Botox in the wings of the nose

Advantages over other methods

To reduce visible defects, Botox is injected subcutaneously into the nose using thin needles. The client feels virtually no discomfort. With non-surgical rhinoplasty you can:

1. eliminate facial and age wrinkles;
2. lift the tip of the nose with Botox;
3. change shape, reduce wings.

Botulinum toxin does not affect blood circulation; modern formulations are practically safe for health. The exception is individual contraindications.

Protocol

Features of the method

The final result of nose reduction and wrinkle removal can be seen weeks after the procedure. The period of effectiveness depends on the units used, as well as the patient's actions during rehabilitation. If you do not follow the doctor's recommendations, this will negate the effect of botulinum toxin. The product is absorbed gradually, recovery lasts from 3 to 7 days. Procedures in our clinic are performed by certified cosmetologists in St. Petersburg.

If for any reason nose reduction with Botox is contraindicated, then alternative methods can be used. Fillers are special gels based on hyaluronic acid. They are used to change shape and correct skin defects. To narrow the wings, the injection is performed in the side part, and to change the back - along its entire length. With the help of fillers, you can smooth out sharp corners on the bridge of your nose and get rid of the hump.

Gummy smile

This cosmetic defect is characterized by excessive exposure of the gum line when smiling. A gummy smile is most often found in people with a small distance between the base of the nose and the Cupid's bow, as well as in those with a prominent nose and an underdeveloped chin. Often in these same people one can observe pronounced nasolabial folds. The effect of a gummy smile is the result of the work of the muscles that lift the upper lip and the complex of the upper lip and muscles of the wing of the nose.

In addition, patients with gummy smiles often have an inverted upper lip, making them poor candidates for lip augmentation with fillers. The ideal option for them is a combination of filler injections and botulinum therapy. To match ideal facial proportions, the upper lip should cover the upper third of the central incisors. It is to achieve this effect that botulinum therapy for a gummy smile is aimed.

Injections are made symmetrically on both sides of the nose with the patient's smile as intense as possible. The BTA drug is administered intramuscularly above the periosteum. The first point of BTA injection is the body of the muscle that lifts the upper lip and the wing of the nose at the border of the junction of the nose and cheeks. The second point is approximately 2 cm closer to the bony edge of the orbit, in the muscle that lifts the upper lip (Figure 11).

BTA should not be injected too close to the zygomatic eminence to prevent penetration of the toxin into the zygomatic major muscle. The initial recommended dose for each side of the face is 2 units. Botox® or 5 units. Dysport®. After 15 days, the result is assessed and, if necessary, additional injections are given.

Complications: The most common complications are asymmetry and drooping of the upper lip. Asymmetry is eliminated using 25% of the initial dose of BTA with assessment of the result after a week. A drooping mid-upper lip may be the result of too much toxin exposure and overactivity of the zygomaticus major muscle.

Commentary by a cosmetologist, dermatovenerologist, doctor of medical sciences, professor, head. Department of Dermatovenereology and Cosmetology, State Budgetary Educational Institution of Higher Professional Education "GGMU of the Ministry of Health of Russia" Yutskovskaya Y.A.:

— The goal of correcting a gingival smile is to reduce the contraction of overactive muscles responsible for exposing the gums, and, accordingly, reduce the “breadth” of the smile. Weakening of the muscles leads to a harmonized and aesthetically attractive smile. The injection pattern and technique depends on the presence of deep nasolabial folds. To assess the condition, the patient should be asked to smile as widely as possible. Exposure of the gums without the formation of deep nasolabial folds: a fairly deep injection into the center of maximum activity in the caudal zone of the m.levator labii superioris. If the exposure of the gums is associated with a deepening of the nasolabial fold, the injection is made in the area of ​​the labial part of the m.levator labii superioris alaque nasi into the bulge in the upper section of the nasolabial fold. In this place the muscle is located literally on the surface; the injection depth should not exceed 3 mm. Dose of the drug: 2 units. drug Dysport.

tip of the nose

The tip of the nose is an important component of its aesthetic appeal. With age, the tip of the nose droops, which emphasizes the convexity of its back. Drooping of the nasal tip in young patients is associated with increased activity of the depressor septum muscle during smiling, which is also often accompanied by shortening of the upper lip. The same phenomenon is observed in those with a prominent nose and an underdeveloped chin.

