Treating nasolabial folds – botulinum toxin versus dermal filler
When we surveyed our audience, one of the most common questions we were asked was – which is better for nasolabial folds, botulinum toxin or dermal filler?
Dr Tim Pearce was quite surprised by this because in his mind these two treatments are not interchangeable, so in this blog, he tries to understand why this is an issue for some aesthetic clinicians by discussing the uses for both treatments and offering some advice for safely injecting the nasolabial folds.
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Understanding the use of botulinum toxin in the lower face
Let’s start with the basics – botulinum toxin relaxes muscles and dermal filler increases the volume underneath the skin, and can strengthen the surface of the skin, or treat a wrinkle directly. The two treatments have different modes of action.
Thus, the only way that you might affect the nasolabial fold with botulinum toxin is if there is the presence of a strong levator labii superioris alaeque nasi muscle – the muscle that lifts both the upper lip and the wing of the nose to create a snarl. If a patient has activity in this muscle and you relax it, you will decrease a shadow in the nasolabial area or the impact of an over elevated top lip, in the same injection approach as you can use to treat a gummy smile.
One of the problems when decreasing the strength of muscles in the lower face is that there are often knock-on effects, because you will change the nature of someone’s smile.
Sometimes this can have further impact on the individual by changing their character somewhat, in terms of how they appear to other people. This may result in them looking like they are giving a different kind of smile, perhaps less enthusiastic, fake, or insincere, which can have significant social consequences. For this reason, Dr Tim is always cautious when treating the lower face with botulinum toxin.
Understanding the use of dermal filler in the lower face
Dermal filler, put simply, occupies space. It is pushing out a line, wrinkle, or fold from behind, thus you are reducing the shadow through projection rather than decreasing it (with botulinum toxin) by stopping the muscle from pulling inwards and causing a shadow.
They work in very different ways hence patient selection is paramount. For example, you would not treat a patient who has a natural snarl or a gummy smile with dermal filler because it may be more appropriate to relax the muscle as a less invasive treatment. Similarly, if a patient has a shadow due to volume loss, the correct treatment would be to replace the volume with a dermal filler, rather than relaxing the muscle, because that may have unintended consequences in terms of how their face moves, as discussed above.
Is it better to use a needle or cannula when treating the nasolabial folds with dermal filler?
Dr Tim notes that the choice between a needle or a cannula is largely based on safety.
When treating the nasolabial folds, the cannula will be a safer option, but a gentle injection technique is important, because you can still cause a vascular occlusion (and a significant one in the nasolabial area) if you are rough with a cannula. Gentle use of a cannula is less likely to cause a vascular occlusion than a gentle injector with a needle, simply because cannulas do not enter vessels very easily.
However, the downside with a cannula is that you tend to spend more time in an intermediate tissue layer. Obviously, the rationale behind the use of cannulas is that they do not go through stronger connective tissue, including arteries, but that also means they tend to stay in the fatty layer. You can push them in further, but the harder you need to push, the harder it is to get to where you want to be, the more likely you are to cause an injury, including entering a vessel.
By staying in the fatty layer with a cannula, this is going to give you a slightly different result which may be less stable over the long term, according to Dr Tim, because the more superficial the placement, the more the filler is likely to move around. He loves the stability you get when you are deep, and that is not something you can get very easily when using a cannula. Thus, the benefit with using a needle is being able to place the dermal filler deep onto the periosteum to create an instant result that will last a long time. However, it is not suitable for treating an entire nasolabial fold, and this is where using a cannula becomes very useful.
You can treat a nasolabial fold with an injection in the pyriform fossa at the ala base to project it forward and reduce a shadow, but you cannot do that same injection if the nasolabial fold runs all the way down to the oral commissures. Hence this is where a cannula is preferable. It would be risky to place a needle in the intermediate fatty layer of the nasolabial fold because that is where the artery tends to dip, hopefully the facial artery is slightly lateral, but it can sometimes snake into the nasolabial fold, so it is much safer to use a cannula in this area, says Dr Tim. In summary, if you are treating an entire nasolabial fold, Dr Tim’s go-to instrument would be a cannula.
