**Non Surgical Techniques**

[10] Gunter, JP, and Rohrich, RJ. Management of the deviated nose: The importance of

septal reconstruction. *Clin Plast Surg*. 1988;15: 43.

82 Miniinvasive Techniques in Rhinoplasty

## **Medical Rhinoplasty – The Treatment of Mimical Patients**

#### Alessio Redaelli

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62071

#### **Abstract**

The plunging tip of the nose is a diffused cosmetically annoying problem. The medical rhinoplasty is a useful tool for the repair/reshaping of the plunging tip of the nose when the genesis is mimical. Botulinum toxin is used to repair this deformity. The anatomical details, the preparation of the materials, and the technique are discussed in this chapter with all the details that will permit the readers to understand and repeat the technique.

**Keywords:** Nasal profile, botulinum toxin A, mini-invasive rhinoplasty, nasal tip, mus‐ cles, nasal angles, depressor septi nasi, levator labii alaeque nasi, Dante's nose, plunging tip, hyper-projected nose, hypoprojected nose, aesthetics, beauty, aging

#### **1. Introduction**

The nose has always been one of the most important organs of our being. It characterizes indelibly our future habits from the very beginning of our life (such as the incredible example of salmons' olfactory imprinting at birth known as natal homing or natal philopatry: the homing process by which they travel for thousands of miles to breed in that particular stream where they were born) until death when we feel that particular smell of death [7,9].

In Chinese face reading, the nose is considered to be the money spot, especially during the ages of 41 to 50.

There is no place in the world where I go, where I am not asked to improve the appearance of the nose, no matter what the race, Asian or European, Afro-American or Japanese.

The nose determines the facial symmetry in a peremptory manner and represents our inner and outer bow. It is certainly one of the most exposed parts of our face to the attention of our partners, when we meet them for the first time. And this was especially true in the past centuries where also the figureheads (figureheads of ships) that adorned the bow of the ship

put clearly in evidence the importance of nose (Fig.1), the bow of our thinking and being. It is therefore not strange that the technique published by me back in 2008 is today definitely one of the most widespread and known techniques of facial rejuvenation.

**Figure 1.** Figureheads of ships.

The facial aging is mainly due to three factors: the first is certainly the important reduction of volumes, the second the mimical movements with the arising of all the wrinkles on the face, and the third is due to the tone of the skin and subcutaneous tissue.

The exact understanding of the genesis of the defects we see all over the face provides the base for the treatments that we then adopt to repair these defects and the nose, of course, underlies these rules.

Knowing exactly when nasal defects became part of official medicine is impossible to date with precision. Egyptians 3000 years ago already knew about nasal surgery, also because of their important experience in embalming the dead. Even in China, because of the tradition of cutting the nose of adulterers, and many other types of criminals, there was a culture in the treatment of nasal defects. In the later period of the Middle Ages, several of these techniques became obsolete. But with the Renaissance there was a new impetus, particularly in Italy with the famous school of the Brancas, in Sicily and Gaspare Tagliacozzi (Bologna) [1]. The Branca and Gaspare Taglicozzi both are very famous for the so-called flap Italian (Fig. 2).

Probably, Jaques Joseph is the father of the modern surgical rhinoplasty, finding also a new method to reshape/repair the abnormally enlarged nasal wings (negroid nose) in black people (1904). But the first real medical rhinoplasty was most probably performed by the Belgian doctor Broeckaert [2] in 1901 (Fig. 3).

**Figure 2.** "Flap Italian."

put clearly in evidence the importance of nose (Fig.1), the bow of our thinking and being. It is therefore not strange that the technique published by me back in 2008 is today definitely one

The facial aging is mainly due to three factors: the first is certainly the important reduction of volumes, the second the mimical movements with the arising of all the wrinkles on the face,

The exact understanding of the genesis of the defects we see all over the face provides the base for the treatments that we then adopt to repair these defects and the nose, of course, underlies

Knowing exactly when nasal defects became part of official medicine is impossible to date with precision. Egyptians 3000 years ago already knew about nasal surgery, also because of their important experience in embalming the dead. Even in China, because of the tradition of cutting the nose of adulterers, and many other types of criminals, there was a culture in the treatment of nasal defects. In the later period of the Middle Ages, several of these techniques became obsolete. But with the Renaissance there was a new impetus, particularly in Italy with the famous school of the Brancas, in Sicily and Gaspare Tagliacozzi (Bologna) [1]. The Branca and

Probably, Jaques Joseph is the father of the modern surgical rhinoplasty, finding also a new method to reshape/repair the abnormally enlarged nasal wings (negroid nose) in black people (1904). But the first real medical rhinoplasty was most probably performed by the Belgian

Gaspare Taglicozzi both are very famous for the so-called flap Italian (Fig. 2).

and the third is due to the tone of the skin and subcutaneous tissue.

of the most widespread and known techniques of facial rejuvenation.

