Filler injection



Nose assessment


I would like to welcome our model Debbie, and you will notice that she has a slight swelling of her lip. This follows some treatment she had the previous day, which can be viewed in the lip masterclass video. In this treatment, I am going to focus on the assessment and injection markings of her nose. You can see that she has quite an obvious deviation of the nose towards her right side. You can also see that the thickness of the dorsum from the radix down towards the tip is relatively wide, and we are trying to effect a narrowing to make the nose look aesthetically more pleasing. We will do this using Juvederm Voluma and a needle technique.


Injection markings


Let’s review the injection markings for Debbie’s nose treatment. You will notice a dotted line, and this reflects the midline. The white line is the deviation that Debbie’s nose has. You will also notice some red dotted lines, and this is the current width of the nose. The idea of this is to inject the product within the midline, but actually focus more towards the left, which will have the effect of bringing the dorsum straighter and also narrower. If I look at her from the profile, you notice that she already has a very nice angle to the dorsum, and accordingly we need to inject equal amounts all the way down.


Nose treatment


In this video, we will treat Debbie using dermal fillers and a needle technique. I am using Juvederm Voluma which I have decanted into a 0.3 ml insulin syringe which has a 30 gauge needle. I begin by applying lateral pressure to the nasal sidewalls and I inject my needle deep so I can place the product onto the periosteum. I am using a slow injection technique and I will use a total of 0.1 ml in a bolus. It is vital to ensure that when using this technique that you inject as deep as possible because all of the vasculature is at a more superficial level. Also, the blood vessels tend to run more laterally, so we try to stay in the midline where possible. After injecting the first bolus, we can use a gentle moulding but we do not want to press too hard because we want the projection that the bolus gives. We can then start injecting slightly more inferiorly using the same technique. Again, you will notice that I am pinching the sidewalls and using the needle to inject at a very deep level. I am using a slow, steady injection technique, and you will notice that despite not having used any anaesthetic, Debbie remains comfortable throughout the injection.


Before proceeding, I make sure that I massage the bolus to ensure that it stays nice and even. I am already aware of a slight narrowing of the nose. I now proceed to the third injection and I am continuing in an inferior direction. I will continue to use the pressure from my thumb and forefinger to ensure that the product stays in the midline. Each bolus that I am injecting is 0.1 cc of product. As I come more inferiorly, I am just going slightly to the left of the midline because her deviation was to the right, and this will counter the deviation. As we get closer to the tip, it is vital to ensure that we are injecting with the adequate depth because the skin thickness in this region is thicker than it is at the dorsum or the radix. I apply a gentle massage, taking care not to flatten the projection that we have created. I can see from the foot of the bed that the nose appears more narrow and there has been an improvement in the deviation. I continue to apply a moulding until I am satisfied with the shape. At this point, I am aware that I need a little bit more projection of the tip of the nose. I will use a further 0.1 cc bolus just in the supratip region. Although my hands are covering my injection, the injection at this point is exactly the same as it was for the previous four injections, the idea being that we are injecting at the full depth of the needle and in a slow, steady manner. After this injection, I will continue to apply a little moulding, and I can see from either the foot of the bed or above her head that I have created the adequate narrowing.


Nose outcome


If we review the outcome of Debbie’s nose treatment, you will notice that this white line is not, in fact, a drawn on white marker line but simply the reflection of the overhead light, and you will see that this light reflection is almost completely in the midline, showing that there has been significant improvement in the deviation. We can also see that the nose appears more narrow compared to pre-treatment, and this is simply due to the central projection. Finally, if I turn Debbie to the side we notice that her angle of dorsum has remained exactly the same. Accordingly, we have created an improvement in the front view without distorting the side view.