Soft Tissue Augmentation for Nasolabial Folds
Gary D. Monheit, M.D.
Associate Professor
Department of Dermatology
University of Alabama at Birmingham
Birmingham, Alabama

The nasolabial fold represents the crease from the nose to the side of the oral commissure separating the cheek from the upper lip. Anatomically, the folds are the peripheral margin of the orbicularis oris muscle at the fusion of levator labii superioris medially and the zygomaticus major muscle laterally. The three branches of the levator labii superioris begin at the base of the nose, bottom edge of the orbit and zygomatic arch inserting into the skin of the upper lip. The zygomatic major originates on the zygomatic arch inserting on the lateral mouth corner.1 These muscles are known respectively as the sneering muscle and the smiling muscle.2 (Fig 1) The repetitive action of these muscles over time contribute to the delineated nasolabial fold. As the zygomatic major contracts and its mouth end rises to the cheekbone, a depression forms along the fold due to the bulging of the cheek.3 The nasolabial fold wrinkle gradually evolves from dynamic to static over time and always runs perpendicular to the direction of pull.2

In addition to the dynamic factor of the smiling and sneering muscles, other factors contribute to the evolution of the nasolabial wrinkle fold. This includes soft tissue atrophy and loss of skeletal muscle and fat, especially in the lower face with a redistribution of fat along the malar fat pad. Loss of suspension of the fat pad along with skin redundancy expands the fold to a deeper groove. In addition, the loss of elasticity and collagen support increases the development of photoaging wrinkles along the nasolabial area.4,5 Because the skin looses elasticity with age, gravity’s pull is most ardent along the lower face from the groove over marionette lines and jowls of the jawline.6 These are the major factors of the aging process – loss of soft tissue volume, repetitive muscle contraction, spasm, ptosis from loss of support and photoaging skin changes of elasticity.(Fig 2)

The prominence of the nasolabial fold is a major change revealing mid face aging. The fold has a dynamic stage in earlier life and a static appearance with aging. This is shown with the newborn face, which has no fold, as well as the paralyzed face in which the fold disappears.

Treatment efforts are directed to correct the following problems: volume, ptosis, muscle spasm and photoaging skin. The differences are individualized in each patient as to the degree of change within the fold and associated factors. In this chapter, we will concentrate on volume correction with injectable fillers as this is the most useful and common treatment correction. Other techniques will also be mentioned such as surgical corrections, resurfacing, and muscle relaxation with Botulinum toxin. They can contribute to correction as secondary factors.

The gradual evolution of the nasolabial fold wrinkle from absence in the 20’s, though mild and moderate grooves in the 30’s and 40’s to final severe grooves parallels the aging process through the decades. Quantitative scales of nasolabial fold prominence have been used to demonstrate the full evolution and guide the physician to proper therapy.7 The Fleming-Poff™ scale (Genzyme Corporation, Cambridge, MA) is an example of a measuring stick to determine groove level on a 0-5-severity level. (Fig 3) Early changes – 0 to 1 – are mainly dynamic as the fold is only exhibited with movement.(Fig 4) Moderate fold prominence exhibits malar fat pad depression at rest and is present because of early fat atrophy.(Fig 5) These individuals will get full correction with volume filling.(Fig 6) The more severe forms involve ptosis as well as volume loss and may not obtain the same degree of correction with injectable filling alone.(Fig 7) Delete Table 1 Citation

Patient Selection
When a patient seeks cosmetic treatment, it is important that they have realistic expectations and are educated on which treatment would be best for their particular concern and why. First of all, the physician needs to understand what the patient perceives as a problem area. After this is accomplished, the physician should begin educating the patient as to the etiology and available treatment philosophy. Changes in the skin due to inherent aging, actinic damage, and loss of subcutaneous tissue are variables different in each patient. This review is best done while a patient is looking into a mirror. Rhytids caused by recurrent movement verses changes in the skin caused by increased laxity and gravity need different treatment for each of these separate issues. When patients focus on prominent nasolabial folds, it is best to begin with simple procedures that have little risk or down time and then progress to more invasive procedures that require time needed for recovery. This then summarizes treatment options. The ideal patient for soft tissue augmentation of the nasolabial folds is a patient with moderate to moderately severe nasolabial folds who wants smoothing of the contour of the mid-face, who understands the risks and benefits of the procedure, and who has realistic expectations. If a patient wants improvement more than soft tissue augmentation can offer or has a prominent cheek overhanging the nasolabial fold, a better option may be a face-lift or a feather lift.(Fig 8) On the other hand, a patient who has fine line signs of skin aging and wants augmentation may better be treated with a good skin care regimen and possibly a noninvasive laser or microdermabrasion procedure.

