Treatments for Nasolabial Folds Based on the Underlying Cause — From Lifting to Fillers and Collagen Injections
Hello, I’m Dr. Dohoon Kim from ODE Clinic.
One of the earliest and most noticeable signs of aging is the development of nasolabial folds. Nasolabial folds can have many different causes, and in most cases, they appear due to a combination of factors. If you choose a procedure without considering these underlying causes, you may see only minimal improvement.
Through a detailed consultation, I assess what type of nasolabial fold you have, and then select and combine options such as Ultherapy, CoolSoniq, XERF, fat-dissolving injections, Emface, dermal fillers, HILO WAVE, Juvelook Volume, Sculptra, Olidia, Ultracol, Radiesse, Elravie Re2O, and LAETIGEN.
Today, as a physician who runs a clinic in Seoul and has treated countless cases, I’ll clearly walk you through the causes of nasolabial folds and the most effective treatment approaches.
Causes of Nasolabial Folds
1. Sagging of Fat Pads (Sagging)
The fat compartments beneath our skin are divided by various retaining ligaments. Over time, these fat pads gradually descend due to gravity, creating contours and folds in the face.
The most representative fat compartment that contributes to nasolabial folds is the malar fat pad.
When we are younger, the retaining ligaments that support the skin are short and firm, but as we age, they gradually stretch and weaken. In addition, the fibrous septae between fat cells, as well as the collagen bundles within the skin, become looser—further accelerating sagging of the fat tissue.
A descended malar fat pad can’t simply keep moving downward indefinitely; instead, it tends to form a deep, valley-like crease. This is what we call the nasolabial fold.
Ultimately, to improve sagging-related nasolabial folds, the following processes are needed:
(1) strengthening the retaining ligaments
(2) strengthening the fibrous septae
(3) adipocyte (fat cell) reduction/destruction
(4) dermal collagen remodeling
I’ll explain which procedures correspond to each of these in the sections below.
2. Volume Loss from Maxillary Bone Resorption (Bone Loss)
With age, bones can also become smaller. In particular, as the maxilla (upper jaw bone) resorbs, a triangular depression can develop next to the nostril.
To improve this type of hollowing, you need to restore volume in the empty space. We use options such as fillers, Juvelook Volume, Sculptra, Olidia, Ultracol, Radiesse, and HILLO WAVE. I’ll cover the differences later.
3. Loss of Skin Elasticity
As we age, collagen breaks down and the skin loses elasticity.
When less-elastic skin repeatedly creases, a visible wrinkle line forms in that area. What people commonly refer to as “nasolabial folds” includes not only the deeper fold created by sagging and volume loss (as explained above), but also the more superficial wrinkle line that can be seen on the surface. This is often the area where makeup tends to settle.
To soften these crease lines, it’s not about filling deep spaces—it’s about supporting the more superficial layers (the upper subcutaneous layer and/or the dermis).
In these cases, we use options such as Elravie Re2O, LAETIGEN, and Ultracol 100.
4. Facial Expression Muscles (Repetitive Folding)
When we smile, multiple facial expression muscles contract, pulling the lips and skin upward. In particular, muscles such as the zygomaticus major, levator labii superioris, and levator labii superioris alaeque nasi (LLSAN) contract. If these muscles attach strongly and close to the skin, they can “tug” the skin inward more forcefully—similar to how a dimple forms.
And as skin elasticity decreases, the skin is pulled more easily, and repetitive folding can worsen the superficial crease lines described above.
To reduce the strength of the skin attachment at the muscle insertion, you can consider microinjections in a way similar to “skin Botox,” but the effect is usually not dramatic. Accepting natural facial expressions and focusing on improving overall skin elasticity is a more realistic way to help prevent worsening of these crease lines.
Treatments That Improve Sagging-Related Nasolabial Folds
To improve sagging of the nasolabial fold area, the key is:
(1) reduction of fat cells in the malar fat pad
(2) strengthening the retaining ligaments and fibrous septae
Now, let’s go through each option one by one.
1. Ultherapy
Ultherapy is a well-known HIFU (High-Intensity Focused Ultrasound) lifting device. It delivers concentrated thermal energy to precise focal points, raising the temperature to above approximately 60°C in a very short time and causing targeted tissue contraction.