**Figure 1.** Figureheads of ships.

86 Miniinvasive Techniques in Rhinoplasty

doctor Broeckaert [2] in 1901 (Fig. 3).

these rules.

**Figure 3.** Broeckaert's syringe.

This doctor had invented a special syringe which was used to inject liquid paraffin (obtained also by pressure) in the soft tissues: here, I do not mention the side effects. We arrive finally to the present day with a huge improvement in all surgical techniques and with the advent of mini-invasive techniques and also of medical rhinoplasty, to be performed exclusively with medical techniques and, in detail, with the combination of botulinum toxin and fillers.

In my experience, over 80% of patients who arrive in our medical studies have major or minor nasal defects but only a small part of these patients, around 15–20%, agree to surgery. Others hesitate to meet the doctor for fear of undergoing an invasive and potentially dangerous procedure or because the defect, although sometimes clearly felt, is still very mild.

Finally, I want to mention that the nose is subject of the important phenomenon of aging just like all other areas of the face. It can get to present a drop of the tip up to 3–4 mm. In addition, a surgical nose perfectly corrected, and beautiful for a long time postsurgery, may after a few years begin to present some skeletonization that can be cured with a resorbable filler.

The main indications for medical rhinoplasty are:


In this chapter, we will focus mainly on patients with mimical deformity.

#### **2. Anatomy**

A quick reminder about anatomy [4,5,9,10] will be useful to readers. The skeleton is described in Fig. 4. Its main parts are the nasal bones, the alar triangular cartilages, the minor alar cartilages, and finally the Great (or major) alar cartilage. The vascularization starts from the lateral nasal vessels and columellar vessels arriving from the external carotid artery and the angular vessels arriving from the internal carotid artery and finally the dorsal nasal artery arriving from the frontal lobe. It is important during all the techniques described in this section to pay particular attention to these vessels that must not be injected.

In the nasal base, triangular, visible from the inferior projection, we can find in the middle the columella, while laterally the nasal wings are well-delineated by the lateral, intermediate, and medial crus of the greater alar cartilage.

The nasal muscles are visible in Fig. 5. The depressor septi nasi muscle and the levator labii alaeque nasi are most important for medical rhinoplasty. The depressor septi nasi muscle has a vector of contraction parallel to the columella and pushes the nasal tip toward the maxillar bone. The levator labii alaeque nasi (elevator of the lip and nasal wings), instead, elevates the nasal wings, contemporaneous with the lip. So we can describe a real rotational movement that characterizes some individuals (Fig. 6).

**Figure 4.** Bones and cartilages of the nose.

In my experience, over 80% of patients who arrive in our medical studies have major or minor nasal defects but only a small part of these patients, around 15–20%, agree to surgery. Others hesitate to meet the doctor for fear of undergoing an invasive and potentially dangerous

Finally, I want to mention that the nose is subject of the important phenomenon of aging just like all other areas of the face. It can get to present a drop of the tip up to 3–4 mm. In addition, a surgical nose perfectly corrected, and beautiful for a long time postsurgery, may after a few

**•** Aesthetical patients: mimical, volumetrical, and for deep bridge enhancement in Far East

**•** Surgical patients: the gold standard for correction is surgery, but they do not accept this

**•** Postsurgical patients: to improve all those little postsurgical defects, once the object of a very

**•** Functional patients: affected by atrophic rhinitis and atrophic generic problems to get a

A quick reminder about anatomy [4,5,9,10] will be useful to readers. The skeleton is described in Fig. 4. Its main parts are the nasal bones, the alar triangular cartilages, the minor alar cartilages, and finally the Great (or major) alar cartilage. The vascularization starts from the lateral nasal vessels and columellar vessels arriving from the external carotid artery and the angular vessels arriving from the internal carotid artery and finally the dorsal nasal artery arriving from the frontal lobe. It is important during all the techniques described in this section