Before deciding on the introduction of BTA, the length of the patient's upper lip and nasolabial angle is assessed. There are 2 ways to administer injections into the depressing septum nasal muscle: percutaneous and intraoral. The latter method is quite difficult to implement, so we will only consider the method of administering BTA through the skin.

Due to the special sensitivity of the nose to external anesthetics, it is recommended to use ice compresses to reduce pain. BTA insertion points are located on both sides of the nasal septum at the base of the medial crus (Figure 12).

The BTA drug is administered superficially in a dosage of 1-2 units. Botox® or 4-6 units. Dysport® for every point. Dosage may vary depending on the desired degree and duration of correction, facial proportions, observed muscle activity and the work of adjacent muscles.

Complications: In general, complications when correcting a drooping nasal tip with BTA preparations are extremely rare. Among the side effects, patients most often name pain. Too much action of toxins on the depressor septum nasalis muscle can lead to ptosis of the upper lip.

Wrinkles in the perioral area

With age, the lips undergo a number of changes, including shortening of the lateral part, enlargement of the dermal part of the upper lip, thinning of the red border and the appearance of many vertical wrinkles around the mouth. These wrinkles, also called smoker's lines, can be the result of sun exposure, smoking, hereditary factors and overactive orbicularis oris muscle, such as in musicians. There are several ways to eliminate wrinkles on the upper lip, including filler injections and various anti-aging procedures. Botulinum therapy is used to correct age-related changes in the perioral area, especially in the presence of deep static wrinkles.

Treatment of the orbicularis oris muscle with BTA preparations is carried out with extreme caution in order to achieve the effect of reducing wrinkles and not affect the normal functioning of the oral area. In addition, it is unacceptable to administer BTA near the corners of the lips. Otherwise, relaxation of the muscles that raise the corners of the lips under the influence of the toxin will lead to ptosis of the lips and drooling. Injecting BTA above the middle of the upper lip will lead to a smoothing of the cupid's bow, which is an undesirable effect from an aesthetic point of view.

In general, 1-2 injections are made into each quarter of the perioral area. To avoid dysfunction of the oral area, it is recommended to administer BTA preparations in very small doses. When the toxin is injected 5 mm from the border of the red part of the lips, a secondary aesthetic effect of slight eversion of the lip is achieved (Figure 13).

Complications: An overdose of BTA drugs will lead to lip dysfunctions such as the inability to form a tube, difficulty pronouncing plosive consonants, and difficulty eating and drinking. For this reason, it is recommended to start botulinum therapy in the perioral area with minimal doses and repeat them as necessary.

Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:

— When performing BTA injections in the perioral area, it should be remembered that the muscles located around the lips are involved in the implementation of important physiological functions. Therefore, correction of this zone must be carried out very carefully. The orbicularis oris muscle is divided into the marginal part (pars marginalis) and the labial part (pars labialis). BTA injections into the labial part allow the lips to be slightly turned out, which creates the effect of increasing their area and volume. Injections into the marginal part of the orbicularis oris muscle are performed in the presence of purse-string wrinkles. Dividing the skin portion of the lip in half and retreating at least 5 mm from the columns of the philtrum and from the corners of the mouth, subcutaneous injections are usually made at 2 points on each side in a dose of 2-5 units. Dysport.