Procedures for correction of the nasolabial groove concentrate on the four major causes. The dynamic phase of wrinkles in many areas is corrected with Botulinum toxin. This is used primarily on the glabella, forehead and crow’s feet.8,9,10 The use of Botulinum toxin in the perioral area has severe side effects by interfering with expression.11,12,13,14 Treatment creates an asymmetric paralytic appearance and thus should not be used around the zygomaticus, levator or orbicularis muscles laterally. It though can be used in the depressor labii superioris to elevate the lateral commissure as an adjunct to filling material in the lower nasolabial fold and marionette lines. Two to five units of Botox Cosmetic™ (Botulinum Toxin, Allergan) are injected into the section of the depressor muscle just above the mandible. This procedure will give minimal adjunctive help to fillers.(Fig 9)

Ptosis is the most difficult factor to correct and requires mainly surgical approaches. These include mid face lifting procedures such as subperiosteal mid face-lifts, endoscopic malar fat pad elevation and cable-suture fat pad elevations.15,16,17,18 The technique of Sulamanidze – Aptos Threads – offers a novel non-surgical approach to malar fat pad lifting to further correct severe nasolabial folds. It is most commonly used in combination with injectable fillers.19

Lasers can be used to correct photoaging skin along the nasolabial fold.20,21 CO2 or Erbium Laser Resurfacing are adjunctive techniques, which can be used in combination with volume filling. The resurfacing techniques include CO2 laser, Erbium laser, non-ablative lasers and most recently, the radio frequency devices that create collagen concentration with fold elevation.22,23,24,25,26,27,28,29 All of these procedures can be used to correct skin defects around the fold and may be used in combination with volume filling.

Volume is corrected with injectable and surgical filling material such as temporary or permanent injectables, solid implants or fat grafts. These procedures will be reviewed in detail for use in the nasolabial fold as volume replacement is the primary method of nasolabial fold correction.

The improvement achievable with soft tissue augmentation of the nasolabial folds depends on the amount of the implant used, the type of implant, the frequency of implantation, and the intrinsic qualities of the nasolabial fold. The benefits of filler substances include softening the nasolabial folds by filling the areas with the deficit of soft tissue thus decreasing the shadows created due to the aging face.(TABLE 1) A single implant or multiple implants can be used to attain the desired affect. If a patient presents with fine lines radiating from the nasolabial folds, the best treatment would be to utilize an injectable filler specific for fine lines plus filling the nasolabial folds with a deeper heavier volume filler for deeper furrows. This method works best when a few of the fine lines are treated with a fine line filler followed by deep filling of the folds, then returning to finish the filling of the fine lines.

Injectable soft tissue fillers are the primary choice for treatment of the nasolabial fold from minimal to severe frown. This chapter will briefly review the agents most commonly used and emphasize the techniques that work best in the nasolabial fold. Soft tissue augmentation is technique-sensitive so the individual procedure for each implant must be mastered.(TABLE 2)

Injectable implants can be as effective as the product packaging claims as long as the implant is injected as directed on the package insert. Variables in efficacy can be noted if the material is injected into the subcutaneous tissue causing much less augmentation compared to when it is injected correctly into the dermis. If the injectable implants are injected too superficially, beading or nodulation can occur. The beading will eventually decrease with time, decreasing fastest in areas with the most movement. When injecting into the dermis and inserting the needle in a forward fashion, the injectable material can be extruded into an area of the dermis that is not the ideal site. Firm massage of the injected sites can help to smooth the contour of the injectable filler and guide the filler to a more optimal location.

