I’d like to introduce our next model, Sonia. Sonia only really has one concern, and that’s due to a procedure she had on her nose, which has left her with a deviation causing a visible asymmetry. She notices this from the front, but also particularly from the side. She feels that she prefers her left profile compared to her right profile, which seems to exaggerate the asymmetry. We can also see that if we were to bend her neck down, the light reflection also exaggerates the asymmetry from the front view. Let’s have a look at Sonia from the side. We can see that her nasolabial angle is normal at approximately 100 degrees. We can then see that, just above the tip, she has a hump, the dorsum is very concave, and she has a low radix. The radix is approximately in line with her pupil, but we would prefer a slightly higher radix in line with her lashes. Accordingly, if we can fill out the concavity and raise the radix, we can improve the side profile. When we do treat her, we have to bear in mind that due to the asymmetry, we need to treat her off centre.
Injection site markings and treatments
I’ve made some markings to guide the injections, and you will notice that there are two horizontal white lines – the lower right line denotes the current position of the radix, and the superior line is where we want to ideally raise the radix point to. The vertical white line is the area of deficiency, and the area that we want to fill. Finally, the red line serves two purposes – it is the current midline, but also the region of maximum convexity in the hump, and an area that we will ideally avoid. You’ll notice that when I put the entry in needle in for the cannula, I’m slightly off-centre. This is because we need to avoid the midline, where we have the maximum asymmetry. This is, however, more risky, because the blood vessels tend to run outside the midline, and take a slightly lateral course.
I am now using a 25 gauge, 38 millimetre cannula. As Sonia has had previous surgery, there will be some degree of scarring and fibrosis, and this will prevent easy passage of the cannula. It’s vital not to force the cannula, so when we encounter some resistance, it’s better to inject some product to open up the tissue plane and you will notice that when I do this the cannula can then be advanced further superiorly. I’m using Juvederm Voluma, because I want maximum lift. I take the cannula up to the position of the new radix that we want to create, and you will notice at this stage that the tip of my cannula is just in line with the upper white horizontal marking. I then use a thumb and finger to localise and lateralise the product as I inject so that I can keep it in the midline, and then I will inject more product as I withdraw the cannula. As I mentioned, the blood vessels tend to be lateral, and because we’re not in the midline, we have to be very careful. The whole time I’m injecting, I’m very alert to the tissue responses, not only in the immediate injection area but also in the glabella, the temple, and the alar fossa. I want to ensure that there’s no sudden alerts that could indicate a vascular occlusion. She’s comfortable during this procedure, and we withdraw the cannula. Having withdrawn the cannula, we now need to mould and massage the product to try and create the symmetry that Sonia is looking to achieve.
We can now see Sonia at the end of her procedure. We can see from the front view that there already appears to be an improvement in the deviation. If I bend her head down, you will notice from the light reflection that in fact, on downward gaze, the symmetry is even better. Let’s now look at her from the side profile. Immediately, we can notice that there is a great improvement in the concavity – she has a higher radix point, in line with her lashes, and a smoother and straighter dorsum. There is the argument that we could have injected a little bit of product at the tip, however I was afraid that we might make the nose appear too big. Accordingly, I will see her for review at six weeks to see if she needs treatment in this area.