Nasolabial Folds: What Does Ulthera Lift — and What Can RF Tighten When That Isn't Enough?

Summary in Three Lines

• A nasolabial fold is where a fixed line on the inner side, where muscle is anchored into the skin, meets the cheek fat on the outer side, which hangs between fibrous columns. When the structures supporting the cheek fat loosen, it appears to spill over the fixed line, creating a step in height and a shadow across the line.
• Ulthera uses a deeper transducer to pull up the supporting layer on the cheek side (the SMAS) and a shallower one to tighten the fibrous columns holding the cheek fat. Rather than erasing the line, it works by reducing the bulge and the step in height above it; the fixed line where muscle is anchored remains.
• For folds driven mainly by reduced skin elasticity rather than sagging, we consider monopolar RF (at ABLE Dermatology, Density), which heats the dermis and fibrous columns broadly; when the causes are mixed, both together; and when the front of the cheek has hollowed markedly, volume restoration first. The two devices are not ranked; they work on different layers.

Why Nasolabial Folds Form — A Fixed Line Anchored by Muscle, with Cheek Fat Resting on Top

It is easy to think of a nasolabial fold as nothing more than a crease in the skin, but the structure actually differs on either side of the line. In a cadaver tissue study that cut the nasolabial region of 7 donor bodies into thin serial sections and rebuilt them in three dimensions (Sandulescu et al., 2019), on the inner side of the line, toward the upper lip, short, dense fibrous columns bound the zygomaticus major muscle to the skin, and muscle cells ran along those columns directly into the dermis. In effect, muscle and skin are tied tightly together there by short cords.

On the outer, cheek side of the line, by contrast, fibrous columns rose vertically from the facial muscles to the skin, standing side by side with fat filling the spaces between them (Sandulescu et al., 2019). Anatomists call these fibrous columns the retinacula cutis: bundles of fibers that connect the skin to the fascia beneath it.

Put together, the inner border of the fold is close to a fixed line that does not move easily, while the cheek fat on the outer side is suspended between fibrous columns. When these columns loosen, the cheek fat can appear to spill over the fixed line, creating a step in height across it. The explanation that sees facial aging as fat sliding downward as the retinacula cutis and the SMAS loosen (the fat-gliding theory) follows the same reasoning. This is an interpretation drawn from structure, but it is exactly why lifting can work on nasolabial folds.

Why the Cheek Fat Descends

Dr. Jeong sees the starting point as the deep fat under the eyes and at the front of the cheek. When deep fat deflates, the superficial fat loses its support and slides down to rest on top of the fold; this explanation comes from a cadaver study of 14 hemifaces (Rohrich et al., 2008). Conversely, a CT study of 109 people (Tower et al., 2020) found that deep cheek fat actually increased with age. So whether a particular face truly has deflation needs to be checked separately.

What Ulthera Pulls in a Nasolabial Fold — Lifting the Supporting Layer, Tightening the Fibrous Columns

Ulthera (Ulthera Prime) is a focused ultrasound (HIFU) device that concentrates ultrasound at a single point to create rows of small thermal coagulation points at a set depth. Collagen where the coagulation points form is denatured by the heat and contracts, and new collagen then forms over several months. In a nasolabial fold, it does two different jobs at two depths.

The Deeper Transducer (4.5 mm) — Lifting the Supporting Layer (SMAS) of the Cheek Above the Fold

The 4.5 mm transducer targets the fascial layer known as the SMAS. In an experiment on 6 unfixed cadavers (White et al., 2007), focused ultrasound could create thermal injury zones selectively in the SMAS layer while the epidermis above was preserved, and the higher the energy and the denser the lines of exposure, the more the tissue contracted. The experiment confirmed that delivering heat in points to the fascial layer actually makes that spot contract.

The depth from the skin to the SMAS, however, varies considerably by area and from person to person. In a study that measured the lower face of 200 people by ultrasound (Kwon et al., 2022), the SMAS lay deeper in the jowl area than in front of the ear and in the lower cheek, and it ran shallower in older and thinner faces. In addition, the front of the cheek just outside the fold and the area around the mouth have some of the thickest superficial fat in the face (a study of 53 cadavers, Kim et al., 2019), so the same 4.5 mm can end up in the deep fat layer rather than in the SMAS. That is why, for the front of the cheek above the fold, we first check that person's SMAS depth on the Ulthera's real-time imaging screen and treat according to that depth. The depth seen on the screen and the point where the heat actually forms can differ.