Injecting material into the nasolabial folds can cause considerable discomfort in some patients. Maximal discomfort occurs at the superior aspect of the nasolabial folds. Some injectables contain an anesthetic which helps with discomfort of the injection.(Table 3) Countermeasures to avoid pain include topical anesthetics, ice, infraorbital nerve block, or simultaneous stimulation with a massaging apparatus. While it may be tempting to inject an anesthetic into the area to be treated, this can distort normal contours and should be avoided. Topical anesthetics help to decrease the pain of the needle puncture, but help minimally with the injection itself or the forward motion of the needle through the dermis.30,31,32,33 Infraorbital nerve blocks or counter nerve stimulation have mixed results, but do help to lessen the pain.(Table 4 – changed from 3) (Fig 11)

Patient Interview
A thorough medical history, family history, and physical exam should be done with each patient. Any history of collagen vascular diseases (CVD) should be noted, as well as hypersensitivity to ingredients of the filler substance. Skin tests should be performed when indicated. Bleeding disorders or anticoagulation medications should be noted. Bruising occurs more frequently when an anticoagulant is used and the patient should be aware of this possibility. The patient should be asked to smile and sneer to evaluate dynamics and symmetry. Any asymmetries in the patient’s appearance should be noted and brought to the attention of the patient and documented in the chart.

The cosmetic patient is questioned as to what bothers them most about their appearance. They are asked to make a “wish list” including up to five aspects of their appearance they would like to have improved with the most important feature to be first on the list. The list is reviewed with the patient, having them demonstrate for us in the mirror exactly what is meant by each topic on their list, and adding suggestions as appropriate. Treatment options are then reviewed with the patient beginning with simple procedures and combined simple procedures with little down time and ending with more long lasting procedures requiring significant down time. If the patient has not had augmentation procedures before, we typically recommend beginning with a product that lasts the least amount of time so that the patient can decide if augmentation is right for them. Although permanent fillers have the advantage of fewer injection sessions to maintain a desired affect, there is less of a margin of error when injected and the products can shift over time and with muscular movement. As the face ages, the site first injected may not be the ideal site for injection five or ten years later in life leaving an unnatural appearance from the permanent implant to the area. The cost of each procedure is reviewed with the patient and written information is given to the patient. They can either proceed with treatment or can schedule a future appointment after considering their treatment options.

Treatment Technique
With every patient who is to be treated cosmetically, after the treatment plan has been made, it is reviewed with the patient and the risks, benefits, and alternatives to the procedure are discussed with the patient who must express understanding and sign an informed consent. Any last minute questions are answered at this time. The patient’s make-up is removed and the areas to be injected are cleansed with ethanol and allowed to air dry. Photographs both distant and close-up are taken at this time including a frontal view, a 45-degree angle view from the front, and a side view. It is important when comparing photographs that each picture is taken in a similar fashion under similar lighting. Make-up should be removed in all pictures and a similar background should be used.

Biodegradable Collagen
Zyderm/Zyplast

Bovine collagen is the first dermal filler approved for usage in the United States. It has a 20-year record of safety as a dermal filler and most commonly used on the nasolabial fold.34 Three types of bovine collagen are presently available – Zyderm I (ZI) is a 3.5% by weight bovine collagen (35 mg/ml). Zyderm II (ZII which is 6.5% mg/ml) and the third agent Zyplast. Zyplast 1.5 cross-linked bovine collagen which constitutes an injectable latticework of bovine collagen, more resistant to degradation with less immunogenicity (Inamed Aesthetics, Santa Barbara, CA). All of these products require skin tests to rule out allergy. Two intradermal injection tests should be performed at day 0, 2 weeks, and both evaluated in six weeks. The collagen is suspended in saline with 1% lidocaine.34 The products have different indications.