In theory, it is known to target the SMAS layer; however, in clinical practice, it is also used to target the subcutaneous fat layer to induce adipocyte reduction.
In particular, because the SMAS layer does not exist in the nasolabial fold region, we often use it with the goal of reducing the size of the malar fat pad. Since nerves are present in this area, we tend to use a 3.0 mm depth cartridge rather than 4.5 mm. (As an exception, for patients with thicker skin and a higher fat volume, we may use 4.5 mm.) If treating only the nasolabial fold area and not other regions, around 100 lines/shots is usually sufficient.
2. CoolSoniq
CoolSoniq is also a HIFU lifting device. Because it incorporates a cooling function, it tends to be less painful. Most importantly, unlike Ultherapy, it comes in a pen-type format, which makes more precise treatment possible.
Especially for nasolabial folds, when using Ultherapy with a larger handpiece, the handpiece can catch on the nose, making it difficult to treat areas close to the nostril. For this reason, recently, for patients whose main concern is sagging in the nasolabial fold area, I often recommend CoolSoniq over Ultherapy. Typically, about 2,000 shots are needed.
3. XERF
If the two options above are ultrasound-based lifting, XERF is a lifting device based on radiofrequency (RF). Unlike Thermage or Density, it allows depth control—so it can provide not only tightening but also lifting, which is a key advantage.
In DEEP mode, the 2 MHz RF energy travels along the fibrous septae between fat cells and induces contraction of the septal network. This is different from Ultherapy and CoolSoniq, which primarily induce fat cell reduction. Because the mechanisms are different, combining them appropriately is often the best strategy.
In addition, when XERF is used in SHALLOW or MIDDLE depth modes, it can improve skin elasticity and help soften superficial crease lines. This is an option I recommend for those who want to improve overall skin firmness and elasticity as well.
4. Fat-Dissolving Injections
Fat-dissolving injections can also be useful in improving sagging around the nasolabial area. Each clinic has its own proprietary formula, so the mechanisms and results can vary slightly, but personally, I find deoxycholic acid–based formulations to be the most effective.
Although these may cause some swelling temporarily, the results are often reliable and cost-effective. Therefore, for patients who find HIFU or RF lifting procedures expensive, this can be a good alternative option.
5. Emface
The procedures I’ve explained so far—Ultherapy, CoolSoniq, XERF, and fat-dissolving injections—use heat or chemical reactions to contract and remodel tissue. Emface, however, provides lifting in a more natural and physiological way.
It strengthens and tightens the zygomaticus major muscle, which lies deep beneath the skin, thereby pulling the overlying soft tissue (including the malar fat pad) upward. Because it uses synchronized RF and HIFES (High-Intensity Facial Electrical Stimulation) technology, it enhances muscle tone and promotes collagen remodeling at the same time.
The main advantages of Emface are its minimal discomfort and virtually no downtime—it can even be done during lunch breaks. However, the downside is its relatively high cost.
Summary for sagging-type nasolabial folds:
Basic combination: CoolSoniq + XERF
Advanced combination: CoolSoniq + XERF + Fat-Dissolving Injections + Emface
Treatments for Volume-Loss–Related Nasolabial Folds
The main advantage of volumizing procedures for hollow nasolabial folds is that the results are both immediate and cost-efficient. However, it’s essential not to simply “fill the hollow” but to inject the product into the correct anatomic plane, depending on the shape and depth of the hollow.
For example, to correct a deep depression near the nostril, you should fill the Ristow space, which lies just above the periosteum. To soften the shadow along the nasolabial line itself, you should inject into the superficial subcutaneous layer along the fold. Most cases benefit from treating both layers. Let’s look at the various volumizing options.
1. Hyaluronic Acid Fillers
In Korea, when we say “filler,” we usually refer to hyaluronic acid (HA)–based fillers. Popular brands include Belotero, Juvéderm, and Restylane. HA is a naturally occurring substance in the skin, making it biocompatible and safe with minimal foreign-body reactions.
Its advantages are immediate results and high moldability—it can be shaped to achieve the desired contour, and if the patient isn’t satisfied, it can be dissolved with hyaluronidase.
The downsides are a relatively short duration (around 12 months) and a rare but serious risk of vascular occlusion leading to skin necrosis or blindness if injected into a vessel. There’s also a small chance of product migration if injected improperly, though this can be prevented by using the right filler type and injection plane.
