo and polynucleotides used alongside the structural approaches above.
The skin in the nasolabial zone is subject to constant mechanical stress from expression and movement. As collagen and elastin decline, the skin becomes less resilient, and the creasing from that movement shows increasingly at rest rather than only during expression. Profhilo used in the cheek and perioral region drives bio-remodelling that improves the structural quality of the skin, making it more resilient and reducing the degree to which the mechanical stress of movement creates static lines in the nasolabial zone.
This is a supportive contribution rather than the primary structural intervention for significant folds. For patients with early or mild nasolabial changes where the primary concern is skin quality and early surface fold development rather than significant structural descent, Profhilo without structural filler may be the most appropriate starting treatment. The tissue quality improvement can meaningfully reduce early fold development before significant structural intervention is warranted.
When Treatment Is Not the Right Answer
Nasolabial folds are a natural feature of the human face. Shallow nasolabial folds are present in almost all adult faces during smiling and in many faces at rest without representing significant ageing. The cultural normalisation of completely fold-free faces from heavily filtered social media imagery has created an expectation in many patients that any visible nasolabial fold needs treatment.
It does not. A practitioner who can look at a patient's nasolabial folds and honestly say that the degree of fold present is within the normal range for the patient's age and anatomy, and that treatment would not produce a meaningfully better appearance, is providing more value than one who treats every nasolabial fold as a clinical problem requiring correction.
The appropriate threshold for treatment is a fold that is noticeably deeper than one would expect for the patient's age, that significantly affects the resting appearance of the face in a way the patient finds distressing, and where treatment would produce a genuine and proportionate improvement. Chasing a completely fold-free face through repeated and increasing amounts of filler produces the heavy, indistinct lower face appearance that many patients later want reversed rather than the natural improvement they originally sought.
Frequently Asked Questions
How much filler is typically needed for nasolabial folds?
This varies considerably by the approach taken and the anatomy being addressed. Midface restoration for the structural cause of fold deepening typically uses one to two millilitres per side in the cheek region. Direct fold filler, where appropriate, involves conservative volumes of typically 0.5ml or less per side. Conservative dosing is a clinical principle for this area rather than a cost-saving preference.
How long does nasolabial filler last?
Filler in the midface used to address the structural cause of nasolabial deepening typically lasts twelve to eighteen months. The midface is an area of relatively limited movement compared to the lips and perioral zone, which supports longevity at the longer end of this range for appropriate products.
Will treating my nasolabial folds affect my smile?
Properly placed structural midface filler and conservative direct fold filler should not affect the smile because treatment is placed in static tissue rather than in the dynamic muscle zone. Smile appearance is related to the perioral muscles rather than the midface fat compartments and fold zone. If you notice any change to your smile after treatment, raise it with your practitioner promptly.
I have had nasolabial filler before, and it did not help much. Why?
This is one of the most common presentations in lower face aesthetic consultations. In most cases, it reflects filler having been placed directly in the fold in a patient where the fold is caused primarily by descended midface tissue rather than local volume deficit. The correct approach for this patient is midface restoration rather than fold filler, and the disappointing previous result reflects treatment of the consequence rather than the cause.
Can nasolabial folds be improved without filler?
Thread lifting to reposition descended malar fat can reduce fold prominence in patients where tissue descent is the dominant cause. Profhilo and skin quality treatments can improve mild early fold development where tissue quality rather than structural descent is the dominant factor. For significant structural folds where volume is the primary driver, filler is the most directly effective tool.
At what age do nasolabial folds typically need treatment?
There is no single threshold age. Some patients notice significant fold development in their late thirties due to early fat descent or low baseline malar volume. Others in their mid-fifties have fold development that is modest relative to their overall age-related changes. The appropriate time to treat is when the fold is significant enough relative to the overall face to benefit from treatment, not based on a calendar age.
If you want an honest assessment of your nasolabial folds and a treatment plan that addresses the anatomical cause rather than simply the visible crease, book a consultation at our Littlehampton or Hove clinic.
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