In the nasal base, triangular, visible from the inferior projection, we can find in the middle the columella, while laterally the nasal wings are well-delineated by the lateral, intermediate, and

The nasal muscles are visible in Fig. 5. The depressor septi nasi muscle and the levator labii alaeque nasi are most important for medical rhinoplasty. The depressor septi nasi muscle has a vector of contraction parallel to the columella and pushes the nasal tip toward the maxillar bone. The levator labii alaeque nasi (elevator of the lip and nasal wings), instead, elevates the nasal wings, contemporaneous with the lip. So we can describe a real rotational movement

procedure or because the defect, although sometimes clearly felt, is still very mild.

years begin to present some skeletonization that can be cured with a resorbable filler.

solution, and so with medical rhinoplasty we can strike a good compromise.

In this chapter, we will focus mainly on patients with mimical deformity.

to pay particular attention to these vessels that must not be injected.

The main indications for medical rhinoplasty are:

difficult postsurgical reintervention.

medial crus of the greater alar cartilage.

that characterizes some individuals (Fig. 6).

and African races.

88 Miniinvasive Techniques in Rhinoplasty

thicker mucosa.

**2. Anatomy**

**Figure 5.** Bones and cartilages of the nose.

The superficial layer is characterized deeply by a superficial fascia that covers all the nasal muscles, extension of the facial SMAS. The subcutaneous layer and epidermis are characterized

**Figure 6.** Nasal motion arrows.

by a thick and less adherent skin at the root of the nose, a very thin and more adherent skin in the middle, and finally a thicker and also adherent skin that covers the tip of the nose.

#### **3. Aesthetical study**

The aesthetical study is based as always on strict rules. All the measures of the face have been described many centuries ago by Italian scientists like Leonardo da Vinci and must be exactly known by every doctor who wants to use this technique.

The main nasal points of interest are described in Fig. 7. The nasal area is from the Glabella to the Nasal spin through Nasion, Rhinion, and Nasal tip.

In the same figure, it is possible to study the main nasal angles: nasofrontal angle, from 115° to 135°; dorsal angle, normally straight or slightly lower; nasolabial angle, from 90° to 110°.

In the perfect aesthetical indication, the nasofrontal and nasolabial angles are slightly reduced, while the dorsal angle is a bit increased (see Fig. 7).

Table 1 lists the main aesthetical indications.

The nose is generally connected to all other areas of the face, particularly the malar area, the lips, and the chin [10]. In particular, Angle's classes are of great importance. I will not dwell too much on their description since this can be studied accurately in many specific texts. I would only emphasize on the importance of Ricketts' e-line, which connects the tip of the nose with the Pogonion. It will always be of great importance to control the real projection of the chin and areas around the nose. It will be of evidence how even a rather long and hyperpro‐

**Figure 7.** Nasal points of interest.

by a thick and less adherent skin at the root of the nose, a very thin and more adherent skin in the middle, and finally a thicker and also adherent skin that covers the tip of the nose.

The aesthetical study is based as always on strict rules. All the measures of the face have been described many centuries ago by Italian scientists like Leonardo da Vinci and must be exactly

The main nasal points of interest are described in Fig. 7. The nasal area is from the Glabella to

In the same figure, it is possible to study the main nasal angles: nasofrontal angle, from 115° to 135°; dorsal angle, normally straight or slightly lower; nasolabial angle, from 90° to 110°.

In the perfect aesthetical indication, the nasofrontal and nasolabial angles are slightly reduced,

The nose is generally connected to all other areas of the face, particularly the malar area, the lips, and the chin [10]. In particular, Angle's classes are of great importance. I will not dwell too much on their description since this can be studied accurately in many specific texts. I would only emphasize on the importance of Ricketts' e-line, which connects the tip of the nose with the Pogonion. It will always be of great importance to control the real projection of the chin and areas around the nose. It will be of evidence how even a rather long and hyperpro‐

**3. Aesthetical study**

**Figure 6.** Nasal motion arrows.

90 Miniinvasive Techniques in Rhinoplasty

known by every doctor who wants to use this technique.

the Nasal spin through Nasion, Rhinion, and Nasal tip.

while the dorsal angle is a bit increased (see Fig. 7).

Table 1 lists the main aesthetical indications.

