Wrinkles Around the Mouth: A CaHA, Ultherapy and RF Combination

I'm Dr. Jong Hoon Lee, one of the doctors at Gangnam HERA in Seoul. I've been in practice for more than 25 years, co-authored the textbook LIFTINGOLOGY, and I'm a board member of the Korean Society of Aesthetic Surgery and the International Petit Medical Society. Wrinkles around the mouth, starting with smile lines, are one of the most common worries I hear. In this video I go through the different lines that form around the mouth and show the combination we use at HERA for the fine, crepey lines that filler alone doesn't fix well.

My short answer: work out the cause first — volume, sagging, elasticity or fine lines. For fine lines around the mouth I combine shallow Ultherapy, a needle radiofrequency device and CaHA, then time touch-ups to the CaHA, because it keeps building collagen long after the devices have worn off.

Which wrinkles appear around the mouth, and when?

They change decade by decade.

• 20s–30s: nasolabial folds (smile lines) start to form.
• Marionette lines below the corners of the mouth follow.
• 40s–50s: as skin around the lips loses elasticity, and with a lot of smiling, vertical lines appear beside the mouth, and smile lines may extend further when you smile.
• 50s, 60s, 70s: fine lines above and below the lips — the ones some people call "cat whisker" lines.

The causes also vary. A smile line can come from a deep groove, from a lot of fat beside the fold, from sagging, or simply from aging. There are many muscles around the mouth. With age they shrink too: fibers decrease, muscle tone drops and skin elasticity falls, so fine lines are almost inevitable.

How do you choose the right treatment for mouth wrinkles?

By separating volume, sagging, elasticity and fine lines — and accepting that most people have more than one. Which area is most deeply lined? Is the main problem lost volume, sagging, poor elasticity, or surface fine lines? The answer points to the tool:

• Volume: filler is the main answer. For people who don't want filler — and there are more of them now — collagen-stimulating injectables (biostimulators) such as Juvelook, or collagen itself, are alternatives.
• Sagging: lifting with threads or Ultherapy to restore firmness.
• Fine lines: skin boosters. Juvelook can be injected into the skin, and CaHA can be spread thinly under the dermis.

If your main concern is a deep smile line rather than fine lines, the best Korean filler for nasolabial folds covers that question, and a real patient's nasolabial fold filler review shows the process.

What combination does HERA use for fine lines around the mouth?

Three layers: shallow Ultherapy, needle RF, then CaHA. Each device behaves a little differently, so these days combinations are common.

1. Ultherapy with a shallow 1.5 mm tip. Most people know Ultherapy for lifting the face and firming the neck, but one of its tips works at only about 1.5 mm. Around the mouth, that ultrasound firms the fine lines.
2. A needle radiofrequency (RF) device. Fine needles carry radiofrequency energy a little deeper, building firmness from inside.
3. CaHA. Devices alone may not give a dramatic change straight away, so we add CaHA. Depending on how many lines there are and how deep, around 1.5 mL per side is usually enough. It covers the shallow lines near the smile fold, multiple vertical lines, the "cat whisker" lines, marionette lines and the crepey texture below the lower lip.

The CaHA treatment you will find on our menu is DCLASSY CaHA Filler. It is placed around the mouth, not in the lips themselves. If you want to compare CaHA with other collagen boosters, I explain the differences in Re2O vs CaHA.

Does the combination hurt?

Less than its reputation suggests. Ultherapy is known as a painful device, but at 1.5 mm there is very little pain — we use the same depth a lot around the eyes. With the needle RF, both needle depth and the energy at the tip can be adjusted, so if you find it uncomfortable we turn it down. For CaHA we use a nerve block so you don't feel discomfort.

How often, and how long does it last?

Plan touch-ups around the CaHA, about two to three months later. Ultherapy is not something you have often. Needle RF is sometimes repeated monthly. CaHA is usually every two or three months. Because the intervals differ, I ask patients to follow the CaHA schedule.

CaHA does not make collagen surge all at once; it builds slowly over a long time. So I do a touch-up at least two to three months later, and at that point needle RF plus CaHA is usually enough. The devices' own effect may only last around six months, but once collagen starts forming, CaHA keeps stimulating the surrounding tissue gradually for about a year to a year and a half. That is why I tell patients they generally don't need to worry for at least a year — with the caveat that everyone responds differently.

What about bruising and recovery?

Most people go straight back to daily life; redness fades in about a day, and any bruise can be covered with makeup.

• Needle RF uses suction: it draws the skin up slightly so the needles enter precisely without the skin slipping. In very thin skin, after one or two pulls I can tell whether it is likely to bruise.
• CaHA moves back and forth under the skin with a cannula, which does not usually bruise easily on its own.
• Age and medication matter. People who worry about fine lines around the mouth are often in their 40s–50s, or 60s and over if there are lip lines, and bruising becomes easier with age. Many also take medication. We talk about blood thinners or aspirin at least a week in advance so that, if your own doctor agrees, they can be paused for a few days.

Ultherapy at this depth doesn't leave visible marks. Needle RF delivers heat, so there can be slight redness, which usually goes within about a day. Mild swelling, bruising and, rarely, other complications are possible with any injectable, and results vary. For Ultherapy specifically, Ultherapy side effects is worth reading.

The honest limits

CaHA results depend heavily on the injector. How much saline it is mixed with, at what ratio, how it is injected, in how small portions and at which layer — these change the outcome enormously. So I'd encourage you to look for doctors with a lot of experience with it. This combination also works on fine lines and firmness; it is not a substitute for filler in a deep groove or for a lift when the problem is real sagging. International patients receive an itemized written estimate before treatment, pay the same as local patients and have an English interpreter throughout. You can see real HERA results in our before-and-after gallery.