Vertical wrinkles from the corners of the lips to the chin

Deep wrinkles from the corners of the lips to the chin can give the face a dissatisfied, gloomy, and sometimes even disdainful expression. The reason for the formation of such wrinkles lies in the combination of several factors: a reduction in collagen levels, atrophy of adipose tissue, and the presence of excess or sagging skin. All these factors can be corrected with plastic surgery and filler injections. In some cases, the depth of wrinkles from the corners of the lips to the chin may increase due to increased activity of the depressor anguli oris muscles, which, when attached to the skin, can pull the corners of the mouth down. Then, by relaxing these muscles with BTA preparations, it is possible to ensure that the zygomatic major and levator anguli oris muscles return the corners of the mouth to their normal position. In some patients, the increase in the depth of wrinkles from the corners of the lips to the chin is facilitated by the activity of the platysma muscles intertwined with the depressing corners of the mouth. Then the effect of BTA drugs should be directed at both muscle groups. Sometimes the best results can be achieved by combining BTA preparations and dermal fillers, with the former enhancing and prolonging the effect of the latter.

To determine the position and feel the depressing angles of the mouth muscles and platysma, the patient is asked to make a grimace and expose a row of lower teeth. Typically, BTA is administered intramuscularly at 2 points on each side. The first of these is the depressor anguli oris muscle, and the second is the platysma cords attached to the lateral part of the orbicularis oris muscle. Insertion of BTA near the corners of the lips or the middle of the lower lip is not recommended to avoid relaxation of the orbicularis oris and depressor lower lip muscles.

The first point is easy to detect by palpation; it is usually located on the continuation of the nasolabial folds on an imaginary vertical line located at a distance of 1 cm from the corners of the lips. The second point is located slightly closer to the outer border of the lower jaw (Figure 14).

Some authors suggest administering one injection of BTA on each side at a distance of no more than 1 cm above the lower edge of the lower jaw on imaginary parallel lines drawn through the corners of the lips. The recommended starting dose is 2-5 units. Botox® or 10 units. Dysport® at each injection point and is subject to adjustment depending on the patient's muscle mass.

Complications: Taking too much BTA or administering it near the corners of the mouth may cause asymmetry or problems with the oral area, such as drooling or difficulty pronouncing certain sounds.

Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:

— The depressor anguli oris muscle is the most superficial muscle in the lower third of the face, therefore, in our experience, it is more rational to administer BTA subcutaneously: the needle is inserted into the skin at an acute angle, almost parallel to the surface. Thus, we control the depth of injection and exclude diffusion of the toxin into the underlying muscles - quadratus and depressor lower lip. In our experience, administration is 6-8 units. Dysport is enough to achieve a pronounced effect.

Dimple on the chin

A dimple on the chin is formed as a result of contraction of the mentalis muscle. The BTA drug is injected into one or two symmetrical points located approximately 1 cm from the line dividing the face in half directly above the protrusion of the chin. It is not allowed to insert BTA closer than 1 cm from the lower lip. Since the mentalis muscle is located deeper than the others, intramuscular injection is recommended to the periosteum, below the dimple. This will prevent the toxin from spreading into the orbicularis oris muscle. Some authors argue that, despite the deep location of the mental muscle, good results can be achieved with superficial injections (Figure 15). The recommended total dose is 2.5-8 units. Botox® or 2.5-20 units. Dysport®.

Complications: If the restrictions on the introduction of BTA near the lower lip are observed, this procedure does not entail any complications other than bruises and hematomas.

Bands of platysma

Age-related skin changes are associated with excessive laxity of the skin, loss of elasticity, formation of a double chin, lipodystrophy, prolapse of the submandibular glands and bone resorption. The subcutaneous muscle of the neck can become overactive, lose tone, or disintegrate, all of which leads to the so-called “turkey neck” effect. Platysma bundles located horizontally and vertically become noticeable with increased contraction.

Botulinum therapy in the neck area is aimed at reducing the external manifestations of platysma contraction. In addition, relaxation of the platysma bands has a positive cosmetic effect on the oval line and wrinkles from the corners of the lips to the chin. The best candidates for botulinum toxin therapy in the neck area are patients who demonstrate active contraction of the platysma during conversation.

BTA preparations are administered to the patient in a sitting position with maximum tension of the platysma in the direction of the cords. Depending on the length of the cord, BTA is inserted into 4-8 points located at a distance of 1.5 cm from each other, grasping the cords with the non-dominant hand (Figure 16).