For deep nasolabial depressions, firmer products like Juvéderm Voluma or Restylane Lyft are typically used, injecting about 1–2 cc per side. To treat the shadow along the fold, softer fillers like Juvéderm Volift or Restylane Volyme can be placed in the subcutaneous layer (around 1 cc per side).
Because nasolabial injections require anatomical precision, it’s best to see an experienced injector.
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Tips for Safe and Effective Nasolabial Filler Treatments
(1) Use a Cannula to Prevent Vascular Complications
Many physicians agree that needle injections are simpler, but using a blunt cannula (e.g., 23 G) greatly reduces the risk of intravascular injection, especially into the facial artery, which could otherwise lead to retinal artery occlusion and vision loss. If a needle must be used, always aspirate for at least 8 seconds before injecting to confirm safety.
(2) Correct Injection into the Ristow Space
When using a needle, always ensure you feel bone contact to confirm placement just above the periosteum, and aspirate again before injection. With a cannula, enter at a 30–45° angle and carefully feel for the “pop” as you pass through fascial layers. Proper placement minimizes migration risk.
2. HILO WAVE
For patients concerned about the foreign-body sensation or vascular side effects of conventional fillers, HILO WAVE—a dual-molecular-weight HA filler—can be a great option. It contains both high- and low-molecular-weight HA with minimal cross-linking.
Because it’s only lightly cross-linked, it’s less likely to completely occlude a vessel or cause lumpiness if accidentally injected intravascularly. The high-molecular-weight HA provides volume, while the low-molecular-weight HA integrates into the dermis, improving skin elasticity and hydration.
The trade-off is a shorter longevity compared to standard HA fillers. Still, for patients who prioritize safety and natural results, HILO WAVE is an excellent choice.
3. Juvelook Volume, Sculptra, and Olidia
These are collagen biostimulators made of poly-(D,L-lactic acid) (PDLLA), a synthetic polymer that safely induces collagen synthesis through a controlled inflammatory response. Although the particle sizes vary slightly among products, the principle and results are similar.
They’re supplied as lyophilized (freeze-dried) powders that must be reconstituted with normal saline before injection. These work well for filling the subcutaneous layer of the nasolabial fold but are not ideal for deep Ristow-space correction, because once the saline is absorbed, only the PDLLA particles remain to stimulate collagen formation. The mechanical lift is therefore limited at deep bony levels.
For patients who also have mid-cheek hollowing along with nasolabial folds, these products provide a cost-effective way to achieve both volumization and skin-firming effects.
4. Radiesse
Radiesse is based on calcium hydroxylapatite (CaHA) microspheres suspended in a carboxymethyl cellulose (CMC) gel. The CaHA particles provide immediate volume and stimulate collagen production by mechanically activating surrounding fibroblasts.
Unlike PDLLA stimulators (Juvelook Volume, Sculptra, Olidia), Radiesse maintains shape right after injection because of its gel carrier. By varying the dilution ratio, it can either serve as a volumizer or primarily as a collagen stimulator.
In my experience, I often mix two different dilutions in a single session to target both deep and superficial layers simultaneously. Because the dilution technique requires skill, it’s best performed by experienced physicians.
Although collagen stimulators may sound inherently safer than fillers, hypersensitivity reactions can occur, leading to granulomatous nodules, which are difficult to treat once formed.
5. Ultracol 200
For those who want a safer collagen stimulator with a lower risk of nodules, Ultracol 200 is a good alternative. It’s made of PDO (polydioxanone)—the same dissolvable material used in surgical sutures.
Because PDO degrades relatively quickly (around 6 months), the risk of nodules is lower. However, shorter persistence also means the collagen-stimulating effect is milder. Therefore, Ultracol 200 is recommended for patients who prefer a gradual and safe collagen-boosting treatment over an aggressive one.
