INJECTION CORRECTION OPTIONS: FILLERS AND BOTULINUM TOXINS

Approximately one-third of patients come with some aesthetic complaints about their nose: a wide dorsum, its curvature, and a wide nasal tip. An even larger group of patients have complaints about the "prominent part" of their face, but remain silent because they are not initially inclined to plastic surgery (usually just afraid of it), and they do not know about the possibility of correction with injection techniques.

I would like to set the record straight: this article will focus on non-surgical aesthetic correction of the outer part of the nose, as the main target audience of Les Nouvelles Esthetiques Ukraine magazine is cosmetologists.

Secondly, I want to emphasize that certain problems can only be solved through plastic surgery, and that it can achieve striking results (photo 1).

But there is also a flip side to the coin: aesthetic rhinoplasty is one of the most difficult tasks in plastic surgery. My fellow surgeons will surely share my opinion: I am extremely cautious about "appearance remodeling" programs, since the result of the operation and the image created by the program, which often provokes high expectations in the patient, can often differ, and the results of rhinoplasty are the most difficult topic to predict. That is why, when patients come with minor nasal defects, it is much more rational to use injection correction techniques. In particular, I use medium (Teosyal Global Action, Teosyal Deep Line) or high density fillers (Teosyal Ultra Deep) to visually correct a slight curvature of the nasal dorsum, the formation of a more sloping nasal bridge, and other "plastic" nasal problems.

The use of botulinum toxin to lift the tip of the nose is justified only for patients who have m. depressor septi nasi activity (the so-called rabbit movements of the tip of the nose) during active facial expressions (for example, during conversation). In the case of correction of the height of the tip of the nose by injecting the drug m. levator labi superioris alaeque nasi, care should be taken, as the procedure may result in elongation of the upper lip. Young women have a lower risk, elderly people and women with an anatomically long upper lip, when the distance from the base of the nose to the Cupid's arch (the edge of the upper lip) is more than 1.8 cm, treatment is strictly contraindicated.

For most patients, I solve aesthetic problems associated with the tip of the nose with fillers. Nowadays, information about correcting the shape of the nose by the reverse principle, that is, by injecting drugs that destroy cartilage tissue (most often called Diprosan), has often been voiced. In this situation, I prefer to be guided by the principles of rationality and safety and believe that the risk of serious complications with this technique does not justify the possible result.

"THE MAIN THING IS THAT THE COAT FITS" (c)

Speaking of the aesthetic proportionality of the nose, I think we should cite the most well-known guidelines.

As a rule, a Caucasian person who corresponds to a certain average concept of "beautiful, harmonious" has the following features

  • a speculative line running from the bridge of the nose along the back of the nose and a vertical line drawn from the bridge of the nose downward form an aesthetic profile angle, which should normally be 30º;
  • when assessing the shape of the nose, the nasolabial angle is of great importance, which should be at least 90º (photo 2);
  • Ricketts's line (photo 3): normally, the line runs at a distance of 4-5 mm from the upper lip and 2-3 mm from the lower lip. Most often, the Ricketts line is used to assess the fullness of the lips, but it can also be used to assess the proportionality of the nose length. We all understand that facial features are perceived in a complex, so quite often an elongated nose can be compensated for by volumizing the chin and moderately filling the lips (photo 4).

Based on my observations, I have concluded that a woman's face looks most harmonious when there is a certain symmetry of the nasolabial and lip-chin. With such symmetry, we can depict a virtual curly bracket that will almost exactly fit the profile of a beautiful woman in the lip area.

Thus, if we are talking about a harmonious face, then the projection of the nose or chin, the volume of the lips, fades into the background. This technique makes it possible to assess the complex symmetry of the lower third of the face.

NASAL LINE EXPOSURE

So, speaking of aesthetic nose correction, the simplest and safest procedures include visual compensation of a moderately pronounced curvature of the nasal line. The filler is placed on the subdermal-dermal border from the bony bump of the nose to the tip, and the drug remains in the skin. The injection is performed with a needle, the drug is used, as a rule, of medium density. I do not recommend going into the subdermal space, as this is fraught with further displacement of the filler (photo 5).

