Your questions, answered directly.
People send Dr. Steffen questions on social media — about aging, about reconstruction, about what's actually worth doing. He answers them on camera. The written versions live here.
Submit a question through the practice's Facebook page or the contact form. Dr. Steffen selects questions that are useful to more than one person and answers them himself — no ghostwriters, no generic copy.
These answers are general education, not medical advice. They can't account for your anatomy, your history, or your goals — that's what a consultation is for. Please don't include personal health details in a public comment.
What actually works for deep nasolabial folds and marionette lines — without filler?
Filler fills the crease but doesn't address why it formed. Depending on the cause, better answers include collagen-remodeling treatments like Morpheus8 and laser resurfacing, a small neuromodulator dose to release the muscle pulling the mouth corner down, structural fat grafting to replace lost midface volume, or — when the cheek and jowl have genuinely descended — surgery that repositions the tissue.
Short version: filler isn’t the only tool, and for deep folds it’s often not the best one. What works depends on why your fold is deep.
Why the cause matters more than the crease
The nasolabial fold — and the marionette lines that run down from the corners of the mouth — form where mobile cheek tissue meets the more fixed tissue around the mouth. They deepen for three reasons that usually arrive together: the midface loses volume and drifts downward, the skin loses collagen and elasticity, and years of expression etch the crease into the surface.
Filler addresses the third-order symptom — the depression itself — without touching the first two causes. That’s why a heavily filled face can look full and still look tired. It’s also why chasing a deep fold with more filler tends to add weight to the very tissue that’s already descending.
So the useful question isn’t “what fills this?” It’s “which of the three causes is doing the most work here?”
Collagen and skin quality: softening the crease
These treatments improve the quality of the skin over the fold. They soften the etched-in component and add some tightening, and they stack well with each other.
- Morpheus8 — radiofrequency microneedling that heats the deeper dermis and the fibrous layer beneath it, driving collagen remodeling and modest tightening. Typically a series of three, with results that continue building for three to six months.
- Microneedling (SkinPen) — collagen induction for texture and the finer etching around the mouth. Gentler, less downtime, more sessions.
- Laser resurfacing — the most direct treatment for the surface component of a crease that’s been written into the skin.
- Chemical peels — tone and texture, and a reasonable maintenance layer between more intensive treatments.
Be clear-eyed about what these do: they make skin behave more like younger skin. They will not lift a cheek that has descended.
Releasing the muscle that pulls the corner down
Marionette lines have a component most people don’t know about. A small muscle called the depressor anguli oris runs from the jawline to the corner of the mouth, and its whole job is to pull that corner down. In some faces it’s simply overactive, and the downturned corner reads as sadness or severity regardless of mood.
A few units of neuromodulator placed into that muscle release the downward pull and let the corner sit more neutrally. This isn’t filler — nothing is added. It’s muscle rebalancing, the effect is deliberately subtle, and it lasts three to four months. For the right face it does more for the marionette line than filler does.
Fat grafting: your own tissue instead of a product
Structural fat grafting replaces lost midface volume using fat harvested from elsewhere on your body, purified, and placed in small aliquots where the volume went.
The trade-off runs in both directions. Where filler is temporary and foreign, grafted fat that survives is permanent and entirely yours, and it tends to improve skin quality in the area over time. But not all of it survives — plan on roughly half to two-thirds taking — and it requires a minor procedure rather than a fifteen-minute office visit.
Surgery: addressing the actual cause
When the fold is deep because the cheek and the jowl have genuinely descended, nothing that works on the surface will fix it. Repositioning does.
A facelift lifts and re-suspends the deeper tissue layer of the face. Flattening the nasolabial fold and the marionette lines isn’t really the goal of the operation — it’s what happens once the tissue is back where it used to sit. That’s the difference between filling a shadow and removing the reason the shadow is there. Results last a decade or more.
How to think about the choice
There’s no single right answer, and anyone who gives you one without looking at your face is selling something. In practice:
- If the skin is the problem, treat the skin.
- If the muscle is pulling the corner down, treat the muscle.
- If the volume is gone, replace the volume — and consider whether your own fat is the better material.
- If the tissue has descended, lift it. Everything else is a temporary discount on the same conversation.
Most faces need some combination, sequenced over time rather than all at once. A consultation is worth having precisely because it sorts out which of these is actually driving what you see in the mirror.
Can a plastic surgeon help with the facial after-effects of Bell's palsy?
Yes — though timing decides which options are on the table. Protecting the eye comes first. After that, reconstructive surgery can restore resting symmetry with static suspension, restore movement through nerve or muscle transfer while the muscles are still viable, and treat synkinesis — the miswired movement that is the most common late complaint. Most of this is reconstructive, not cosmetic, and is generally covered by insurance.