As described above, the cheek fat hangs between fibrous columns running from the SMAS up to the skin, so when the SMAS contracts, there is a route by which force can pass to the columns and fat above it. Dr. Jeong designs the direction so that this contraction pulls obliquely outward and upward, toward the cheekbone, at an angle of roughly 45 degrees. The idea is to lift the supporting layer on the cheek side against the direction in which the cheek fat came down.

The Shallower Transducer (3.0 mm) — Tightening the Fibrous Columns (Retinacula Cutis) That Hold the Cheek Fat

The 3.0 mm transducer creates coagulation points in a layer shallower than the SMAS, that is, around the fibrous columns that hold the fat within the cheek tissue that has descended over the fold. In a 2025 expert consensus on MFU-V (Lin et al., 2025), most of the panel likewise summarized the 4.5 mm transducer as targeting the fascial layer and the 3.0 mm transducer as targeting the retinacula cutis. This consensus, however, concerns treatment of the abdomen and arms, so it is only indirect evidence for the face, and the manufacturer describes 3.0 mm as the deep dermis; the layer actually reached differs by area with skin thickness. That is why we treat while viewing the layers on the Ulthera's real-time imaging screen.

Because the fibrous columns stand perpendicular to the skin, Dr. Jeong's view is that laying coagulation points evenly over an area in a crossing pattern, rather than in one direction only, can tighten many columns evenly. The expectation is that as the columns tighten, the sagging of the cheek fat suspended between them lessens and the step in height across the line becomes lower. Pulling up and tightening the layers that support the cheek fat in this way can reduce the bulge above the fold, so that the line looks noticeably softer.

In a Real Face — A Single Case Seen on MRI

So far, this change has been examined on MRI in a single case report (Kim and Choi, 2025). The midface of one 32-year-old man was treated with Ulthera Prime at 4.5 mm and 3.0 mm, and MRI scans taken before treatment and 3 months later were compared: the SMAS had thickened by about 0.1 mm (0.03–0.16 mm), and the fat in the lower cheek had thinned more than the fat in the upper cheek, so the ratio of upper to lower fat thickness increased at all three measured points. It looks as though fat that had gathered lower down shifted back slightly upward and more evenly. As the record of a single person, it is no more than a clue, but it matters as MRI data on how upper and lower fat thickness changed after lifting.

This is Dr. Jeong's treatment approach as far as anatomy can explain it. No study has yet directly compared directions or placement patterns with one another, so this part is a clinical design based on anatomy. Which layer each transducer depth reaches, and what designing the direction means, are covered in detail in Ultherapy Explained.

What Changes with Ulthera — Less a Line Erased Than a Smaller Step in Height

How much things actually improve is what many people want to know. In a prospective single-arm study (Li et al., 2026), 28 women aged 33 to 55 received one focused ultrasound lifting session and were followed for 12 months. The volume and maximum depth of the nasolabial fold region improved most at 3 months, with maximum depth reduced by a mean of 0.28 ± 0.08 mm. The figure may look small, but with nasolabial folds, the step in height above the line and the shadow shape the overall impression more than depth does.

In the same study, response differed with the shape of the fold: wide, short folds improved more than narrow, long ones (Li et al., 2026). That points the same way as the structure described above. In folds where cheek fat rests broadly over the line, a larger share of the problem is something lifting can address; in narrow, long, deeply set folds, a larger share belongs to the fixed line itself. This study had no control group, however, and the name of the device used could not be confirmed, so the figures themselves should be read as a reference only.

So when people say their nasolabial folds improved after Ulthera, it is closer to meaning that the cheek fat above the line has descended less and the step in height has shrunk, rather than that the line has been erased, because the fixed line where muscle is anchored into the skin remains. The border stays; the ledge above it becomes lower. If a fold has formed because cheek fat is resting on it, lifting alone can soften the overall impression considerably.