Summary of Volume-Restoring Treatments
Treatment | Main Benefit | Drawbacks |
|---|---|---|
HA Filler | Immediate, predictable volume correction | Possible foreign-body sensation, vascular risk |
HILO WAVE | Safe, natural feel, instant result | Shorter duration |
Juvelook Volume / Sculptra / Olidia | Collagen stimulation + volume restoration over larger areas | Cannot lift deep hollows strongly; risk of nodules |
Radiesse | Improves both deep hollows and skin elasticity simultaneously | Higher price; requires skilled technique |
Ultracol 200 | Safer, lower risk of nodules | Weaker collagen-stimulating effect |
Treatments for Superficial Crease-Type Nasolabial Lines
Up to this point, we’ve discussed treatments that address the fold portion of the nasolabial area caused by sagging and volume loss.
However, in some patients—particularly those with long-standing folds or with expression muscles that attach very close to the skin—a visible crease line can form, as seen in the example below.
These fine lines are located in the dermis or epidermis, not in the deeper subcutaneous tissue, so they need to be treated by stimulating collagen production from the skin’s surface inward, rather than filling from below.
Let’s take a look at the main treatment options.
1. Ultracol 100
Ultracol 100 is a collagen stimulator made from polydioxanone (PDO), the same biocompatible material used in dissolvable surgical sutures.
Unlike Ultracol 200, which has larger particles suited for deeper areas, Ultracol 100 has smaller particles, making it ideal for fine wrinkles, creases, and enlarged pores.
Compared to PDLLA-based skin boosters like Juvelook Skin Booster, Ultracol 100 is safer for manual, superficial microinjections, as PDLLA products carry a higher risk of forming nodules if injected too close to the surface.
Ultracol 100 provides a gentle, controlled collagen induction process, suitable for thin or delicate skin.
2. Retizen
Retizen is not a collagen stimulator but a product that contains Type I collagen extracted and refined from porcine sources.
It comes in liquid form, allowing for injection in small microdroplets to create tiny “embossed” papules along fine wrinkle lines—similar to how Rejuran Healer is administered.
Because Retizen delivers collagen directly, it’s particularly effective for improving surface texture and reducing fine creases.
Its advantage lies in having almost no risk of granuloma formation, but as it is derived from porcine collagen, allergic reactions can occur in sensitive individuals.
3. Elravie Re2O
Elravie Re2O is a newer human-derived ECM (extracellular matrix)–based skin booster that contains collagen and elastin.
Because it’s formulated from human tissue, it has a much lower chance of allergic response compared to Retizen.
It is supplied as a powder that requires rehydration before use. The injection technique is slightly more advanced because if the product isn’t fully dissolved or becomes clumped, small nodules may form.
Unlike Retizen, which is injected just beneath the surface, Re2O is usually placed a bit deeper, within the mid-dermal layer.
A typical syringe contains 5 cc, which is enough to treat not only the nasolabial area but also improve overall facial firmness and elasticity at the same time.
Frequently Asked Questions
Q. What about thread lifting?
A. Thread lifting can temporarily elevate sagging tissue, but its effectiveness for nasolabial folds is limited.
The barbed threads used in most lifting procedures are designed to anchor into dense fascia, such as the jawline area. However, the nasolabial region mainly consists of soft fat tissue, where barbs cannot anchor well.
As a result, the threads often lose tension within days, and the fold returns quickly.
That said, because thread lifts can create short-term visible tightening, they can still be considered for special occasions or events when immediate improvement is desired, knowing the results may be temporary.
Q. Can skincare or facial massage help?
A. Functional skincare products that boost skin elasticity can slightly soften superficial crease lines, but they cannot correct actual sagging or deep structural folds.
Similarly, massages may temporarily improve circulation and lymphatic drainage, but they cannot reverse the anatomical changes that cause nasolabial folds.
Final Thoughts
Today, we explored the various causes and treatment options for nasolabial folds, one of the most common aesthetic concerns with aging.
Because the causes—whether sagging, volume loss, loss of elasticity, or muscle-related folding—differ from person to person, the best approach should always be customized to each individual’s facial anatomy, budget, and goals.
I always recommend starting with a personalized consultation to identify the exact type and cause of your nasolabial folds.
By understanding the underlying structure, we can design a treatment plan that effectively improves the fold’s depth, skin elasticity, and overall facial harmony.
This is Dr. Dohoon Kim from ODE Clinic, Seoul.
Thank you for reading!
Author: Dr. Dohoon Kim, Chief Director of ODE Clinic
Specialty: Anti-aging (Lifting, Volumizing, etc.)