Zyderm I is primarily indicated for superficial defects while Zyderm II and Zyplast are used for deeper depressions and grooves.34 Zyderm I should be reserved for superficial defects and thus not as applicable as a primary treatment for the nasolabial fold which usually requires deep correction with greater volume change. It is placed in the papillary and upper reticular dermis. One hundred fifty to 200% over-correction is required and the endpoint of injection is a “peau d’orange” or blanching of the skin. Zyderm I is best used in combination with Zyplast or another heavier filler to correct the remaining fine wrinkles after the nasolabial groove is volume corrected.(Fig 12) This is a layering technique which will give a full correction to the dermal defect.(Fig 13)

Zyplast is a denser substance with greater longevity. It must be injected into the mid reticular to deep dermis and is especially useful for treatment of the nasolabial fold. Zyplast is placed at a mid dermal level with a 30-gauge needle at a 10-20 degree angle from the skin surface. The material is deposited serially in small volumes with a flow in the mid dermis.35

There are variable techniques developed for nasolabial fold injections which are also applicable to other injectable fillers.

The three injection techniques most commonly used in the nasolabial fold are: serial puncture, threading and fanning.(Fig 14) I find all three are useful for most injections. Serial puncture indicates the use of multiple injections into the mid dermis going up to the nasolabial fold, injected medial to the line/fold at a 30-degree angle. The injected implants are then massaged for even distribution. Threading technique uses a one-inch 30-gauge needle which is advanced at a 30-degree angle below the depth of the nasolabial fold. The filler is then injected as the needle is slowly drawn out. This fills the depth of the fold through the trough evenly. The fanning technique is used for diffuse volume filling and useful for the triangle at the superior aspect of the nasolabial fold as it approaches the alar lobule. Multiple 30 degree mid dermal pathways are formed out and from the groove to elevate the superior angle evenly. It is also useful for volume filling at the lateral lip commissure to elevate the corner of the nasolabial fold and marionette line. Zyplast injections should never be over-corrected and always within a mid dermal level, avoiding a peau d’orange.

Two or more implant sessions at intervals no less than two weeks apart may be needed for maximal correction. Touch up implants are performed at four to twelve-month intervals to maintain full correction.(Fig 15)

Best results are obtained by combining Zyplast with Zyderm I for correction of all levels of dermis within the fold. The two materials are layered with Zyplast injected first to 100% correction of the deeper groove. The author’s choice of techniques is to use the threading method first for volume filling and the deeper aspects of the groove. The serial puncture technique is then applied to areas of depression after full threading of the fold. Further volume filling is performed at the superior sulcus. It usually takes 1-2 cc. of Zyplast to correct most nasolabial fold volume deficiencies. Then, Zyderm I is placed above the Zyplast for the remaining wrinkle within the fold and any accessory wrinkles. Massage is necessary after each injection to avoid nodulation and assure a smooth, natural implant.

The variation in longevity is due to dynamic motion and mechanical stress along the nasolabial fold; continuous smiles break collagen down faster.

Though Zyderm/Zyplast is historically a reliable, forgiving product, disadvantages include the potential for allergy and need for skin tests prior to injection, the relative short duration and potential adverse events including nodulation, allergic potential, vascular infarction with deepest injection and the rare event of cystic formation.37,38,39,40,41,42

CosmoDerm/CosmoPlast® (Inamed Corporation) is a second-generation collagen wrinkle filler as a human bioengineered collagen product. It is derived from dermal fibroblast cells seeded and incubated in a bioreactor to produce a human collagen product. The type I collagen is isolated from the dermal tissue, purified and mixed with lidocaine and phosphate buffered saline. CosmoDerm I, II and CosmoPlast are used as injectable fillers in the nasolabial folds similar to the methods of Zyderm and Zyplast. No skin test though is required and the product is believed to last as long as Zyderm/Zyplast products, which is 4-6 months. It also can be used in combination with other products including hyaluronic acid fillers. It has an excellent record of safety and minimal adverse events. It produces little swelling or bruising with the least amount of down time of any filler presently available.(Fig 16)

Hyaluronic Acid: Restylane (Medicis Aesthetics), Hylaform (Inamed/Genzyme), Juvederm (Inamed)