Folds Where Ulthera Alone Falls Short — Reduced Skin Elasticity, a Hollowed Front Cheek, Severe Sagging

Some folds are not resolved by Ulthera alone. In these cases, other approaches are considered as well, and there are broadly three situations.

Folds Where the Skin Itself, Rather Than Sagging, Is the Problem

This is when the cheek fat has not descended much, but the skin is thin and has lost elasticity, so the line looks creased. Here the dermis accounts for a larger share than the SMAS and fibrous columns that Ulthera mainly works on, so lifting alone changes relatively little. This is Dr. Jeong's judgment; we have not found a study that compares this type on its own.

Folds Where the Front of the Cheek Has Hollowed and Reducing the Fat Layer Further Is a Concern

In the MRI case above (Kim and Choi, 2025), it was not only the lower fat that thinned: fat in the upper, inner cheek also thinned from 6.68 mm to 5.69 mm, by close to 1 mm. In a face where the front of the cheek has already hollowed, this means energy aimed at reducing the sagging area may also reduce areas that ought to provide support.

That does not mean people whose front cheek has hollowed should not have Ulthera. In the same report, the authors wrote that to reduce the risk of fat atrophy, coagulation points should not be overly concentrated in the layer where the fibrous columns lie, with treatment guided by real-time ultrasound (Kim and Choi, 2025). Why cheeks hollow, and how heat acts on fat, are set out in our column on cheek hollowing after Ulthera.

Folds with Severe Sagging

A systematic review of focused ultrasound studies (Contini et al., 2023) listed very severe skin laxity and a BMI over 30 as relative contraindications, because good results became less frequent as laxity and BMI increased. Severe sagging is similar for the RF discussed below, so energy-based treatment alone has limits, and a surgical consultation may sometimes be needed. We do not offer facelift surgery.

What Monopolar RF Tightens — Broad Heating of the Dermis and Fibrous Columns

For folds where the skin itself is the problem, the option Dr. Jeong considers is monopolar RF. The RF device we use is Density, which applies monopolar and bipolar RF in sequence.

Points of Heat, or Broad Heating

RF passes an electric current through the skin, generating heat from the tissue's electrical resistance, and that heat spreads to the surroundings. Where Ulthera places small coagulation points dot by dot at a set depth, monopolar RF heats the dermis and the fibrous columns beneath it over a relatively broad volume.

In a 2004 tissue study (Zelickson et al., 2004), collagen fibrils thickened and their borders blurred down to a depth of 6 mm in bovine tendon exposed to monopolar RF, and in human abdominal skin, expression of the gene that makes type I collagen increased. The interpretation is that heat contracts collagen immediately, and new collagen formation follows.

Where the heat goes is shown by computational modeling. In a computer model study using an RF model with a broad electrode placed on the skin surface (Jimenez Lozano et al., 2013), some of the fibrous columns within the subcutaneous fat absorbed more power than the surrounding fat, especially columns aligned with the direction of the electric field, and that heat spread into the surrounding fat lobules over time.

Taken together, these two studies suggest that what monopolar RF targets is the elasticity of the dermis and fibrous columns that support the skin. As tissue and model studies, they did not look at nasolabial folds directly, but this is how the principle can be understood. Dr. Jeong also considers monopolar RF for folds with a hollowed front cheek, when we would rather not reduce the fat further through focused coagulation (this is Dr. Jeong's judgment; no direct comparative evidence has been found). That heat can reach the subcutaneous fat depending on the settings is discussed in our column on myths about RF lifting.

RF Studies That Looked Directly at Nasolabial Folds

The clinical studies below were done with monopolar RF devices other than Density, so their figures cannot be carried over as results for Density.

In a 2005 prospective study (Kushikata et al., 2005), the nasolabial folds, marionette lines and jowl sagging of 85 Japanese women were treated with monopolar RF and followed for 6 months. On physician assessment, relatively good improvement was seen at 3 months, with further improvement at 6 months. This study had no control group.

There is also a larger study. A 2026 multicenter, randomized, assessor-blind trial (Wang et al., 2026) enrolled 230 adults aged 30 to 60 with mild to moderate skin laxity and analyzed 212. Each participant received a single session with one of two monopolar RF devices, and 3 independent assessors rated the degree of improvement (GAIS) from photographs, focusing on the nasolabial folds. At both day 90 and day 180, most participants in both groups were rated "improved" or more. This means many people were judged in photographs to have improved; it does not mean the depth of their nasolabial folds decreased to the same extent. And because the trial compared two devices with each other, there was no untreated control group.

