Botulinum Toxin Injection



Let me introduce you to our next patient, Annie. Annie has seen me for a number of years, and when I first met her, she was complaining that she felt that she was getting a collapse around the area of her mouth (those were the words that she used). What she meant was that when she had a deep smile, she noticed that she could see excessive gum above her teeth, a horizontal line on the upper lip, a decreased distance between the nose and the lip, a deepening of the nasolabial fold, and finally that the nose tip itself was plunging down during the smile. This has been described by some authors as a rhino-gingivolabial smile and we feel that it may be due to a hypertrophic depressor septi nasi muscle.


Now let’s look at her from the side profile. We can see she has a prominent dorsal hump on her nose, and that the rest of the nose hooks downwards. This is exacerbated during smile, when she has a very short distance between the bottom of the nose and the upper lip. We can also see the nasal ala riding up and deepening the fold, and finally we can see excessive gum above her teeth during this animation. She is requesting treatment to improve her animation, and we can see that if we were to fill out her radix at the top of the nose, this could improve the hump, also lifting the nasal tip. Ideally, we would do this by filling at the anterior nasal spine. Her treatment plan will be filler at the radix, filler at the anterior nasal spine, and Botox to treat the hyperactive lip elevator muscles and depressor septi nasi.

Anatomy markings

Let’s now examine the surface anatomy of some of the muscles that we target when we treat patients who have a gummy smile, and you will notice that I have highlighted the muscles here. The first muscle that I want to talk about is the levator labii superioris alaeque nasi. This muscle arises from the maxilla and inserts into the ala of the nose, and also has an attachment in the orbicularis oris muscle. Its action is to elevate the nostril as well as acting as a the central lip. We also have the levator labii superioris and the zygomaticus minor. I have shown these two muscles only inserting into the nasolabial fold because, although they do insert into the orbicularis oris, they have a dermal attachment here, and are in fact responsible for the muscular component of a deep nasolabial fold. When we treat patients with excessive gummy smile or a deep nasolabial fold, if this is mild, we can treat them purely by targeting the levator labii superioris alaeque nasi, or LLSAN. However, in some patients this activity can be excessive, and some authors have described another treatment point, called the Yonsei point. On the right, in green, you can see how we would target just the LLSAN in a mild case such as Annie’s. If we do want to treat patients who have excessive activity in this region, then you can see on the left that there is another point marked in black, and this is the Yonsei point. This is located approximately 1 centimetre from the nasal ala, and the idea is that this would target all three elevator muscles. Do be very careful in using this point, because it can cause significant distortion and asymmetry. Finally, after treating the lip elevators, I will also treat the depressor septi nasi under the nose.


Injection site markings and treatments

We are treating Annie with Botox for her rhino-gingivolabial smile. I will ask Annie to snarl to excessively activate this muscle, as when I get her to do this I can see the thick belly of the muscle. I will inject her deep with Botox just lateral to the nasal ala, with 1.5 units, which can be a little uncomfortable for the patient. I will repeat this on her left with the same dose of 1.5 units. Be cautious when treating the mid and lower face with Botox, and always use the lowest dose possible to give an effect. We will finish off treating in this region by treating the depressor septi nasi. I elevate the tip, place my needle at the columella deep, and inject a further 1.5 units of Botox. This last injection can be very uncomfortable.


Dermal filler treatment of nose

We are treating Annie’s nose with dermal filler to target some asymmetries. We begin by targeting the dorsal hump. When I treat her at the radix I pinch the skin, insert the Voluma with a 27 gauge needle, aspirate, and when I am deep onto the bone, I will inject 0.2ml of product in this deep location. I am localising and lateralising product with the thumb and finger of my non-injecting hand and continuously observe all the surrounding tissue for any signs of vascular occlusion.


After injecting her at the radix, I move on to treating the dorsum further down. She has a resting asymmetry in her nose, and a deviation to the right. Accordingly, I will now place a little bit of product, again in a deep location, but slightly to the left of the midline to correct this resting asymmetry. The technique here is also with a needle, and just like treating her radix, I will inject my needle deep, aspirate, and, when I am happy with the location, I inject a small linear thread of product while still pinching the sides of the nose. As before, I am vigilantly observing her tissue for any signs of vascular compromise, and I will massage the product to mould it into position.


Finally, I move onto treating her in the anterior nasal spine to elevate the tip. This is an uncomfortable area to be injected in for the patient. I elevate the tip and, aiming at the base of the columella, inject my needle in. When I hit the bone of the anterior nasal spine I aspirate and then inject a small bolus of Voluma at this location. The total volume here will be 0.25ml. At the same time, I am pinching the sides of the nose to ensure that the product stays compartmentalised within this region. The purpose of injecting in this region is to create some support for the base of the nose.


Immediate treatment outcome

When we see Annie immediately following treatment, we are aware of an improvement in the symmetry of her nose when viewed from the front, and we can observe this a little bit better if I tilt her head down. We can see that she is a little less deviated to her right than pre-treatment. If I turn her towards me, we can see that there has been a very subtle improvement in her dorsal hump, but we may be able to improve this further. The more striking change is the opening up of the angle at the tip of the nose, so the nasolabial angle, which was less than 90 degrees before treatment, is now about 100 degrees, and this is clearly more attractive. We will see that the tip is now risen, however when she smiles it will plunge down again, and this is because we need the Botox action of the depressor septi nasi and the levator labii superioris alaeque nasi to kick in. We can see that the dorsal hump looks better from her right side, and we will look forward to seeing Annie at her six week review to see what results she has managed to obtain.


Treatment outcome at 6 weeks

We now welcome back Annie, 6 weeks after we treated her rhino-gingivolabial smile, and also some dermal filler to her nose. We can see she looks great at rest, and if she smiles it looks very natural. Let’s remind ourselves of what her smile looked like before – you can see that before, she had excessive gingival display, decreased distance from the tip of the nose to the lip, a horizontal crease, and excessive nasolabial fold, all of which have improved substantially. If we look at her from the side, we can see that she has maintained the open angle at the base of the nose to the lip, the nasolabial angle, with a smoother dorsum, and less dorsal hump. Again, when she smiles, you can see that she had a very plunging tip before treatment, but now the structure has maintained her nose in a more attractive position during the smile.