Short version: yes — but when you ask changes the answer, and the first priority is almost never the one people come in asking about.
Most Bell’s palsy recovers on its own
Before anything surgical: the majority of people with Bell’s palsy recover completely, and most of that recovery happens within the first three to six months — particularly when corticosteroids are started early in the course.
That matters because it sets the clock. Reconstruction isn’t considered while recovery is still underway. The picture generally has to stabilize, usually somewhere around the twelve-month mark, before anyone can honestly say what’s left to reconstruct.
If you’re still early, the right answer is eye protection, appropriate medical management, and time.
The eye comes first
When the picture doesn’t fully recover, the most urgent problem is usually the one that gets the least attention: the eye.
If the eyelid doesn’t close completely — lagophthalmos — the cornea is exposed every night and every blink. That’s not a cosmetic issue. Untreated exposure leads to corneal drying, ulceration, and vision loss. Lubrication and taping are the stopgap; they’re not a plan.
Surgical options here are well established and reliable:
- An upper eyelid weight — a small platinum or gold implant placed under the skin of the upper lid, letting gravity close the lid that the muscle no longer can.
- Lower lid tightening — a lateral tarsal strip or similar canthal procedure to correct a lid that has drooped away from the eye and stopped draining tears properly.
- A brow lift on the affected side — when the brow has dropped far enough to crowd or block the upper visual field.
These are functional operations. They’re the ones to sort out first.
Restoring symmetry at rest
Static procedures don’t restore movement. What they restore is balance — how the face sits when it isn’t doing anything, which is how it sits for most of the day.
Static suspension uses a strip of the patient’s own fascia lata, or a suture-based sling, to re-suspend the corner of the mouth and rebuild the nasolabial fold on the affected side. The result doesn’t move, but it corrects the pull of the working side and stops the resting face from reading as paralyzed. For patients who aren’t candidates for reanimation, or who don’t want a larger operation, it’s a meaningful and durable improvement.
Restoring movement
This is the part people mean when they ask about facial reanimation, and it divides sharply on one question: are the facial muscles still viable?
While they are — generally within the first eighteen to twenty-four months after onset — a new nerve supply can be routed to them:
- Nerve transfer, borrowing a nearby working nerve (the nerve to the masseter is the common choice) and connecting it to the facial nerve.
- Cross-face nerve grafting, running a graft from the healthy side to drive the affected side, which is what allows a smile to be triggered by genuine emotion rather than by clenching.
Past that window, the muscles have atrophied and there is nothing left to reinnervate. The operation changes: you have to bring in new muscle.
- Free functional muscle transfer — typically the gracilis from the inner thigh, transplanted with its own artery, vein, and nerve.
- Temporalis tendon transfer — redirecting an existing chewing muscle to raise the corner of the mouth, a shorter operation with a faster recovery and a different quality of result.
These are subspecialized reconstructions. Part of an honest evaluation is being told plainly which of them fits your case and whether a dedicated facial reanimation center is the right place to have it done.
Synkinesis: the complaint that’s more common than paralysis
Here’s what surprises most people. The most frequent long-term problem after Bell’s palsy isn’t a face that won’t move. It’s a face that moves wrong.
As the nerve regrows, fibers find their way back to the wrong muscles. The eye narrows when you smile. The cheek tightens when you blink. The neck band flares when you talk. The affected side can feel permanently tight. This is synkinesis, and it’s genuinely treatable:
- Targeted neuromodulator injection to quiet the specific muscles firing out of turn — the mainstay of treatment, repeated a few times a year.
- Neuromuscular retraining with a therapist experienced in facial rehabilitation, which is not optional and does much of the real work.
- Selective myectomy or neurectomy for muscles that stay tight despite the above.
Patients often arrive assuming nothing can be done about this. Something usually can.
What this costs, and what to bring
Reconstruction after facial paralysis is reconstructive, not cosmetic. Eyelid procedures for corneal exposure, brow lifts for visual field obstruction, static suspension, and reanimation procedures are generally covered by insurance when documented appropriately. Our staff verifies benefits before your consultation.
Bring what you have: the date of onset, what treatment you received and how quickly, any EMG or nerve conduction studies, and — if you have them — photos or video from before the palsy and from the months since. How much you recovered and how fast is what determines which of the options above are actually open to you.
Ask it, and it might be answered next.
Questions come in through Facebook and the contact form. If yours would help someone else in the same position, Dr. Steffen will answer it on camera and it will be written up here.
For anything specific to your own care, call 573-556-7722 or request a consultation.
Get the answer for your face, your case.
General education only goes so far. A consultation is where the answer gets specific — your anatomy, your history, and an honest read on what's worth doing.