Deep wrinkles form from a combination of repeated muscle movement, volume loss, and loss of skin elasticity with sagging. If expressions are the cause, Botox is typical; if wrinkles deepened from hollowing, filler; if sagging is central, lifting; and if sagging is severe, a thread lift or facelift. Trying to solve every wrinkle with one treatment easily leads to overtreatment.
Contents
Why do deep wrinkles form?
As we age, collagen and elastic fibers in the dermis decrease, skin elasticity falls, and the structures supporting tissue weaken, so the cheeks and lower face sag. Add facial volume loss, and existing wrinkles deepen. When smiling or frowning is repeated, wrinkles that at first appeared only with expressions become wrinkles that remain even at rest.
- Expression lines: forehead, between the brows, around the eyes
- Volume loss + sagging: nasolabial folds, marionette lines
- Loss of elasticity: neck lines
How do the treatments differ?
| Treatment | Main action | Suited to |
|---|---|---|
| Botox | Reduces muscle movement | Expression lines on the forehead, between the brows and around the eyes |
| Filler | Replaces volume in hollow areas | Deeply etched wrinkles, volume loss |
| Laser and radiofrequency lifting | Improves skin elasticity and sagging | Fine lines, loss of elasticity, mild sagging |
| Thread lift | Physically lifts sagging tissue | Moderate sagging |
| Facelift | Surgically corrects sagging skin and tissue | Severe sagging and deep wrinkles |
Which wrinkles does Botox work well for?
Botox temporarily reduces the movement of the muscles that create wrinkles. In a meta-analysis of 7 placebo-controlled randomized trials (1,474 patients), Botox for frown lines was clearly more effective than placebo and also improved frown lines at rest, with no difference in side-effect frequency compared with placebo.[1]
However, static wrinkles that are already deeply etched may not respond enough to Botox alone. The effect usually appears after a few days, the change can be seen within 1–2 weeks, and it lasts for a period before gradually wearing off.
Related readingHow to look at forehead wrinkles by type is covered in "Forehead wrinkles: which treatment suits me? An approach by type" (Korean).
How is filler used for deep wrinkles?
Filler is a treatment that places material under the skin to fill hollow areas. It is used when, as with nasolabial folds, volume loss has deepened the fold. In a meta-analysis of 14 randomized trials (1,190 patients) of hyaluronic acid filler for nasolabial folds, the degree of improvement differed by filler type (monophasic vs biphasic).[2]
Filler can cause bruising, swelling, pain and lumps, and rarely infection or vascular complications, so you should receive an approved product from a medical professional. If sagging is also present, repeating filler alone can make the face look unnecessarily heavy.
In a systematic review of 19 studies on facial hyaluronic acid filler, common side effects included swelling, pain, redness, bruising, lumps and firmness, and more swelling and lumps were reported in the nasolabial fold area than in other areas.[3]
Common myths and facts — treatments for deep wrinkles
| What many people think… | What the evidence shows |
|---|---|
| "Even deep wrinkles disappear with Botox." | Botox works well on expression lines, but has limits for static wrinkles that are already etched. |
| "Filling nasolabial folds with filler is all it takes." | If sagging is the cause, filler alone is not enough and can make the face look heavy. |
| "Lifting also fills hollow areas." | Lifting addresses elasticity and sagging; it does not directly replace volume. |
| "The more treatments at once, the better." | They are combined when needed, but not everyone needs combination treatment. |
In what order should I check before choosing a treatment?
- Check the location of the wrinkle
- Distinguish expression lines from static wrinkles
- Check the degree of skin elasticity and sagging
- Check for volume loss
- Choose the matching treatment
If sagging is pronounced, a thread lift may be more suitable; if the skin is very loose and sagging around the cheeks and jaw is severe, a facelift may be more suitable.
Related readingCriteria for considering a facelift for nasolabial folds with severe sagging are covered in "How to get rid of nasolabial folds: when is a facelift needed?" (Korean).
