Cheek volumization and the nasolabial fold

Sir: We have read the article by Mowlds and Lambros1with great interest and enthusiasm. The findingsof their study show that the nasolabial fold does notimprove after cheek injection.By analyzing three-dimensional images of the facebefore and immediately after cheek injection of high-G′ hyaluronic acid, they demonstrate that the perceivednasolabial fold improvement, reported after cheekinjections,2,3 is attributable to overall improvement infacial appearance rather than to actual nasolabial foldimprovement. As a consequence, it might be ruled outthat the nasolabial fold is a consequence of cheek deflatingand it is likely attributable predominantly to changein the corner of the mouth and to muscular traction.4This finding is of paramount importance becausecheek overvolumization is frequently performed in anattempt to achieve something that will not occur: correctionof the nasolabial folds. This practice is responsiblefor the bloated, overfilled appearance of thecheeks. Cheek overfilling gives a bulging, unnaturalresult, especially on animation.Increasing cheek volume and enhancing malarprojection, by injecting the deep medial cheek fatcompartment, is part of the treatment because lostvolumes should be replaced.5 It is overfilling in anattempt to improve nasolabial and nasojugal folds thatcauses unnatural results. In fact, we see more and morepatients asking to avoid that overfilled appearance. Wealso strongly agree with the authors’ statement that“young faces benefit from filling prominences andolder faces benefit from filling hollows.”We would like to emphasize how important it is tofill the nasolabial fold and nasojugal crease directly inthe subdermal plane as they become hollow with age.The benefit of treating these areas is clearly shownby the case presented (Figs. 1 and 2). The result isobtained progressively (in two sessions separated by 10days) using LP–nonanimal stabilized hyaluronic acidgel (Restylane Perlane, now Lyft, Restylane; Q-Med,Uppsala, Sweden). The result is long lasting and canbe maintained by yearly repeated injections (Fig. 2).Treating the nasolabial and nasojugal creasesdirectly allows not only elimination of the crease but alsomaintenance of a natural result by avoiding overfillingof the cheek. We aim at supporting the breakthroughfindings of Mowlds and Lambros that volumizing thecheek does not improve the nasolabial fold. Filling ofthe cheek must be performed judiciously to reshapethe cheek, and any attempt at treating the nasolabialfold by volumizing the cheek will fail. To flatten thenasolabial fold, it should be directly injected.