Filler injection




I have Gill here with me now, and she has told me that ideally she would like to have some treatment to her nose. She feels that her nose is too wide and consequently she is interested in any treatment that might give her an apparent thinning. I’ve already mentioned to Gill that when we treat the nose, we do get better outcomes when we treat something like a dorsal hump or any treatment higher up on the dorsum. However, when we look at the nose, we can see that there is a disparity between the width at the tip and the thinness at the dorsum. Accordingly, if we treat her along the dorsum and project and elevate the tissue, it may give her a thinner appearance. The second issue Gill has is her nasolabial folds, and she has found that over the last few months and years, these are getting worse. If I turn her to the side, what we can see is that these folds really represent a degree of sagging from the midface. Consequently, she has a little bit of volume loss just superior to the fold, and any procedure that would lift the skin in the midface along the cheekbone would improve the appearance of this fold. The strategy to treat Gill would be first to target the cheekbone and give her a lateral cheek lift, then if she still had any fold we could treat this directly.


Injection site markings and treatments


The strategy to treat Gill’s nose is very simple, we will use a cannula inserted at the tip and deposit the product along the dorsum. I will treat Gill’s nose with Juvederm Voluma using a cannula. I pinch the sides of the nose and insert a 23 gauge needle to make the entry hole for the 25 gauge cannula, and as I pinch the sides of the nose, I make sure I enter the cannula as deep as possible, ideally just above the cartilage and the periosteum. After adjusting my grip on the cannula, I ensure that if I do find any part of the nose difficult to facilitate cannula entry, I can inject just a little bit of product to open up the tissue plane. It’s important never to force the cannula. Once I’m at the tip, which I’ve already marked off (you can see the tip of my cannula as indicated by my finger), I will then use a finger and thumb to localise the product. I’ll inject small amounts of the Voluma as I withdraw the cannula, so this is a long retrograde linear thread technique. The finger and thumb allow me not only to compartmentalise and mould the product as I am injecting, but they also give me some feedback as to the amount of volume that I’m injecting and the tissue response to it. Higher up on the nose, near the radix and the dorsum in the midsection, the skin is relatively thin and the pressure is low. As we get towards the tip, the skin is thicker, there is more fibro-fatty tissue, and the pressure is high. Accordingly, it’s important not to overinject this area. Secondly, this is also where Gill has the thickest part of her nose. Following treatment, I will apply a very gentle mould and massage to get a smoother result, and this is easy to do with Voluma.


Treatment outcome


Immediately following treatment, we can already see a significant improvement. The central elevation and projection has given us the appearance of a much thinner nose, which passes more gently, transitioning from the dorsum to the tip. We can see from both oblique views that this gives her the appearance of a more defined nose.