**Table 1.** Aesthetical indications.

jected nose may be such that, in some cases, for an opposite hypoprojection of the zygomaticmalar and mental areas, for example, in a second skeletal class. (Fig. 8)

#### **4. Treatment of mimical patients**

In a wide number of studies, it is confirmed that about 60% of patients with the typical plunging tip of the nose present a really mimical genesis for the hyperactivity of the depressor septi nasi (depressor of the nasal tip) or the levator labii alaeque nasi (elevator of the lip and nasal wing).

The treatment of these patients is based on the use of Botulinum toxin A.

**Figure 8.** The importance of the chin. An interesting case of a Middle Eastern patient, 2' skeletal class, who was treated with a filler on the chin, before and after treatment. It is immediately possible to see how many changes occur as well as the projection of the nose, and overall changes on the whole face.

Botulinum Toxin A (BTxA) is a neurotoxin approved in many countries and also in Europe. Its "On-Label" use is in the glabellar region. Other uses and also the treatment of mimical patients with the plunging nasal tip, include an "Off-Label" indication.

While for an "On-Label" treatment, the informed consent could even be oral (although I always ask the patient to sign up in writing anyway), in all "Off-Label" indications I remind all readers that the informed consent must necessarily be in writing.

All classical contraindications of BTxA must be completely investigated and as always in medicine a complete anamnesis must be done. We cannot treat patients with myasthenia and myastenic form syndromes (Lambert Eaton) and patients who are allergic to components of the product.

Patients requiring a fine control of the movements of the upper lip, and peri-oral area, like the players of musical instrument or singers, are a strict contraindication.

#### **4.1. Materials approved in Europe**

The materials approved in Europe (Fig. 9) are:


The different preparations are not interchangeable and the specific units are diverse, just like their action in the tissues.

All classical contraindications of BTxA must be completely investigated and as always in medicine a complete anamnesis must be done. We cannot treat patients with myasthenia and myastenic form syndromes (Lambert Eaton)

Patients requiring a fine control of the movements of the upper lip, and peri-oral area, like the players of musical instrument or singers, are a strict

� **Vistabel/Vistabex/Cosmetic Botox**: Derived from **Botox**, Allergan, Irvin California. It can be stored in the refrigerator between 2° and

� **Azzalure**: Distributed in Europe by Galderma, directly derives from **Dysport**, Ipsen. It is moderately stronger than Botox; it must be stored in a refrigerator between 2° and 8° and is available in vials of

� **Bocouture**: Distributed in Europe by Merz, directly derives from Xeomin. In Europe, it is available in vials of 50 U. It can be stored at

and patients who are allergic to components of the product.

contraindication.

125 U.

room temperature.

**Figure 9:** Materials approved in Europe.

<H2>*Materials approved in Europe* 

The materials approved in Europe (Fig. 9) are:

8° and it is in vials of 50 or 100 U.

**Figure 9.** Materials approved in Europe.

#### **4.2. Preparation of materials**

Botulinum Toxin A (BTxA) is a neurotoxin approved in many countries and also in Europe. Its "On-Label" use is in the glabellar region. Other uses and also the treatment of mimical

**Figure 8.** The importance of the chin. An interesting case of a Middle Eastern patient, 2' skeletal class, who was treated with a filler on the chin, before and after treatment. It is immediately possible to see how many changes occur as well

While for an "On-Label" treatment, the informed consent could even be oral (although I always ask the patient to sign up in writing anyway), in all "Off-Label" indications I remind all readers

All classical contraindications of BTxA must be completely investigated and as always in medicine a complete anamnesis must be done. We cannot treat patients with myasthenia and myastenic form syndromes (Lambert Eaton) and patients who are allergic to components of

Patients requiring a fine control of the movements of the upper lip, and peri-oral area, like the

**• Vistabel/Vistabex/Cosmetic Botox**: Derived from **Botox**, Allergan, Irvin California. It can

**• Azzalure**: Distributed in Europe by Galderma, directly derives from **Dysport**, Ipsen. It is moderately stronger than Botox; it must be stored in a refrigerator between 2° and 8° and is

**• Bocouture**: Distributed in Europe by Merz, directly derives from Xeomin. In Europe, it is

The different preparations are not interchangeable and the specific units are diverse, just like

be stored in the refrigerator between 2° and 8° and it is in vials of 50 or 100 U.

patients with the plunging nasal tip, include an "Off-Label" indication.

players of musical instrument or singers, are a strict contraindication.

available in vials of 50 U. It can be stored at room temperature.

that the informed consent must necessarily be in writing.

as the projection of the nose, and overall changes on the whole face.

