The treatment of the nasolabial fold by injection of hyaluronic acid is today one of the most frequently performed aesthetic-oriented medicine procedures. It appeals thanks to its simplicity, its immediate effectiveness, and its ability to subtly restore the harmony of the face. However, despite its minimally invasive nature, this procedure remains a medical act, and as such, it may lead to side effects, transient reactions, or even, in rare cases, more serious complications.
It is essential that the patient be clearly informed of this before making any decision, not to worry them unnecessarily, but to allow an informed choice based on a realistic understanding of the treatment. The nasolabial fold, due to its anatomical position and vascular richness, requires rigorous technical mastery. When the treatment is performed by an experienced physician, undesirable effects are rare and generally mild. But they do exist, and must be addressed with seriousness and transparency.
The vast majority of effects observed after a hyaluronic acid injection in the nasolabial fold are related to a local reaction : they occur naturally in response to the introduction of a foreign body into the dermal or subcutaneous tissue. These reactions are predictable, temporary, and mild, and disappear spontaneously within a few hours or days.
Among the expected reactions, a slight redness at the injection site, mild edema along the fold, or a local feeling of tension are frequently observed. These manifestations are due to the mechanical penetration of the cannula or needle, as well as the presence of the gel in previously untouched tissue. They do not constitute a complication, but a common post-procedure effect that the physician anticipates and monitors.
In some cases, a localized bruise may appear, particularly if a small superficial vein has been grazed. This small bluish mark presents no danger and resolves within a few days. It is recommended to avoid anti-inflammatory drugs and anticoagulants before the injection to limit this risk.
When certain manifestations after the injection persist beyond 7 to 10 days, or are accompanied by abnormal signs, a medical reassessment is required. This does not necessarily indicate a serious complication, but a local reaction that requires treatment adjustment or simple monitoring.
Some patients report a sensation of a nodule or small lump under the skin at the fold. This may correspond to a transient accumulation of product, poor tissue integration, or a slightly off-center deposit of hyaluronic acid. Most often, this irregularity diminishes spontaneously, or can be corrected by a gentle massage performed by the physician. In rarer cases, a hyaluronidase injection can resolve the issue without sequelae. Dr. Romano does not perform hyaluronidase injections.
Some undesirable effects can occur when an indication is poorly determined, an inappropriate hyaluronic acid is chosen, or the injection technique lacks precision. When the gel used is too volumizing, too firm, or injected too superficially, it may result in an excessive correction appearance, with the formation of a visible ridge at rest, or even the appearance of a Tyndall effect — a blue-gray coloration under the skin, due to improper light diffusion through the product.
Although medically benign, this type of imperfection affects the aesthetic quality of the result. Its prevention relies on a thorough knowledge of the physicochemical properties of the injected hyaluronic acid and perfect technical mastery. In the case of a result deemed unaesthetic, the product is resorbable.
Furthermore, exclusive use of the needle, rather than the cannula, may increase the risk of bruising or accidental intravascular injection. The cannula ensures superior vascular safety compared to the needle, making it, for many physicians, the preferred tool in the treatment of the nasolabial fold.
Although serious complications are rare, they do exist and must be fully explained during the consultation. One of the most feared is vascular occlusion, which occurs when an injection compresses or obstructs a blood vessel, preventing tissue perfusion downstream. In the nasolabial region, richly vascularized, this risk is theoretically present, particularly in patients with a history of local surgery.
Warning signs include sudden pain, local pallor, a burning sensation, or loss of sensation. In extreme, untreated cases, this can lead to skin necrosis, or, in very rare cases, ocular complications if there is an embolism in the orbital circulation.
That is why any injecting physician must be trained to recognize the early signs of a vascular complication and have an emergency management kit, including sufficient hyaluronidase. The speed of intervention is critical. Injected within minutes following the incident, the antidote often allows this complication to be treated without sequelae.
Hyaluronic acid-based products used in aesthetics are of very high purity, non-animal in origin, and have an exceptional tolerance profile. However, like any biological product, they can trigger immune reactions in some patients.
Immediate allergic reactions are extremely rare, but when they occur, they take the form of extensive edema, itching, or, in severe cases, anaphylaxis. The physician must always ask the patient about their allergic history and be equipped to intervene if necessary.
Granulomas correspond to a chronic inflammatory reaction to a foreign body. They can appear several weeks or months after the injection, and manifest as an inflamed nodule, sometimes red or tender. Their management relies on medical treatment (local or systemic corticosteroids) or enzymatic therapy, depending on their nature.
These reactions remain exceptional, occurring in less than 0.1% of cases according to literature data.
The quality of the skin directly influences how it reacts to injections, particularly in the nasolabial fold. Thin skin, weakened by sun exposure, age, or significant laxity, is generally more sensitive to injectable products. In this case, hyaluronic acid may take longer to integrate, sometimes resulting in a slight temporary visibility of the product or a transient local reaction.
Conversely, thicker or fibrous skin, with high tissue density, may react differently: if the injection is performed too superficially, small temporary nodules may appear.
That is why a careful analysis of skin quality, combined with a perfectly adapted technique, is essential. It not only helps prevent these undesirable effects but also ensures a harmonious and natural correction, while allowing targeted management of any reactions.
In patients who have previously received injections in the nasolabial fold or other areas of the face, the occurrence of side effects may be influenced by the presence of residues from previous products, sometimes invisible on clinical examination. Some older formulations, or the injection of large quantities, may have left areas of fibrosis or chronic inflammation, which react unpredictably to a new injection.
It is therefore essential, during the first consultation, to reconstruct the patient’s aesthetic history in detail and to identify any previously treated areas. If doubt persists, the use of high-frequency ultrasound can help visualize residual product deposits and adapt the injection strategy accordingly. This level of precision helps prevent unforeseen interactions and significantly reduces the risk of side effects.
Article written by Dr Romano Valeria
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