Filler injection




I’d like to introduce our next patient, Sheena. As you can see Sheena is young and very beautiful. Accordingly, she is only seeking some very subtle treatment – when I asked her what she was interested in having done, she said that she had three primary concerns; the undereye area, where she wanted a little bit of improvement in her dark eye circles, her lips, and finally a very subtle improvement in her nose. Let’s look at all of these areas in turn.


Nose assessment


When we look at Sheena’s nose, we notice that the tip appears slightly wide. One of the reasons for this is that she has a normal and narrow dorsum, and there is a very abrupt transition to the tip, making it appear more bulbous. If we can smooth the transition between the dorsum and the tip, it will give the impression of a smaller tip as well. Another aspect of treating her nose is due to the fact that she has muscle hyperactivity – she is able to voluntarily dilate the nostrils excessively due to dilator naris activity. This is something that can be treated with Botox, and if we can stop her from dilating her nostril, it will also help thin the nose. When we turn Sheena to the side and examine her nose from the lateral profile, we will notice that she has a degree of concavity in the dorsum and that the radix is low, perhaps in line with the lower lash line. Ideally, we want to increase the radix to the upper lash line, and in doing so, we will need to lay the filler down on the dorsum, and we can give her dorsum a more pleasing shape and give the impression of a thinner nose. We would do this by treating with product in the midline, ideally using a cannula.


Btx injection site, markings, and treatment


When we treat excessive nasal flare with botulinum toxin, the muscle we’re targeting is the dilator naris muscle. You can see that Sheena has the ability to contract this muscle, thereby causing excessive dilation of her nostrils. She can do this voluntarily, so we can use Botox in this region to reduce this and give a slightly thinner appearance of her nose, especially on inspiration and animation. I have a technique whereby I use a rolled up piece of gauze inside the nose so that when we inject, it protects and gives some resistance against the push of the needle. The gauze is now inside the nostril, and you will notice that I will insert the needle point just into the skin, which can be tender. When I am mid-depth, I inject the first 3 units and I will repeat this on the other side. Instead of gauze, you can also use dental roll. Because the nostril is relatively thin, without using some form of protection on the other side, it’s very easy to push right through and end up inside the nostril.


Treatment outcome


We now see Sheena at the end of her treatments, let’s just recap what we’ve done. We’ve treated her under eye hollows, added refinement to her nose by decreasing the apparent width of the tip, and did a subtle rejuvenation of her lip to add definition and a little eversion. We can see that although she is young and attractive, and presented with minimal treatment indication, we can use very subtle techniques to create an impactful result. If we look at Sheena from the side, we notice that we have eradicated the under eye hollows and created a pleasant eversion and projection of the lips, which are symmetrical from both sides. If I turn her completely towards me, we are aware of an improvement in her nasal profile, and a much better eversion and projection of the lip, which still conforms to the Ricketts line analysis. I now turn her to the front so we can test her animation, and we notice that her smile is natural, she has a fuller lip during the smile, and when she pouts, the pout is also symmetrical and not over projected. This is the ideal lip rejuvenation result.


Dermal filler treatment of nose


In preparation of treating Sheena’s nose, we’ve already marked out the area we wish to augment. We will start above the tip as this is already prominent, and make a pre-hole with a 23 gauge needle. I’m using a 25 gauge cannula, and the product I’m using is Juvederm Voluma. I pinch the sides and advance the cannula deep and in the midline, as this is the safest plane. Sheena has not had any anaesthetic, but you will notice that she is very comfortable during the procedure. Once my cannula tip is at the top, where I want to create the new radix (you can see this through the skin) I can start injecting small amounts of product. I will use my thumb and forefinger to lateralise and compartmentalise the product, and stop it slipping down the side walls of the nose. I’ll inject small amounts of product and then withdraw my cannula in a retrograde manner. As I do so, I will advance my finger and thumb along the side wall so I can continue to keep the product in the midline, where I wish to keep it. The advantage of using a product from the Vycross range is that we can inject it in an area and then mould it according to the shape we desire to achieve. I will be careful to stop injecting before I get to the tip as it is already bulbous. The idea here is to improve the transition from the dorsum to the tip. Having injected, I will now gently mould and massage the product. Following the treatment, we can see that the dorsum appears thinner and there is a better transition to the tip, which has the effect of making the tip look thinner as well. If we turn Sheena to the side, we can see that the dorsal projection has also improved, and we now see that the radix is certainly in line with her upper lash line. Overall, this has the effect of giving a more pleasing transition from radix down to the tip.