92 Miniinvasive Techniques in Rhinoplasty

the product.

**4.1. Materials approved in Europe**

available in vials of 125 U.

their action in the tissues.

The materials approved in Europe (Fig. 9) are:

All the materials are in a dry-vacuum vial and must be prepared just prior to the treatment. For the dilution, physiological solution is normally used [3,8].

Vistabel 50 U is diluted with 1.25 ml (1 U in 0.025 and 4 U in 0.1 ml). Azzalure 125 U is diluted with 0.63 ml (5 U in 0.025 and 20 U in 0.1 ml). Bocouture 50 U is diluted with 1.25 U (1 U in 0.025 and 4 U in 0.1 ml)

In particular conditions (for particularly fine areas as for example the mouth, to treat very thin muscles, etc.), it is possible to dilute less to obtain a very concentrated material. If we dilute less or more, the U contained in the final solution will be accordingly different.

Why do I often dilute less? What is the philosophy behind this concept? If the readers check the specifications in the leaflet inside the vials, they will find that some side effects such as headache, ocular disorders such as blepharo-ptosis, and eyelid edema are likely to occur (between 1/10 and 1/100). I believe that these side effects can be due to the excessive dilution. This can lead to an excessive spread of the toxin in anatomical regions that are too close not to be affected by its effect (such as the upper eyelid). This can happen especially in some patients with particular kind of atonic tissues. Prudence in aesthetic medicine is one of the most important issues to follow.

Finally, I want to highlight the syringe I use normally, a 0.5 ml syringe for diabetes or, better, a 0.3 ml syringe for diabetes with inserted needle 30 G x 8 mm. The demi-type syringe is perfect (Fig. 10).

**Figure 10.** A demi-type 0.3 syringe.

#### **4.3. Study of patients**

Before the treatment of mimical patients, it is mandatory to completely study their movement, to exactly understand if there is an indication to the treatment and which muscles must be injected. For this reason, we have a moment that is so important to understand the movements: the first 2 or 3 minutes of the visit, when we give our hand to the patient and she/he is completely natural, and moves without being conscious of being observed.

In these first moments of the visit we have the opportunity to see the nasal tip that is much depressed in mimical patients, and especially if we have to see the rotational movement, we speak few lines before.

In the majority of patients, we can see the typical movement of the depressor septi nasi: the tip of the nose is pushed down toward the maxillar bone (Fig. 11 b). In such patients, it is possible to see also the contemporary movement of the levator labii alaeque nasi as the nasal wings can arise. At the same time, the nasolabial angle tends to reduce, much lower than 90°.

**Figure 11.** A mimical patient is studied before the treatment in frontal projection (a) and in profile (b)

#### **4.4. Treatment of the "Depressor septinasi" muscle**

The depressor septi nasi muscle, as described earlier, is inserted on the maxillar bone at the nasal spine. Its fibers rise toward the nasal tip through the columella [8,9].

This treatment is based on the injection of fibers or in the colummella or at the nasal spine. I normally use a 0.5 ml syringe for diabetes. I inject 4 U Vistabel/Bocouture or 10U Azzalure.

The left hand opens the side of the columella to be injected, making also a light rotation of the nasal base.

**Figure 12.** Injection of the columella.

**4.3. Study of patients**

94 Miniinvasive Techniques in Rhinoplasty

speak few lines before.

Before the treatment of mimical patients, it is mandatory to completely study their movement, to exactly understand if there is an indication to the treatment and which muscles must be injected. For this reason, we have a moment that is so important to understand the movements: the first 2 or 3 minutes of the visit, when we give our hand to the patient and she/he is

In these first moments of the visit we have the opportunity to see the nasal tip that is much depressed in mimical patients, and especially if we have to see the rotational movement, we

In the majority of patients, we can see the typical movement of the depressor septi nasi: the tip of the nose is pushed down toward the maxillar bone (Fig. 11 b). In such patients, it is possible to see also the contemporary movement of the levator labii alaeque nasi as the nasal wings can arise. At the same time, the nasolabial angle tends to reduce, much lower than 90°.

completely natural, and moves without being conscious of being observed.

**Figure 11.** A mimical patient is studied before the treatment in frontal projection (a) and in profile (b)

nasal spine. Its fibers rise toward the nasal tip through the columella [8,9].

