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Indications
Indications
Although often considered the standard area for many trials leading to FDA approval, direct treatment to this area has diminished over the years in favor of approaches that address the root cause of nasolabial folds, such as treatment of the adjacent upper medial/lateral cheeks and preauricular area. Nasolabial folds are not immune to agerelated volume loss as may be seen with deepening of the nasolabial crest. An indirect approach may be utilized with complete treatment by directly addressing asymmetry and superficial rhytides.
A meta-analysis of 18 randomized clinical trials (n = 2,521) and seven nonrandomized clinical trials (n = 346) showed an improvement in the mean Wrinkle Severity Rating Scale by 1.21 at 6 months post treatment. The Juvederm family achieved the best efficacy; however, in a subgroup analysis, the incidence of adverse events was significantly higher than with other HA products.105 Another meta-analysis of four randomized clinical trials (n = 331) showed equivalence between CaHA and HA in
hematoma and nodule formation.106 Subsequent trials published after the meta-analyses demonstrated HA efficacy107โ114 in the nasolabial folds. Other fillers studied in clinical trials include PMMA,115โ117 PLLA,110,118โ122 cross-linked dextran,117,123 and polycaprolactone.124,125
Fillers Direct nasolabial crease correction can be achieved with soft-tissue filler injections. It is a matter of debate as to whether to start superiorly or inferiorly. In general, complete effacement is not desirable, especially in the superior part of the nasolabial crease as it tends to flatten the face, making it appear unnatural. Three injection planes may be utilized based on the treatment goal. Supraperiosteal slow bolus or towering placements on the pyriform fossa helps to correct superior nasolabial volume loss and provide nasal tip elevation. Injection in the nasolabial fat pad can address tissue augmentation needed to treat volume loss. Filler placement in the nasolabial fat pad should be aimed at improving the inferior two-thirds of the nasolabial groove. Retrograde threading, fanning, or microaliquots can be used for filler placement in the nasolabial fat pad. The third injection plane is subdermal, when the goal is to address superficial nasolabial rhytides through microaliquots, fanning, threading, or cross-hatching techniques. Juvederm Volbella, Juvederm Ultra, Restylane Refyne, Restylane Fynesse, or Belotero Balance are a few examples that can be used in the subdermal plane. More dense fillers such as Juvederm Volift, Juvederm Ultra Plus, Restylane Defyne, and Belotero Intense are typically used for the nasolabial fat pad. More volumizing fillers with lifting properties such as Juvederm Voluma, Restylane Volyme, and Belotero Volume are preferably used in the supraperiosteal plane.
Injections are performed slowly and cautiously with 27- to 30-gauge needles for tissue augmentation in all three described planes. Fanning and threading with blunt cannulas (1ยฝ or 2 in, 27 or 25 gauge) with an entry point inferomedial to the nasolabial fold are preferably used for filling the nasolabial fat pad due the proximity of the blood vessels embedded in the adjacent deeper muscular planes. The nasolabial midface viaduct point can also be used as an entry point for blunt cannulas.84