Filler injection

Assessment

Hello and welcome to this video, in which I would like to introduce you to our model, Yana. Yana is 29 years young and she has come to us with a single concern. She would like to see if there is anything we can do to help improve the shape and contour of her nose. It’s a very mild concern, and to really appreciate it what we have to do is look at Yana in profile. What I’m going to do is sit her up. When we look at her from the side, you can appreciate that there is a gentle convexity in the dorsum of the nose here, giving her a mild dorsal hump.

 

This really allows us to discuss the whole scope of the non-surgical rhinomodulation, and the idea here is that we want to try and disguise the appearance of this hump by adding some product above and perhaps adding some product below. What that will do is give us a straighter contour to the nose. At the same time, we can look at the various angles; if I look first at the frontonasal angle, at the moment it’s about 140 degrees, and after treatment, we will reduce this by perhaps 5 degrees, to around 135. If we look at the nasolabial angle, you can see that’s probably less than 90 degrees, and ideally, in a female patient, we want that to be a little bit more obtuse, perhaps 100 to 110 degrees. We will add the product onto the anterior nasal spine to lift the tip. The sequence of injections will be above the bump, below the bump, on the anterior nasal spine, and finally, we’ll look to see if we need anything in the tip.

Non-Surgical Rhinoplasty Marking Up

Before we inject, let’s review the blood supply. The facial artery has a tortuous course after it enters the face and often in the region of the modiolus it will give off a superior labial artery. The superior labial artery, in turn, will give off a columella branch which can then supply the tip of the nose. The rest of the facial artery traverses towards the nasal alar where it can give off a subnasal and lateral nasal branch, continuing as the angular artery on the sidewall of the nose. From the ophthalmic artery, we have a branch called the dorsal nasal, and there are often anastomoses between the branches of the external carotid and the internal carotid in the region of the nose. The second thing to note is that the midline tends to be relatively avascular because the dorsal nasal tends to run lateral to the midline. The midline tends to be a safer plane of injection, and the blood vessels tend to be more superficial in the fibrofatty layer. If we look at the depth of tissue, we have the skin, the fibrofatty layer, muscles, cartilage, and bone. Accordingly, our injection will be deep and in the midline. Finally, it’s worth noting that at the radix the skin is medium and the pressure is low. At the mid-level, the skin is thinner and the pressure is higher; at the tip, the skin is thickest and the pressure is the highest. This will influence how we inject.

 

I now have my various points of injection. I will inject high up to increase the radix point. At the moment, her radix is roughly below the line of her lower lashes, and I want to bring it higher, in line with her upper lash line. I will then inject the area below the bump, and we miss out the region of the dorsal bump. I will then move onto the anterior nasal spine, and lastly, if I need to, I will inject at the tip just to elevate in this region.

Treatment

We’ve just iced the area to give a bit of vasoconstriction and make it more comfortable, and we’re now going to wipe the area. You will notice that I’m going to squeeze either side with my finger and thumb to stop the product from spreading and then I’m going to inject the product deep down onto the cartilage using slow injection pressure. After injecting just a small amount, exactly 0.1 ccs, it’s worth looking to see what improvement we’ve had already. If I ask Yana to turn towards me, we now notice that the dorsal hump has almost completely eradicated, so we can see a much smoother frontonasal angle. Near eradication of the hump already with very little product – accordingly, I will now miss out point 2, and go onto the anterior nasal spine. We’ve iced the area, we’re going to sterilise, and I’m going to lift the tip and start injecting. This injection is exactly 0.15 cc of product. After each injection, I like to see the improvements that we’ve made, so again I’m going to sit her up. Already we can see that the shape of the nose and also the nasolabial angle, which before was quite depressed, has started to lift, and now it’s probably sitting at about 95 degrees, which is just ideal for a female patient. Finally, what I’m going to do is put a little drop in the tip to elevate the tip. We’re just going to clean first and then I’m going to insert my needle; this is slightly more painful. Between my fingers, I’m going to inject a little bit of product here to lift the tip. In this region, it glides over the lower nasal cartilages, and it will increase the tip with just 0.02 cc of product.

 

Now we can see a beautifully improved contour of the nose. We have a very pleasing frontonasal angle, a straight dorsum without any interruption, a slightly elevated tip position, and an improved frontonasal angle. In total, we used 0.3 ccs of product, so about a third of a syringe, and the total injecting time was probably less than 3 minutes. However, although people do refer to it as the 5 minute or 15 minute nose job, I do recommend taking caution. Although this is a very satisfying area to treat, it does remain a particularly precarious part of the anatomy to inject, so do take your time and ensure that you are injecting safely.