The moderate initial recommended dose is 2 units. Botox® or 5 units. Dysport® for every point. Too deep administration and overdose should be avoided.

Complications: Often, after injections of BTA drugs into the neck area, bruises remain. It is recommended to avoid injecting BTA into the pharynx due to the risk of exposure of the underlying muscles to the toxin, which can lead to difficulty swallowing, weakening of the neck and dysphonia. Botulinum therapy is also not suitable for correcting horizontal wrinkles on the neck. In addition, due to the large number of injection points for BTA drugs, the anti-aging neck correction procedure is quite expensive.

Comment by cosmetologist, dermatovenereologist Ya. A. Yutskovskaya:

— To date, some experience has been accumulated and there are published data on botulinum therapy for horizontal neck wrinkles. Correction of this area, of course, requires a combination of botulinum therapy and injection plastic surgery using the most flexible and easily sculpted fillers. BTA injections as monotherapy are not always effective. The total dose of Dysport for the correction of neck wrinkles is 50-60 units. Botulinum toxin is injected along the wrinkle at points located 5 mm above it, at intervals of approximately 1 cm. As a rule, the drug in standard dilution is additionally diluted 2 times with saline solution.

Combined techniques

BTA preparations are used both separately and in conjunction with other agents, during one or more sequential procedures aimed at treating different layers of the skin and its imperfections. Over the past few years, the principles of facial rejuvenation have undergone significant changes and have moved from a two-dimensional approach to correcting hypodynamic wrinkles to a three-dimensional approach, which also includes the aspect of tissue volume lost with age. This has led to some changes in the clinical use of BTA drugs. Now doctors are trying to correct not one, but several areas at once in order to achieve the most natural result. In addition, BTA preparations are increasingly used in conjunction with other products, including dermal fillers. The combined use of BTA and fillers corresponds to the concept of a three-dimensional approach to rejuvenation and provides more aesthetically attractive and long-lasting results. When administered together with a filler, BTA slows down metabolic processes in the surrounding tissues and thereby prolongs the period of action of the filler.

BTA also enhances the effect of laser rejuvenation, since collagen production in immobilized tissues occurs faster. For example, excellent aesthetic results can be achieved using laser lip rejuvenation with preliminary (1-2 weeks before) administration of BTA. Regular (with an interval of 4-6 weeks) BTA injections after anti-aging procedures prolong their effect.

In addition, BTA preparations are successfully used in conjunction with chemical peels, especially in patients with signs of photoaging.

BTA injections can also be combined with various plastic surgeries, for example, eyebrow lifting, blepharoplasty of the lower and upper eyelids and rhytidectomy.

Immunogenicity

Immunological complications during botulinum therapy are reduced to acute allergic reactions to human serum albumin. This phenomenon is possible when too high doses of the toxin are administered, which leads to the formation of IgH antibodies, the number of which increases in direct proportion to the volume of the administered BTA drug. The result of this reaction of the body is inactivation of the toxin. However, in aesthetic medicine, BTA preparations are usually used in very small doses, so the issue of immunogenicity is not a cause for concern.

Conclusion

BTA injections are the most popular facial rejuvenation procedure, 100% effective and safe when the dosage is observed. It is important to remember that BTA preparations are not interchangeable. With the shift in the concept of rejuvenation towards a three-dimensional approach that takes into account the importance of tissue volume loss, BTA preparations are increasingly used in combination with hyaluronic acid fillers and other procedures, which makes it possible to achieve the most harmonious and long-lasting aesthetic result.

The nose plays an important role in the facial aesthetics of both men and women. In this regard, it is easy to understand the growing interest in correcting imperfections in the shape, size and volume of the nose over several centuries or even since ancient times. In the last decade, all surgical and cosmetic minimally invasive techniques have been developing exponentially.

Methods of rejuvenation and correction of nasal imperfections have been widely developed in medicine of the third millennium. In many cases, non-surgical correction methods are attractive due to their low invasiveness. We will describe a technique for the combined use of botulinum toxin A (BTxA) and absorbable fillers for aesthetic correction of the shape of the nose.