In wrinkle consultations, I ask patients, "Please smile — now relax your face." Wrinkles that show only when smiling point to Botox; wrinkles that remain at rest point to volume or sagging. These 30 seconds prevent more unnecessary treatments than anything else.
Deep wrinkles call for Botox, fillers, lifting or a facelift depending on which of muscle, volume, elasticity or sagging is the cause. Choosing a method that fits the cause of your wrinkles, rather than a trending treatment, is how to avoid overtreatment.
🔬 Supporting research
Peer-reviewed international journal articles that support this article. Click a title to open the PubMed abstract.
- Plastic and reconstructive surgery 2015 — meta-analysis of randomized controlled trials, 7 studies · 1,474 patients Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Glabellar Lines: A Meta-Analysis of Randomized, Placebo-Controlled, Double-Blind Trials. Key finding: Botox effective for frown expression lines — already-etched static wrinkles need another approach In text [1] · PMID 26313835 · DOI
- Journal of cosmetic dermatology 2022 — meta-analysis of randomized controlled trials, 14 studies · 1,190 patients The selection of hyaluronic acid when treating with the nasolabial fold: A meta-analysis. Key finding: nasolabial fold filler results also differ by product In text [2] · PMID 35037733 · DOI
🎬 Watch — Dr. Park Seong-Soo · BongBong Plastic Surgery
Related videos from BongBong Plastic Surgery's official channel and Dr. Park Seong-Soo's channel. Videos are in Korean and play on YouTube.
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4:57 Facial muscle exercises that worked even for a doctor (the difference between lifting and tightening) (Korean) Dr. Park's channel · 2024.04.18 -
3:00 Are nasolabial folds genetic? Why nasolabial filler gave me a monkey-like look (Korean) BongBong official · 2019.01.08 -
1:03 Recommended for beginners: what's the difference between filler and Botox? (Korean) BongBong official · 2018.08.03
Frequently asked questions (FAQ)
Will Botox alone make deep wrinkles disappear?
No. Botox is effective for expression lines, and its effect on deeply etched static wrinkles is limited. Filler or treatment for elasticity and sagging may be needed.
If my nasolabial folds are deep, should I just get filler?
Hollow areas can be refined with filler, but if sagging is also present, sagging should be assessed rather than repeating filler alone.
Can lifting improve deep wrinkles?
It can help wrinkles deepened by loss of elasticity and sagging, but if volume loss is the cause, lifting alone will not solve it.
Can I get Botox and filler together?
They work differently, so they can be used together when needed. However, not everyone needs combination treatment.
When is a facelift considered?
It is considered when the skin is very loose and sagging around the cheeks and jaw is severe, so that sufficient improvement cannot be expected without surgery.
📖 References
Click a [number] in the text to jump to its source, and ↩ to return. Only papers whose title, journal and year were verified on PubMed are listed.
- ↩ Guo Y, Lu Y, Liu T, et al. Efficacy and Safety of Botulinum Toxin Type A in the Treatment of Glabellar Lines: A Meta-Analysis of Randomized, Placebo-Controlled, Double-Blind Trials. Plast Reconstr Surg. 2015;136(3):310e-318e.PMID 26313835 · DOI— meta-analysis of placebo-controlled randomized trials, 7 studies · 1,474 patients — Botox clearly improves frown lines, no difference in side effects
- ↩ Peng T, Hong WJ, Fang JR, Luo SK. The selection of hyaluronic acid when treating with the nasolabial fold: A meta-analysis. J Cosmet Dermatol. 2022;21(2):571-579.PMID 35037733 · DOI— meta-analysis of randomized trials of HA filler for nasolabial folds, 14 studies · 1,190 patients — degree of improvement differs by filler type
- ↩ Colon J, Mirkin S, Hardigan P, Elias MJ, Jacobs RJ. Adverse Events Reported From Hyaluronic Acid Dermal Filler Injections to the Facial Region: A Systematic Review and Meta-Analysis. Cureus. 2023;15(4):e38286.PMID 37261136 · DOI— systematic review of side effects of facial HA filler, 19 studies — swelling, pain, bruising, lumps and more, varying by area
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