The depressor septi nasi muscle, as described earlier, is inserted on the maxillar bone at the

This treatment is based on the injection of fibers or in the colummella or at the nasal spine. I normally use a 0.5 ml syringe for diabetes. I inject 4 U Vistabel/Bocouture or 10U Azzalure.

The left hand opens the side of the columella to be injected, making also a light rotation of the

**4.4. Treatment of the "Depressor septinasi" muscle**

nasal base.

The other hand holds the syringe and injects perpendicularly to the columella axis (Fig. 12). If we inject the muscle along the columella, the risk of affecting nearby muscles is usually nil.

It is possible also to inject the muscle at the nasal spine (Fig. 13). In this case, it is possible also that a very small quantity of toxin can spread in some fibers of the nearby muscles, especially the Buxinator muscle that makes the deep muscular layer around the lips. This is the reason why some patients come back for a retouch 15 days later, reporting sometimes that they feel a bite in their cheeks: the buxinator muscle, for some days, partially loses its precision in keeping food under the teeth. It disappears by time and a useful advice for patients regarding this possible side effect is to pay attention to chewing.

**Figure 13.** The nasal spine.

#### **4.5. Treatment of the "elevator of the lip and nasal wing" muscle**

In Fig. 13, it is possible to see the important elevation of the nasal wing up and laterally, clearly visible in the profile projection. This is very important especially in black and Far East races, where the widening of the nasal base while smiling is very typical.

**Figure 14.** Points of injection of "levator labii alaeque nasi" muscle (a). In (b) it is possible to see the position of the elevator muscles of the upper lip: 1 – levator labii alaeque nasi, 2 – elevator of the lip, 3 – zygomaticus minor, 4 – zygo‐ maticus major.

In Fig. 14a and b, it is possible to see the injection points and the elevator muscles of the upper lip.

Normally, I inject at the elevator of the lip and nasal wing at their half, just laterally to the nasal wings, as visible in Fig. 14a. It is important to remain medially, since just laterally to this muscle we find the elevator of the lip [8,9].

As has been said many times, it is of great importance to study the patients. So, if we have a concomitant gummy smile, the risk of injections will be very low. Otherwise, if we do not want definitely a lip lowering, we will remain totally in the "elevator of the lip and nasal wing" [8].

So if we have a concomitant gummy smile, we want a greater spread of the toxin and I dilute with the normal dilution (1.25 ml for Vistabel/Bocouture and 0.63 for Azzalure) or even more.

If, instead, I want to avoid any spreading in nearby muscles I will dilute the material with a lesser quantity of physiological water (1 ml for Vistabel/Bocouture and 0.5 for Azzalure).

There is no real rule about the number of Units to use, but if we want to remain prudent I suggest the readers not inject more than 4 U Vistabel/Botox/Bocouture/Xeomin or 5 U Azza‐ lure/Dysport.

Example 1:

**4.5. Treatment of the "elevator of the lip and nasal wing" muscle**

96 Miniinvasive Techniques in Rhinoplasty

where the widening of the nasal base while smiling is very typical.

maticus major.

lure/Dysport.

we find the elevator of the lip [8,9].

lip.

In Fig. 13, it is possible to see the important elevation of the nasal wing up and laterally, clearly visible in the profile projection. This is very important especially in black and Far East races,

**Figure 14.** Points of injection of "levator labii alaeque nasi" muscle (a). In (b) it is possible to see the position of the elevator muscles of the upper lip: 1 – levator labii alaeque nasi, 2 – elevator of the lip, 3 – zygomaticus minor, 4 – zygo‐

In Fig. 14a and b, it is possible to see the injection points and the elevator muscles of the upper

Normally, I inject at the elevator of the lip and nasal wing at their half, just laterally to the nasal wings, as visible in Fig. 14a. It is important to remain medially, since just laterally to this muscle

As has been said many times, it is of great importance to study the patients. So, if we have a concomitant gummy smile, the risk of injections will be very low. Otherwise, if we do not want definitely a lip lowering, we will remain totally in the "elevator of the lip and nasal wing" [8]. So if we have a concomitant gummy smile, we want a greater spread of the toxin and I dilute with the normal dilution (1.25 ml for Vistabel/Bocouture and 0.63 for Azzalure) or even more. If, instead, I want to avoid any spreading in nearby muscles I will dilute the material with a lesser quantity of physiological water (1 ml for Vistabel/Bocouture and 0.5 for Azzalure).