With this comprehensive approach, BTxA will reduce the imperfections associated with muscle hypertonicity, while hyaluronic acid fillers will correct all imperfections in the nasal profile from root to tip. Nose correction based on a clear knowledge of anatomy and the use of correct filler injection techniques will avoid most side effects. Patients rated this correction method as effective and long-lasting.

Let's pay attention to the subtleties of nose correction using botulinum toxin A (BTxA).

Previously, when correcting this area, we chose the blockade point, which was located at a distance of 1.5 cm from the inner corner of the eye to the middle of the back of the nose. It was at this point that the intradermal injection was made. Thus, with the introduction of 4 units of the drug Dysport (1 division of an insulin syringe when diluting a bottle of 500 units with 1.5 ml of saline), we reduced the motor activity of the nasal muscle (m. nasalis).

At the moment, it is more relevant to use another technique - turning off the nasal muscle without blocking m. levator labii superioris alaeque nasi, because in practice, it became clear that the blockade almost never works properly.

To improve the effect, you can turn off m. levator labii superioris alaeque nasi. It is more convenient to do this using the following protocol:

— insert the needle lateral to the wing of the nose into the deepest part of the nasolabial fold. We touch the needle to the nasal bone and, retreating slightly, inject the drug in 1-2 divisions of the insulin syringe.

Among the side effects, we can expect increased diffusion of the drug, which leads to decreased mobility of the upper lip, and the lip may fall onto the teeth. To avoid such complications, it is recommended to use a 1.5 ml dilution of Dysport rather than 2.5 ml.

You can block this muscle higher up, but you must remember that the angular artery runs along the bony dorsum of the nose. Muscle m. The levator labii superioris alaeque nasi runs almost along the seam between the nasal bone and the upper jaw. Therefore, if we want to block without complications, we need to find a point above the wing of the nose in the place where the nasal bone just begins, at the moment of transition to the upper jaw. M goes in this hollow. levator labii superioris alaeque nasi, and it is better to block right here.

How to narrow anatomically wide nostrils

In old anatomy textbooks, the muscle responsible for widening the nostrils was considered a branch of the m. levator labii superioris alaeque nasi and passed to the wing of the nose. It was considered as one continuous nasal dilator with the function of widening the nostrils. Now it is considered as a separate transverse muscle that expands the wings of the nose.

To reduce the activity of the muscle that is responsible for the expansion of the wings of the nose, it is enough to inject 0.5 divisions of an insulin syringe diluted by 1.5 ml directly into the hole above the wing of the nose. Remember that administration at this point can be either intradermal or subdermal. In this place we are not in danger of either diffusion of the drug or distortion of the nose.

Should I turn off the depressor septum muscle? Nobody does this in clinical practice. Overactivity of this muscle is quite rare. And given that fillers are now used to sculpt the nose in a very wide range, it is a safer option as an alternative to rhinoplasty.

Subtleties of nose correction using hyaluronic acid fillers

Lifting the tip of the nose with filler is not very difficult if you correctly understand in what place, to what depth and how much correction needs to be done. To obtain maximum results, it is necessary to introduce filler at the border of the dermal and subdermal layers along the septum itself.

It is also mandatory to create a base bolus under the cartilaginous legs that make up the septum itself. In order to consolidate the result obtained, it is necessary to soften the transition from the forehead to the bridge of the nose and in this place place one bolus of the drug in an amount of 0.3 to 0.5 ml.

A good aesthetic result is obtained by introducing a small amount of the drug subdermally along the dorsum of the nose using a linear technique through a cannula. This correction technique will give not only the effect of lifting the tip of the nose and narrowing the nostrils in front, but also aesthetically improving the patient’s profile.

The emergence of minimally invasive methods, especially aesthetic correction methods, allows highly qualified doctors to correct many minor deficiencies, which in many cases required surgical correction. Today, it is possible to achieve significant improvement in appearance, which satisfies patients and does not require surgical intervention.