Filler injection

Assessment

 

In this video, I would like to introduce you to our next patient, Emma. Emma is 48 years young and she has come to us with just a single concern; she wants to improve the shape and contour of her nose. As you can appreciate from the front, there isn’t really any deviation or asymmetry, but if I turn her towards me you can appreciate that the concern is very, very mild indeed, but what she has is a slight depression at the radix and just above the tip, which leads to the appearance of a mild dorsal hump. Using the soft tissue filler, what we can do is inject the product just above and below and give her a straighter dorsum, which is what she really wants. If we continue that down we will find that not only do we get a straighter contour all the way down to the tip, but it will also do it without excessively widening because, from the front, the shape of her nose is very nice. This is a very simple technique using a perpendicular deep injection above and below the hump.

 

Treatment

 

This treatment will be very simple – I have marked out an area in the radix region. Her current radix lies at the level of her lower lashes and I want to increase that point to the upper lash line, then I will miss out the area of the bump and inject just below. I will use a needle technique with Juvederm Voluma, which has been decanted into a 30 gauge insulin syringe. We’re just going to clean the area before I inject – I keep the markings on but of course, I don’t inject through any of the markings but in between. I pinch the skin and inject my needle perpendicular down onto the nasal cartilages, then I slowly inject. My finger and thumb stop the product spreading laterally and I am injecting a small quantity, initially a bolus of 0.1 ccs. Once I’ve injected, I’ll examine from the side and just give a gentle mould. The idea is not to excessively manipulate the product and now I can look to see what that first injection has done. We can already see that there is now a much better continuity from the radix down to the area just below where the bump could be seen. Now, we will inject the area below as well.

 

I’m just going to turn her slightly towards me, then I’ll clean the area, and just like before we’re going to pinch from the sides and inject the area just above the tip. The injection depth here is deep. I’m observing the tissue just to ensure there is no excessive blanching. When we inject, especially close to the tip, there can be a little bit of blanching, which is unnerving when you’re not used to the tissue reaction because of course we normally associate blanching with intravascular injection, but high-pressure areas like the nasal tip will just blanche as the product is injected. It becomes a useful skill to be able to distinguish between natural blanching, the blanching we get with the product, and the blanching that might signify an intravascular injection.

 

We’ll just have one more injection, so we’re going to sterilise again and the last little amount of product is going to go in now. I can see that she’s nice and comfortable now, and having injected that amount I will now just gently mould. Just from the side, I can see that I still require a little bit more, and I like to build a nose up like this because it avoids excessively injecting too much product, because, of course, we can add in but we can’t take out. You’ll notice that I’m injecting very slowly. The product will take the path of least resistance so it’s important to inject slowly otherwise you may find the product just comes straight back up the needle track and we want to try and keep it deep and in the midline to get the best result. I will now just give a gentle moulding and massage before assessing the final result. I’m just using a little cloth, and it’s important not to apply too much pressure. Let’s have a look at how that appears now. We can now see that the hump she had has almost completely disappeared, and we have a much smoother outline from the radix all the way down to the tip, so this is a more pleasing angle for her. Her nasolabial angle was already good so I didn’t need to elevate the tip, and you can see that that’s a relatively straightforward technique.