There is no real rule about the number of Units to use, but if we want to remain prudent I suggest the readers not inject more than 4 U Vistabel/Botox/Bocouture/Xeomin or 5 U Azza‐

In the case of a 63-year-old patient who comes to me for the treatment of BTxA for facial wrinkles, in the study prior to treatment it is possible to clearly see the depression of the nasal tip by muscular genesis.

She has a good indication for the treatment of nasal depression muscles.

**Figure 15.** The patient is studied before in basic position (a), during movement (b), and after 15 days (c).

The patient was treated only in the columellar injection point with 2 U Vistabex per side. I used a 0.5 ml syringe and the dilution used was with 1.25 ml.

I probably made a mistake not to treat also the levator labii alaeque nasi, since the movement was very important and especially after 15 days it was more visible, compared with the image of the movement before the procedure.

#### **Author details**

Alessio Redaelli\*

Address all correspondence to: mail@docredaelli.com

Visconti di Modrone Medical Center, Milan, Italy

#### **References**


## **Botulinum Toxin in the Nasal Area**

Diego Schavelzon, Guillermo Blugerman, Gabriel Wexler and Lorena Martinez

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/62070

#### **Abstract**

[3] Redaelli A. Botulinum toxin dilution: our technique. *J Cosm Laser Ther* 2003; 5: 218–

[4] Dayan SH, Kempiners JJ. Treatment of the lower third of the nose and dynamic nasal

[5] Rohrich RJ, Huynh B, Muzaffar AR, et al. Importance of the depressor septi nasi muscle in rhinoplasty: anatomic study and clinical application. *Plast Reconstr Surg*

[7] Redaelli A. Medical rhinoplasty with hyaluronic acid and botulinum toxin A: a very

[8] Redaelli A. *The Botulinum Toxin A in Aesthetic Medicine, for the Treatment of Hyperhidro‐ sis and in Odontostomatology: Basic Principles and Clinical Practice*. 2nd ed. Firenze:

[9] Redaelli A., Braccini F. *The Medical Rhinoplasty: Basic Principles and Clinical Practice*.

[10] Redaelli A, Braccini F. *Facial Aging: Medical, Surgical and Odontostomatological Solu‐*

simple and quite effective technique. *J Cosm Dermatol* 2008; 7, 210–220.

tip ptosis with Botox. *Plast Reconstr Surg* 2005; 115(6): 1784–1785.

[6] Redaelli A. *The Aesthetic Medicine*. Firenze: See-Editrice; 2009.

2000; 105(1): 376–383; discussion 84–88.

219.

98 Miniinvasive Techniques in Rhinoplasty

OEO; 2012.

Firenze: OEO; 2010.

*tions*. Firenze: OEO; 2011.

Introduction: Botulinum toxin type A for aesthetic purposes has been used since 1987, proving to be one of the most popular procedures in aesthetics due to its effectiveness in softening dynamic wrinkles.

Nasoglabellar lines or bunny lines:They are the result of the contraction of the nasal trans‐ versus. They can be primary or secondary, the latter as a result of muscle blockade in glabel‐ lar region, generating a compensatory contraction.

Specific application

Nasal tip ptosis: As people age the nasal tip tends to fall due to gravity forces and due to the kinetic action of the depressor of the septum muscle. The application of Botox in this area will only have positive results if the ptosis is of muscular cause.

Nasal flutter: Physical or emotional stress causes the involuntary contraction of the anteri‐ or and posterior dilator naris. Also the injection in these muscles produces the stretching of nostrils of very wide noses, when these muscles are active (they can move the ala).

Hyperhidrosis of nasal dorsum: The precise diagnosis of the areas is done through the Mi‐ nor test (iodinated alcohol and starch). The injection is done in the dermis until the skin turns white, 1– 2 UI per injection, separating them by 1cm.

Multiple eccrine hidrocystomas: This papula-cystic lesion, described by Andrew Ross Rob‐ inson, has a transparent dome through which a blue color is seen, usually confused with blackhead. They originate in sweat ducts and come out associated with hyperhidrosis.