For more on this debate, why not have a read of another blog by Dr Tim which asks, is needle or cannula safer for dermal fillers?
How to treat severe or deep nasolabial folds with dermal filler, and when is plastic surgery a better option
In these cases, a multi-layered approach really helps, explains Dr Tim, and you can use all the things we have discussed in this blog.
He tends to start in the deepest tissue layer, on the periosteum in the pyriform fossa for a stabilising injection. This acts to stabilise the mid face, in terms of movement, but also creates a little bit of projection. The next layer up is the fatty layer where he uses a cannula to layer some product to create resistance to the movement and add some volume. Above that, you can use a needle to treat any creases – entering the dermis and the mid-dermis with the needle. If the crease is more pronounced, you can perform a horizontal injection, entering at 90 degrees to the crease, and layering three or four injections to resist the downward movement of the cheek.
Although, we must consider the rest of the face, and Dr Tim does recommend treating the upper face and the cheeks first, this advice is simply highlighting the sequential approach in the nasolabial fold area as a lower face treatment. You can include botulinum toxin, if appropriate, but typically Dr Tim would predominantly approach the area with dermal filler because it is more effective for the lower face.
Similarly, as part of a holistic assessment of your patient’s whole face, you can determine if they need plastic surgery rather than dermal filler treatment. You should review the quality of their skin, how much sagginess is present, and how much tissue descent. When using dermal filler, you are limited in terms of how much lift you can create, which is, at best a mild lift. Therefore, treatment does not suit much older patients with significant tissue descent.
If there is a fold, and on palpation it feels like a heavy amount of tissue leaning over towards the nose, realistically you are never going to easily pull back tissue that has folded over. You can create projection outwards to achieve a little bit of unfolding, but if the tissue is really slumped over onto the nasolabial fold, you know you have a nasolabial fat pad that is resting on top of the crease, which is going to be much harder to resolve. It will also be very costly with short term, mild results for the patient, thus a referral to a plastic surgeon is more appropriate.
You can also find Dr Tim Pearce on Instagram if you have any questions or comments about dermal filler treatments and facial anatomy.
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Aesthetics Mastery Show
Nasolabial fold advice
In this episode, Dr Tim discusses the instances in which you need to use Botox vs Dermal Filler and shares his top tips for producing great results and staying safe when injecting this area. Watch the full Aesthetics Mastery Show here.
The show has already been watched over 10k times and has generated over 30 comments from practitioners, including:
“I love how you explain about the differences between using a cannula and a needle. Thank you. You touched on filler and Botox for the nasalabial fold. How about using biostimulators to generate own collagen instead? In my understanding, filler to the peri-oral area get metabolised very quickly as it is a higher movement area. Would love your thoughts on this.”
Dr Tim’s Clinical Advisor, Mary replied:
“Bio stimulators can be very powerful however we like to sleep at night. Biostimulators such as calcium hydroxylapatite (radiesse) are a non dissolvable product and should a complication arise such as vessel occlusion you are increasingly restricted when trying to restore blood flow. Non filler bio stimulation such as microneedling we can get on board with!
In a separate discussion, Amanda Corrao asked:
“Since certain products are going to be best deep and for lift such as in the pyreform aperture and others are better more superficially along the fold as it extends towards the oral commissure..do you recommend your patients use multiple products in one session for best results? And if so do you find hesitancy on the cost of that?”
Tim’s Clinical Advisor, Mary replied:
“If doing a other treatment using different viscosities of filler yes it would be better to have a more dense filler deep and a softer one more superficial. But most prefer just one syringe we find that volift by juvaderm works good at different depths. Also Teosyal dynamic but strong fillers like rha3 and 4 work good too. Just not too superficial.”
Read more questions and answers or join in the debate on our YouTube channel.
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Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.
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