The hyaluronic acid products are the most recently approved family of injectable fillers for contour defects.43 These are especially applicable for the nasolabial fold in which the unique viscoelastic properties and high water retention capacity fill the groove in a very natural manner. Hyaluronic acid is chemically, physically and biologically identical in the tissues of all species. It, thus is biocompatible with little or no allergenicity. The body rapidly clears the hyaluronic acid molecule in 24-48 hours so that it needs stabilization to be effective as a dermal implant. This occurs through the process of cross-linking which is slightly different for each product. Restylane® is a bacterial based product while Hylaform is derived from rooster coxcombs. Both products are purified and stabilized by cross-linking producing a hydroscope gel that is gradually eliminated by isovolemic degradation.44 Both Restylane and Hylaform have been approved by the FDA for intradermal injection to correct the nasolabial folds. This is especially applicable since the nasolabial fold was the area chosen for the paired double-blind studies used for efficacy and safety of the products.45 Both studies used Zyplast as a control but differed in intent. The Restylane study compared products on either side of the face in a double-blind paired comparison. It was to demonstrate efficacy and longevity. The Hylaform study was a “non-inferiority” study with outcomes for efficacy at four months. Both products were successful with the following outcomes:
1. Both products achieved correction equal to or better than Zyplast at 4 months.
2. Both products were declared safe with no need for skin test. The AE profile was safe.
3. Both were declared safe and effective treatment for correction of the nasolabial folds.

Neither product has lidocaine; thus pretreatment topical anesthesia and/or local blocks are needed for patient comfort. I prefer using betacaine with an infraorbital nerve block. (TABLE 3)

The products are packaged as a gel within a syringe with 0.7 ml. product and a 30 gauge ½ inch needle. They should be injected into the mid dermis with only 100% correction, no over correction (Medicis Aesthetics, Scottsdale, AZ) (Inamed Aesthetics, Santa Barbara, CA)

Restylane and Hylaform can be injected into the nasolabial fold by all three defined techniques: serial puncture, threading and fanning. The viscoelastic properties of the gel make it malleable for massage in the fold resulting in a very natural correction.(Fig 17) The implant should not be placed superficially as it results in nodulation with a bluish discoloration to the skin.

The hyaluronic acids are relatively free of side effects with a very small risk of allergic or inflammatory reactions. Rare granulomas have been reported from both products in Europe.46,47,48,49 This filler, like all the biodegradable products are forgiving because they will resorb and side effects go away with time. (Fig 18)

Calcium Hydroxyalpatite (Radiance: Bioform)

Calcium Hydroxyalpatite (CaHA) is an inorganic substance that mimics the structure of bone. In the United States, it is marketed as Radiance. Radiance is currently FDA approved for use in oral maxillofacial defects and for soft tissue vocal fold augmentation and as a radiographic tissue marker (BioForm Medical, Franksville, WI). CaHA is currently widely used in Europe as a soft tissue filler. Radiance is not approved in the United States by the FDA for cosmetic applications and is an off-label use for soft tissue augmentation.50

In its soft tissue injectable form, CaHA microspheres are suspended in a carboxycellulose absorbable gel, and it is injected into the dermis or subcutaneous tissue. As the gel is absorbed, collagen deposition into and around the microspheres causes collagen formation and enhances augmentation. It is expected to last between two to five years with break down products of calcium and phosphorous.51

Radiance has been used effectively for correction of nasolabial fold defects by deep dermal injection. A local nerve block is needed for its comfortable usage. The gel is injected through a 25 or 27 gauge needle and the correction is usually 1:1. It is advisable to under correct the fold as lumpiness and medial over correction can produce a deformity. Conservative correction with follow up correction in two to four weeks is advisable. The pliability of the substances allows post injection massage minimizing irregularities or lumpiness which can occur. It is expected to last over two years.(Fig 19)

Poly-L-lactic acid: Sculptra (New-Fill): Dermik

Poly-L-lactic acid (PLLA) received conditional FDA approval for treatment of HIV-related lipoatrophy under the trade name Sculptra on March 2004.52,53,54,55 However, the FDA has not yet approved Sculptra for general cosmetic use in the United States. Studies of this product are currently underway to gain FDA approval. Poly-L-lactic acid has been marketed as New-Fill in Europe since November 1999.