Correction of the "blocked" nose bridge is performed in several stages:

  1. Correction with botulinum toxin ("Dysport" according to the scheme shown for this type of nose bridge).
  2. After the effect of botulinum toxin has worn off, we perform filler correction - usually in two stages:
    • we compensate for an overly deep nasolabial angle. The injection is performed using the supraosseous linear retrograde method with a high-density filler. The volume of the drug for the entire nasal bridge should not exceed 0.5 ml. The main danger of this correction is the possibility of circulatory disorders with too large a volume of the drug, in this regard, you should not try to achieve full compensation, since an increase in the volume of the drug leads to an increase in the risk of ischemic manifestations and edema;
    • Correction of the "proud man's wrinkle". The injection is performed using the intradermal method with medium-density filler. The injection is performed from the side wall, at the bottom of the crease, a kind of arch is formed. To enhance the effect, I usually place additional intradermal "stiffeners" perpendicular to the arch.

INCREASING THE NASOLABIAL ANGLE

Working with the nasal tip and nasolabial angle is also quite safe if you use the basic principles of anatomical rationality.

To create a steeper nasolabial angle, I form a bulla at the base of the nasal columella. I take the columella in a "pinch" and inject it perpendicular to the supraperiosteal injection with high-density filler, the volume of the drug can reach 0.5 ml. After the injection, I must perform a "compacting" massage (with strong compressive movements from the nasal septum and upper lip to the base of the nose), which prevents the drug from spreading between the cartilage legs.

As a rule, an increase in the nasolabial angle leads to an elevation of the tip of the nose (Photos 6-7).

The formation of a more aesthetic nasal tip is indicated both for young patients who have a small nose with a widened tip and for older patients who have such widening due to age-related tissue hypotrophy and ptosis. It is important to comprehensively evaluate the proportions of the face and predict whether such a correction will lead to increased facial disharmony.

THINNING THE TIP OF THE NOSE

When shaping the "aristocratic" (as patients often say) tip of the nose, it is important to understand the principles of chiaroscuro on the face. By strengthening the shadow of the triangle above the nasal entrance, we visually make it already. As a rule, I evaluate the "three edges" that form the upper face of the nasal pyramid (photo 8):

  • I "sharpen" the back of the nose with a linear retrograde motion. The injection is made from the border of the nasal bone, at the point where the skin ceases to be loose and becomes elasticly connected to the underlying tissue. The injection is performed at the dermal-subdermal border to prevent the drug from spreading;
  • I form the second "rib" along the edge of the nostril, making it sharper. The injection is made along the two front thirds of the nostril length, as shown in Photo 9, below the injection is directed to the tip of the nose;
  • as a rule, there is no need to form a third "rib" lying on the columella, but if the aesthetic result requires it, I go intradermally from the base of the nose and move along the center of the columella to the tip of the nose. In no case should you go into the subdermal space, because we risk complications of ischemia or trauma to the a. septi nasi, which runs between the pedicles of the alar cartilage (Photo 10).

Thus, as a result of these manipulations, we form the "sharper" faces of the nasal pyramid and sharpen the tip of the nose with two bullae that have merged into one. This technique is quite safe and gives a fairly good aesthetic result.

IMMOBILIZATION OF THE WINGS OF THE NOSE

Another method of aesthetic nose correction is often called the injection of botulinum toxin into the m. nasalis pars transversa (the muscle that expands the wings of the nose). I rarely perform this procedure because very few patients demonstrate the ability to actively dilate and constrict the nostrils.

During the procedure, I use 0.5 units of Dysport 500, diluted by 1.5 ml (about 4 units), performing a subdermal injection (intradermal injection is unlikely to be effective, as the porous skin of the nasal wing will "release" the drug) (photo 11).

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To summarize, I would like to say that most cosmetologists are quite cautious about performing non-surgical nose correction, fearing complications in the form of necrosis and ischemia mentioned in the media, on the Internet, etc. However, I believe that with rational approaches, a thoughtful assessment of facial harmony, and a multi-stage approach, such a correction is both justified and safe. The right choice of a patient, the formation of adequate expectations, the use of safe correction techniques - all this will bring satisfaction from a job well done, allow the patient to improve the quality of life and form a new vector of development in the practice of an aesthetician. Dare to do it, colleagues!