Filler injection




I have with me here Katrina, who is interested in any treatment that might improve the shape of her nose. We are aware that non-surgical rhinoplasty procedures are getting increasingly more popular, and Katrina here doesn’t like either the front view of her nose, or in fact the side profile. There are a number of treatments that we can use to influence the shape of the nose, and we can use these fillers to improve the height of the nose, to influence any lumps or bumps there may be on the nasal dorsum, to influence the supratip area, and we can also use the filler either to raise or lower the tip if it is excessively elevated.


When looking at the nose, it is clearly important to assess the patient both from the front and profile views. If I turn Katrina to the oblique side, we are now more aware of the dorsal hump with an area of hollowness above and below the hump. The idea of non-surgical rhinoplasty is to influence certain angles of the face, and this is the underlying essence of non-surgical rhinoplasty – small changes in angles can give significant visual improvement. The first angle to look at is the frontonasal angle, the angle from the forehead going onto the dorsum of the nose. If this angle is too acute and approaches 180 degrees, we run the risk of creating what is often referred to as a ‘Roman nose,’ therefore we must ensure that we keep the angle below 170 degrees. Next, we can also influence the radix. The radix is the point where the nose meets the glabella, and if we look at Katrina here, we notice the radix is at about the level of her mid-pupil height, however we would typically want the radix to be slightly higher than this, in line with her upper lashes. Please note that in this view, you can see a little scar to the left of the radix, which I actually missed during assessment. We can see that Katrina has an obvious hump and a normal supratip break. The next angle to look at is the nasolabial angle. In women, this is typically 105-110 degrees, and in men this angle is usually more acute, approximately 90 degrees. We can see if the tip is excessively raised this angle will become more obtuse, and if the tip is depressed, this angle becomes more acute or narrow.


Anatomy markings


Let’s now review some of the relevant anatomy. If I turn Katrina to the side and we look at her jawline, you will notice that I have made a marking, and just anterior to the masseter I can feel the pulsation of the facial artery as it courses across the mandible. From this region, it has a tortuous course towards the modiolus. This needs to be tortuous to allow for mouth opening movements. It then proceeds in a straight line towards the nasal alar. Near the modiolus, the facial artery can give off an inferior labial artery and a superior labial artery. The superior labial artery can give off columella branches which supply the tip of the nose. The facial artery at this point changes name to the angular artery, which runs up along the nasal sidewall, and can give off a subnasal artery and a lateral nasal artery. All of these vessels are derived from branches of the external carotid artery. In addition, we have branches from the ophthalmic artery, namely the supratrochlear artery, the supraorbital artery, and the dorsal nasal artery. Accordingly, there is an anastomotic link between the external carotid and the ophthalmic artery. It’s important to notice in the nose that these vessels are not in the midline, but are usually placed just slightly lateral to the midline. Also, the vessels tend to be more superficial rather than deep. Accordingly, the safest plane to inject in the nose is in the midline in a deep plane, thereby avoiding all the blood vessels.


Injection site markings and treatment


Let’s now review the injection markings prior to treatment. The white line that I have drawn vertically denotes the midline, and allows me to keep a symmetrical result. The red lines denote both the upper and lower extent of the dorsal hump, and clearly we will inject less product in this region. We then have two horizontal green marks. The lower green mark is where we have our current radix break point, and we can see that it is low down. The higher green mark is where we ideally want to create the new radix, and the purple mark denotes the entry point for our cannula. When treating the nose, I like to measure before I treat to ensure the cannula I use will be long enough. You can see that I will need approximately 4 centimetres from entry to the upper radix, so I will use a 40 mm cannula. I begin the treatment by applying some ice in a sterile glove to the tip of the nose. This gives us some numbness, but also gives some focal vasoconstriction. I will then proceed to make the entry hole for the cannula. We’ll give the skin another clean with some chlorhexidine, and then I will use a 23 gauge needle. I pinch the sides of the nose and insert just the bevel of the needle to allow entry of the cannula. At the same time, I keep my thumb and finger pinching the sides to prevent excessive bleeding, and after removing the needle, I will very gently insert a 25 gauge, 40 mm cannula. It’s important to ease this cannula into the plane and remain in the midline. In patients who have not undergone any surgery, this is usually straightforward, however, if the patient has had fractures or surgery, there may be scar tissue that prevents the passage of the cannula. You can now see the tip of my cannula is exactly where I want it, in the upper green line, and I can proceed to inject. I use a thumb and finger on the sides of the nose to prevent product migrating down the sides, and I will then inject very small amounts of Juvederm Voluma as I withdraw the cannula back out towards the entry hole. My finger and thumb not only prevent migration of product, but they also give me feedback as to how much fill we are achieving. We continue to inject the product along the dorsum, avoiding excessive injection of product within the upper and lower red marks, which denote the region of the dorsal hump, and then just injecting a little bit more before we exit completely. Voluma, being a Vycross product, is very mouldable. You will notice at his point that the scar she had on her left nasal sidewall has become more prominent. I must confess that I missed the scar when I assessed the patient before treatment, and it was only at this point that I could see that the scar had become more prominent. Accordingly, I made the decision to inject a little bit more product to improve the appearance of this scar. When we pass the cannula for the second time, it’s often easier as the product has already opened up the tissue plane, secondly, the local anaesthetic in the product has made the patient more comfortable. Due to the presence of the scar, I now inject a little bit more of the Voluma at the radix. At the same time, I’m using my index finger to massage and mould the product, thereby lifting the scar. After withdrawing the cannula, I will apply a little gentle massage and moulding to see if we’ve made enough impact in this region. I can see that the scar is slightly better, but I still want some improvement, so I will now inject directly with a needle. I am injecting from the side, and this is more precarious than staying in the midline, so I inject very tentatively with a small amount of Voluma directly underneath the scar. The total amount injected would be negligible, perhaps 0.05 ml.


Treatment outcome


I now have Katrina at the end of her procedure, and we are immediately aware of a very nice symmetrical result from the front view. If I turn her to the side, we will see that she also has a much straighter dorsum and the hump is reduced. We have maintained a nice frontonasal angle at the same time, and if I then turn her to the other side, we will notice that as well as reducing the hump, the appearance of the scar has not diminished considerably. We can also see that the nasolabial angle is maintained as we would expect, as we didn’t treat in this region. Accordingly, this is the result following a non-surgical rhinoplasty procedure.