PLLA is a synthetic polymer which is resorbable, biocompatible, and biodegradable. It has been used for several years in multiple medical devices and is a component of vicryl suture. PLLA can be injected into the deep dermal tissue or subcutaneous tissue. The area to be filled should be under corrected. After injection, gradual degradation takes place by hydrolysis while gradual deposition of collagen occurs.56,57

The initial volume correction, due to implantation of the PLLA decreases over the next few days as the diluent is resorbed. The area treated with PLLA will then slowly refill as the tissue reacts to the implant. A gradual increase in the volume will continue to occur over the next few months.58 Three treatment sessions are needed for full volume correction. The result though has been found to last up to three years.

The side effects of this material are similar to other injectables and include erythema, edema, and bruising at the injection site. Palpable but nonvisible subcutaneous nodules on the lip have been noted in some patients which can resolve spontaneously. These nodules may be due to over-correction. Massaging the treated area after injection may reduce the incidence of this side effect. Rare cases of sterile abscess, late granuloma formation and hypersensitivity reactions have been reported.59,60

Sculptra is injected with a different technique than the other wrinkle fillers. It is layered as a deep dermal and subcutaneous soft tissue filler that is used mainly to correct volume deficits rather than wrinkle correction alone. The technique of Vleggar demonstrates injection with a criss-cross pattern to lay down a uniform matrix for new collagen to be deposited in the deep dermis.(Fig 20) To correct nasolabial folds, the entire lower facial area should be blended to augment tissue and provide a volume enhancing effect. That not only corrects the furrow but also redefines the lost volume in surrounding skin and soft tissues.(Fig 21) A 27-gauge needle is used to implant the gel into deep dermis and subcutaneous tissue in a criss-cross pattern. No more than 1-2 ml is injected with under correction. The area is then massaged and iced to decrease inflammation. Two or three repeat procedures are performed for full correction. The product has been found to last two to four years.57

Non-biodegradable fillers include both injectables and solid products. (TABLE 5 – changed from 4) Over a period of time, our patients do request longer lasting fillers and discuss permanence. There are both advantages and disadvantages of these products. Most importantly, the physician must understand that errors and complications are not forgiving and in some cases, not correctable.

Silicone is the oldest filling material in the United States first used in 1930 and used for nasolabial fold augmentation since 1965 by Orentreich and Associates.61,62 The Dow Corning material had a viscosity of 360 centistokes, ideal for microdroplet deep dermal injection.63 The fine droplets are deposited as an under correction with only minimal change in the nasolabial fold.64 Collagen is laid down around the droplets and the process is repeated at six-month intervals until the desired correction is obtained. Optimal correction has been followed for over 30 years by Orentreich and Barnett with good cosmetic correction.65 The patient though must be alerted to the fact that aging changes facial contour and the silicone may “bead up” or change position as wrinkles and features fall. The most common complications seen are implant migration and nodulation.66,67,68,69 These are usually technique related.70,71 (Fig 22)

The Dow Corning silicone is not approved by the FDA. Other forms of silicone, though, are presently approved for ophthalmic usage. These are: Adato-Sil (5000 cs) and Silikon (1000 cs). They are presently being used as a dermal filler as an off-label usage.

Artecol is a permanent injectable filler used to correct the nasolabial fold since 1994.72 Polymethyl-methacrylate (PMMA) microspheres are suspended in bovine collagen for intradermal injection. The product is manufactured by Rofil Medical International but presently is not FDA approved. The product has had clinical trials in the United States under the name of Artefill. (Fig 23)

The suspension of bovine collagen and PMMA microspheres is injected into the deep dermis with 100% correction of the fold, yet not over correction (Artes Medical Inc., San Diego, CA). With three to four months, the collagen is degraded as new collagen is formed around the microspheres.51 The product is well indicated for deep nasolabial folds for long term correction.73,74