Who Responded Well to RF

In a 2007 prospective observational study (Sasaki et al., 2007), 25 people treated with monopolar RF were followed for 12 months: the 19 who improved steadily had a mean initial tissue mobility of 3.4 mm, while the 6 who did not respond started at 4.4 mm. In other words, people whose tissue moved more, meaning it was already more lax, responded less. In the same study, less photoaging and shallower wrinkles and folds were associated with a good response, while skin thickness and fat thickness did not predict response. The finding is that responses to RF were more favorable in people whose sagging was milder and whose wrinkles were shallower at baseline.

So for folds where the skin has thinned and creases along with fine wrinkles, we consider addressing skin elasticity first with RF.

Ulthera and RF — Different Layers, Not a Ranking

The two methods differ in how they generate heat and in the layers they mainly reach. The table below summarizes what this article has covered, device by device.

Studies That Looked at the Two Side by Side, and Together

A 2019 randomized split-face study (Alhaddad et al., 2019) followed 20 people for 6 months with evaluator blinding. One side of the face was treated with Ulthera-type focused ultrasound (MFU-V) and the other with monopolar RF, and face and neck laxity grades improved on both sides from day 30 and remained improved through day 180. The study did not look at nasolabial folds separately.

As for using the two together, there is a 2018 study (Kwon et al., 2018) in which 22 Korean participants received monopolar RF and focused ultrasound in sequence on the same day, once each; 20 weeks later, sagging and the jawline had improved, and biopsies showed increased dermal collagen. Because the study had no control group, it cannot establish that combining them brings an added benefit.

So rather than steps on a ladder, the two devices are closer to options that work on different layers. Depending on whether a fold is driven mainly by sagging or mainly by the skin's own elasticity, one is chosen first, or the two are used together.

What to Consider First — Decided by What Created the Fold

What to do first depends on what created the fold. The following is not a classification established by research, but the criteria we use in clinic, based on anatomy and the studies above.

In actual practice, a mix of cheek fat sagging and reduced skin elasticity is common. When the front of the cheek has hollowed markedly or a narrow, deep line is the problem, empty volume or the line itself matters more than tissue to pull and tighten, so volume restoration such as filler, or treatment that addresses the line directly, may come first. With severe sagging, a surgical consultation may be needed, but we do not offer facelift surgery.

Check in the Mirror First

In front of a mirror, gently support the front of your cheek outward and upward, toward the cheekbone. If the fold fades a lot, you can think of Ulthera first; if it barely changes and the skin looks thin and creased, RF; and if the front of the cheek is flat and hollow from the upper part down, volume. What to address first for facial sagging as a whole is covered separately in our facial sagging self-diagnosis guide.

How We Plan Treatment

At the consultation, we first support the front of the cheek up toward the cheekbone and sort out whether the main issue is cheek fat sagging, skin elasticity or lost volume. For folds driven mainly by sagging, we plan Ulthera to pull up the supporting layer and tighten the fibrous columns; for folds where thin skin creases, RF to address elasticity; for a mix, both together; and where volume has been lost, volume restoration first. If you tell us the result of your mirror check, together with anything you were not satisfied with after a previous lifting treatment, it helps us decide whether to repeat Ulthera, switch to RF or combine the two.

Precautions and Limits of the Evidence

The causes of nasolabial folds and the structure of the face differ from person to person, so results can vary even with the same treatment. The selection criteria in this article are general criteria used in clinic and do not replace an individual diagnosis.

After focused ultrasound treatment, temporary redness, swelling, tenderness, bruising and a tingling sensation can occur, and nerve irritation symptoms or fat atrophy are reported rarely. After monopolar RF treatment, temporary redness and swelling are common, and burns are reported rarely. A consultation about your skin condition and any medications you take is needed before treatment.

