Biostimulator in the nasolabial fold: indication and limits

The nasolabial fold (popularly, "smile lines") is one of the most frequent concerns in the office. The traditional answer is to fill it directly. In recent years the idea has grown that many folds are a consequence of lost midface support, and that treating the source can soften them indirectly. The collagen biostimulator enters this reasoning. This page discusses when this indirect support makes sense, when it does not, and the risks of a sensitive vascular area. Product, volume and technique follow the instructions for use and training, at the discretion of the qualified professional, according to the rules of their professional council (in Brazil, CFM, CFO and others).

Why does the fold appear?

The nasolabial fold is the boundary between the cheek and the upper lip. Over time, the cheek fat compartment descends, ligaments loosen, the skeleton undergoes resorption and the skin loses elasticity. The result is a deeper crease, sometimes with a "shadow" over the lip. In many patients, the main cause is descent and volume loss in the midface, and the fold is only the sign. The layer-by-layer reading is in midface aging.

What does indirect support mean?

The idea is to improve cheek support so the fold looks less marked, without injecting product into it. This can be done with dermal filler at support points, with a biostimulator or with a combination of both strategies. With a biostimulator, the improvement is gradual and depends on each patient. The expected gain is softening, not erasing the fold, which aligns expectations with physiology.

When does indirect support make sense?

For the direct approach, see nasolabial fold filler, and for the cheek strategy, biostimulator in the cheeks and biostimulator in the midface.

The area is vascular and sensitive

The nasolabial fold follows the course of the facial artery, which continues as the angular artery beside the nose and connects with the circulation of the eye region. The superior labial artery leaves the facial artery near the commissure. The danger triangle of the face describes the risk zone of communication between facial circulation and intracranial and ocular structures.

The variability of the vascular course is great, which is why solid anatomical training matters more than any rule of thumb. See vascular anatomical variations.

Specific risks of using a biostimulator

• Nodule and irregularity, in an area of creasing and movement. See factors linked to nodules.
• Vascular event, rare and serious.
• Asymmetry, common when there is already asymmetry between the folds.
• Swelling and hematoma.
• Insufficient result from an expectation of erasing the fold.

Hyaluronidase should be available whenever hyaluronic acid is used in the same session. It does not act on biostimulators, and the team needs to know this difference.

How to decide between direct, indirect or a combination?

The reasoning goes through layers of questions. What does the patient want: immediate effect or gradual improvement? What causes the fold: midface descent, bone loss, skin? How tolerant is the patient of more than one session? How good is the skin? And what vascular risk do you and they accept? In many cases, the professional combines cheek support with a targeted treatment of the fold, or stages it over sessions. What makes no sense is applying a single solution to every fold.

Asymmetric folds and other differentials

Almost no face has identical folds on both sides. The difference can come from bone asymmetry, jaw position, chewing habit, sleeping side or muscle hyperactivity. Before any procedure, document the asymmetry with photos at rest and smiling, because the patient tends to attribute to the treatment what already existed. If the fold is deeper on one side because of hyperactivity of the levator labii superioris or dental support, the cause is not volume, and the treatment must be different. See asymmetry after filler for differential reasoning.

It is also worth distinguishing the nasolabial fold from other lines in the area, such as the marionette line and the pre-jowl sulcus, because the support reasoning is different for each. The marionette line usually reflects loss of support in the lower third and the corner of the mouth; the nasolabial fold, in the midface. Mixing the two readings leads to treating the wrong place.

Interval and reassessment

Because the effect of the biostimulator is gradual, assessing the fold on the day of the session says nothing about the final result. The general recommendation is to schedule the follow-up in a few weeks and reassess with standardized photos, at the same angle and in the same light as the initial consultation. The decision to repeat should wait for that reassessment. If the patient wants a quick effect for an event, tell them the biostimulator is not the most suitable method for short deadlines, and discuss alternatives. See standardized clinical photography and clinical follow-up visit.

Communicating with the patient

Many patients arrive asking to "fill the smile lines." When the assessment shows the cause is support, the conversation needs to explain why the strategy may be different. Simple terms help, and being frank about the gradual nature of the biostimulator avoids frustration.

Where does Harmy come in?