Artefill is designed for implantation into the deep reticular dermis. Implanting Artefill is more technique sensitive than injecting collagen due to its viscosity and permanence. The viscosity of Artefill is three times higher than that of Zyplast and therefore a greater and a constant pressure should be applied to the plunger of the syringe throughout the injection procedure. Also due to the increased viscosity, more pain occurs during injection compared to collagen. Before injecting, one should exert a firm and steady push on the plunger of the syringe to ensure that there is no blockage of the needle and that the material is moved to the tip of the needle and is ready for injection. The needle should be inserted into the deep reticular dermis tunneled just beneath the area to be filled while maintaining constant pressure on the plunger of the syringe. The material should only be injected while withdrawing the needle. Otherwise, it is as if you are injecting into a wall of tissue and the material injected can move in any directions away from the of the needle tip taking the path of least resistance. The areas should be slightly overcorrected. When injecting into the reticular dermis, a firm resistance is felt and a lifting of the skin is noticed. If the needle is in the subcutaneous tissue, the resistance will be much less and a much greater amount of product will be needed to achieve a lifting of the skin. If while injecting Artefill, a blanching occurs, the needle is placed too superficially. If this occurs, it is important to stop the injection immediately and massage the area with firm pressure helping to deepen the injected material. At the end of implantation, massage all areas gently. If lumpiness is noted, massage more firmly. Patients should limit movement of the injected site for the next three days as Artefill can be pushed deeper into the skin with pronounced movement during this time. The implant site can be taped for approximately three days serving more as a reminder to try to keep the area still than as a dressing. The patients are instructed that they may develop edema and erythema over the next few days.

The area should be allowed to settle for several weeks and the patient should then be reevaluated to see if any further augmentation is needed. If further augmentation is needed, Artefill should be injected in a layered fashion with care taken not to inject the material too superficially.

When correcting the nasolabial folds with Artefill, two to three strands are implanted in a parallel fashion 1-2 mm medial to the nasolabial fold. This is because the nasolabial folds are involved in many facial expressions. For the first three days after injection Artefill is more easily dislodged and due to muscular movement of this area can be moved laterally with facial expression during this time.74

Side Effects/Complications
The tolerability and acceptability of side effects due to Artefill is low due to the longevity of the implant and therefore the potential for nonresolving side effects. Although the PMMA microspheres are nonallergenic, allergic reaction can occur with Artefill as it can with any injectable collagen preparation. Even with a test-site, allergic reaction can occur.

True granuloma formation is a rare occurrence, occurring in less than 0.01% of patients and occurring 6-24 months after Artefill treatment. This side effect may not be reversible.74,75 In summary, Artefill is a permanent product with permanent results and permanent complications. Care must be taken to avoid the latter.(Fig 24)

As opposed to these injectable products, long-term correction can also be attained with fat injections. This is a more complicated surgical procedure involving fat harvesting, centrifuging and then injecting. There is down time with significant swelling, inflammation and bruising; thus it is not a procedure to be taken lightly. In fact, I like to try a simpler temporary filler first prior to fat injection procedures. This will show the patient the type of correction that can be obtained before this longer lasting procedure is performed. The following concepts have made fat injection a reliable and long lasting procedure:
1) Fat is harvested atraumatically and handled in-vitro carefully to preserve the live fat cells;
2) Small alloquats of fat are injected in dispersed tissue – microlipoinjection;
3) Fat is injected deeply into muscle and deep subcutaneous tissue for best survival.

The FAMI technique (Fat Autograft Muscle Injection) developed by Roger Amar, MD is a reliable method of deep fat injection to correct the lower face and nasolabial fold.76,77,78,79 It involves a careful analysis of muscle and fat loss around the nasolabial fold with correction of fat into those areas of loss. For example, deep nasolabial folds are corrected by microlipoinjection into the following muscles: levator labii, zygomatic major, orbicularis oris, depressor anguli oris and mentalis. This is performed through the use of a specially designed cannula through which the fat is injected longitudinally through the muscle mass and fat above.(Fig 25)

The thin patient with severe folds and skeletonized lower face responds to this operative procedure. The fat is injected through definitive incision sites for volume replacement of the lower face. Volume replacement will give longlasting (1-5 years) correction of folds and a new contouring of the lower face.80,81,82 (Fig 26)

Conclusion
This chapter has explored the available techniques to correct the nasolabial folds with emphasis on individualizing correction to meet each patient’s needs.