The sources cited in this article include cadaver anatomy and tissue studies, tissue and computer model studies, an MRI single case report, clinical studies without a control group, randomized comparative studies, an observational study, ultrasound and CT measurement studies, an expert consensus and a systematic review. It has not been confirmed that Ulthera returns descended cheek fat to its original position, that nasolabial fold results differ with a particular direction or crossing pattern, or that switching to RF changes the result in folds that responded little to Ulthera.

The intended uses of Ulthera stated in the U.S. FDA 510(k) document (K180623, 2018) are lifting the eyebrow, lifting lax submental (beneath the chin) and neck tissue, and improving lines and wrinkles of the décolleté; use in the nasolabial fold area is based on clinical judgment.

References

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3. Tower JI, Gordon NA, Paskhover B. Deep Cheek Fat Volumes and Midfacial Aging. Aesthet Surg J. 2020;40(5):467-475. doi:10.1093/asj/sjz185
4. White WM, Makin IR, Barthe PG, et al. Selective creation of thermal injury zones in the superficial musculoaponeurotic system using intense ultrasound therapy: a new target for noninvasive facial rejuvenation. Arch Facial Plast Surg. 2007;9(1):22-29. doi:10.1001/archfaci.9.1.22
5. Kim JH, Choi WS. MRI-Based Assessment of Microfocused Ultrasound-Induced Midface Lifting. J Cosmet Dermatol. 2025;24(10):e70477. doi:10.1111/jocd.70477
6. Kim YS, Lee KW, Kim JS, et al. Regional thickness of facial skin and superficial fat: Application to the minimally invasive procedures. Clin Anat. 2019;32(8):1008-1018. doi:10.1002/ca.23331
7. Kwon SH, Ahn GY, Lew BL, et al. Clinical Implication of the Regional Thickness of the Lower Facial Skin, Superficial Fat, and Superficial Musculoaponeurotic System on High-Intensity Focused Ultrasound Treatment. Dermatol Surg. 2022;48(5):527-531. doi:10.1097/DSS.0000000000003393
8. Lin F, Vachiramon V, Casabona G, et al. Microfocused Ultrasound With Visualization for Body Indications: A Global Expert Consensus on Best Practices for Treatment of the Abdomen and Arms. J Cosmet Dermatol. 2025;24(10):e70449. doi:10.1111/jocd.70449
9. Li X, Xie G, Yang Z, et al. Evaluating the Long-term Effects of Microfocused Ultrasound on Facial Tightening Using Quantitative Instruments: Efficacy and Safety. Aesthetic Plast Surg. 2026;50(2):692-706. doi:10.1007/s00266-025-05205-z
10. Contini M, Hollander MHJ, Vissink A, et al. A Systematic Review of the Efficacy of Microfocused Ultrasound for Facial Skin Tightening. Int J Environ Res Public Health. 2023;20(2):1522. doi:10.3390/ijerph20021522
11. Zelickson BD, Kist D, Bernstein E, et al. Histological and ultrastructural evaluation of the effects of a radiofrequency-based nonablative dermal remodeling device: a pilot study. Arch Dermatol. 2004;140(2):204-209. doi:10.1001/archderm.140.2.204
12. Jimenez Lozano JN, Vacas-Jacques P, Anderson RR, et al. Effect of fibrous septa in radiofrequency heating of cutaneous and subcutaneous tissues: computational study. Lasers Surg Med. 2013;45(5):326-338. doi:10.1002/lsm.22146
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14. Wang Z, Li T, Wa Q, et al. Efficacy and safety of a novel monopolar radiofrequency device for skin tightening: a multicenter, randomized, 6-month, assessor blind, positive parallel-controlled, non-inferiority trial. Lasers Med Sci. 2026;41(1):39. doi:10.1007/s10103-026-04841-4
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18. U.S. Food and Drug Administration. 510(k) Premarket Notification K180623: Ulthera System. 2018. https://www.accessdata.fda.gov/cdrh_docs/pdf18/K180623.pdf

From Consultation Through Treatment

A board-certified dermatologist examines you directly, identifies which layer the cause sits in, sets the device and the parameters, and then carries out the procedure as the same physician. This is not a structure in which a consultant sells the treatment.

The number of sessions, the intervals, the maintenance point and the cost are agreed together before the first session.

Related care: Nasolabial Fold Treatment in Seoul · Ultherapy PRIME in Seoul