Smile lines (nose-to-mouth) and marionette lines (mouth-to-chin) deepen when the cheek above them drops or deflates and the skin folds over the fixed crease at the edge of the lip. The cheek drops as its ligaments loosen with age; it deflates as the cheekbone loses bone and fat; and the skin over it loses collagen. Repeated expression, sun and smoking speed all three. Which of these is behind your lines decides whether they need lifting, restoring, tightening or simply softening, and Dr Nish Shah MD identifies that at consultation.

Usually not as the first step, because the line is a symptom of what the cheek above it has done, and filling it alone pads out the crease while the cause remains. Where the cheek has dropped, filler in the fold adds weight to a lower face that is already heavy. Where the cheekbone has deflated, restoring it lifts the fold from above. Light filler in the line itself is the last step, added only if a line remains, and in younger faces with the cheek in place it is sometimes the only step needed. Dr Nish tells you which at consultation.

Threads lift a cheek that has dropped; filler restores a cheekbone that has deflated; which works better depends on which has happened to your cheek, and Dr Nish decides at consultation. If the cheek pad has slid down and the fold has deepened with a heavier lower face, a PDO midface thread lift moves it back on the day and the fold softens from above. If the cheekbone has flattened and the face looks tired rather than heavy, reversible cheek filler rebuilds it and lifts the fold with it. Many faces from the mid-40s need both, in order.

At Medisha Clinic in Mayfair, treating smile and marionette lines costs from £350 for light filler in the fold to £750 for a PDO midface lift. Cheek filler is £350 per ml, usually 1–2 ml per side. Smile or marionette line filler is £350 per ml. Sofwave™ full face is £1,400 where the lower face has loosened. Chin filler is £350 per ml. Reviews are included. Consultation with Dr Nish is £50, redeemable in full against treatment. The clinic is at 58 South Molton Street, Mayfair, London W1K 5SL, 3 minutes from Bond Street station.

Because the filler went into the fold while the cheek above it had dropped, so it added volume to a lower face that was already too heavy. This is the commonest reason smile-line filler disappoints. The answer is to lift the cheek with threads or restore the cheekbone with filler first, which softens the fold from above, and to use little or no filler in the line itself. If you have filler in the fold now, it can be dissolved with the enzyme kept on site before the cause is treated.

A PDO midface lift lasts 12 to 18 months; cheek filler 12 to 18 months; filler in the fold itself 6 to 12 months because the area moves; Sofwave™ is maintained with a yearly session. Treating the cause tends to last longer than filling the line, because the structure that folded the skin has been moved or rebuilt rather than padded. Dr Nish reviews you at 2, 4 or 12 weeks depending on the treatment and sets out a maintenance schedule.

Yes — marionette lines usually come with downturned corners and a receding chin, and they are treated as one. Restoring the chin takes the weight off the corners; a small amount of filler at the corners turns them level; and the line from corner to chin is softened last, only if it remains. This is planned as peri-oral rejuvenation rather than as separate line-filling, and performed by Dr Nish in one visit.

Discomfort is mild and downtime is short. Filler is placed under numbing cream or local anaesthetic, with possible swelling or a small bruise for a few days. A thread lift is performed under local anaesthetic, with mild swelling for about 48 hours and 2 weeks of care. Sofwave™ is performed under numbing cream and has no downtime. Most patients return to work the same day after filler or Sofwave™ and the next day after threads. Dr Nish gives written aftercare and his direct contact details on the day.

The crease from nose to mouth exists at every age; it becomes a line at rest in the 30s and a fold in the 40s as the cheek above it drops or deflates. In the 30s, with the cheek in place, light filler or Sofwave™ is usually enough. From the mid-40s the cheek itself usually needs lifting or restoring first. There is no upper age limit; the decision is based on what the cheek has done, not your age.

Side effects are mild and temporary for most patients: swelling, a small bruise or tenderness for a few days after filler; swelling and occasionally a visible thread end after threads, which settles or is corrected. The rare but serious risk with any filler is injection into a blood vessel, and the nose-to-mouth area has important vessels, which is why Dr Nish places filler deep with each deposit checked and keeps the dissolving enzyme on site. All risks are explained at consultation.

Yes — where the cause is a dropped cheek, a PDO midface thread lift softens the fold from above with no filler; where the cause is loosened skin, Sofwave™ tightens it with nothing injected at all. Filler is only essential where the cheekbone has deflated, and even then it goes on the bone, not in the line. Dr Nish tells you at consultation which answer your face needs and whether filler is part of it.

Medisha Clinic treats the cause of smile lines before the line itself, and because Dr Nish Shah MD performs threads, structural filler and Sofwave™, he has no reason to fill a fold that should be lifted. He is Brand Ambassador and Key Opinion Leader for dermal fillers and PDO threads, the Senior International Clinical Trainer at Derma Medical who teaches both to other doctors, and an official certified Sofwave™ practitioner and partner. With over 30,000 non-surgical treatments he is one of the most experienced aesthetic doctors in the UK and London. The dissolving enzyme is on site at every appointment. Rated 5.0 on Google from 128 reviews. 58 South Molton Street, Mayfair, London W1K 5SL, serving Mayfair and Marylebone.