**Keywords:** BOTOX nasal applications, Botulinum toxin, bunny lines, dynamic wrinkles, gingival smile, nasal anatomy, nasal cosmetic procedures, nasal dermatology, nasal dy‐ namics, nasal flutter, nasal hyperhidrosis, nasal muscles, nasal proportions, nasal tip pto‐ sis, nose aesthetics, multiple eccrine hidrocystomas, minimal invasive procedures, muscle blockade, wide nose

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **1. Introduction**

Since 1987, Botulinum toxin type A has been used to enhance the aesthetic appearance of the upper third of the face (Fig. 1). The main effect is softening of dynamic wrinkles by diminishing mimic muscles contraction. Nowadays, the cosmetic use of Botulinum toxin is no longer limited to this area and has extended to the inferior third of face, neck, and the medial facial area and to the nose, which is the main subject of this book.

**Figure 1.** Commercial presentation of Botox®. Syringes used for application.

Botulinum toxin type A's popularity has increased in the past years, proving to be the most popular aesthetic procedure in the world, according to international scientific societies, mainly due to its safety and predictable results. We have large experience in the use of Botulinum toxin in the nose and other facial areas. In this chapter, we will share our experience with Botulinum toxin type A in nasal muscles.

#### **1.1. Nasal muscles**

According to Latourneau and Daniel [1], the superficial musculoaponeurotic system (SMAS) that covers the nasal dorsum and ala is composed by eight muscles that share common fascias with neighboring areas such as lids, cheeks, lips, and forehead.

**Figure 2.** Nasal muscles. Front view.

Different authors have classified these muscles based on various criteria (Figs. 2 and 3). Aiach and Levignac [2] classify them according to the level of insertion in relation to the nostrils: above or below. Griesman [3] uses a physiological criterion, dividing them in elevators, depressors, dilators, and constrictors:

	- **◦** *Procerus*

**1. Introduction**

100 Miniinvasive Techniques in Rhinoplasty

Since 1987, Botulinum toxin type A has been used to enhance the aesthetic appearance of the upper third of the face (Fig. 1). The main effect is softening of dynamic wrinkles by diminishing mimic muscles contraction. Nowadays, the cosmetic use of Botulinum toxin is no longer limited to this area and has extended to the inferior third of face, neck, and the medial facial

area and to the nose, which is the main subject of this book.

**Figure 1.** Commercial presentation of Botox®. Syringes used for application.

with neighboring areas such as lids, cheeks, lips, and forehead.

Botulinum toxin type A in nasal muscles.

**1.1. Nasal muscles**

Botulinum toxin type A's popularity has increased in the past years, proving to be the most popular aesthetic procedure in the world, according to international scientific societies, mainly due to its safety and predictable results. We have large experience in the use of Botulinum toxin in the nose and other facial areas. In this chapter, we will share our experience with

According to Latourneau and Daniel [1], the superficial musculoaponeurotic system (SMAS) that covers the nasal dorsum and ala is composed by eight muscles that share common fascias

	- **◦** *Alar nasalis (dilator naris posterior)*
	- **◦** *Depressor septi nasi*
	- **◦** *Transverse nasalis*
	- **◦** *Compressor narinum minor*

#### **◦** *Dilator naris anterior*

**Figure 3.** Nasal muscles. Lateral view.

The *procerus* originates in the *transverse nasalis* aponeurosis, nasal bones periosteum, and nasal lateral cartilage perichondrium, and ends in glabellar skin. As an elevator it antagonizes the *transverse nasalis* depressor action.

The *levator labii superioris alaeque nasi* originates in the medial portion of the *orbicularis oculi* and the frontal process of the maxilla, inserting down in the nasolabial fold, nasal ala, and skin and muscles of the upper lip. It has a nasal fascicle that covers the origin of the *transverse nasalis*. The main function is to elevate the nasal ala and open the nostrils.

The *anomalus* originates in the frontal process of the maxilla inserting in nasal bones, nasal lateral cartilage, the *procerus*, and the *transverse nasalis*. It is present in 50% of the population.

The *alar nasalis*, also known as *dilator naris posterior*, originates in the maxilla over the lateral incisor and inserts in the nasal ala. This muscle opens the nostrils.

The *depressor septi nasi* originates in the nasal spine of the maxilla inserting in the membranous septum and medial crus of alar cartilages. The contraction of this muscle turns downward the nasal tip. According to Zide [4], there are some superficial fibers that originate in the *orbicularis oris*, and insert in the columella, which are responsible for the elevation of the lip as the nasal tip turns down.

The *transverse nasalis* originates in the maxilla above the incisor fossa, sharing some fibers with the *levator labi superioris alaeque nasi*, then it inserts in an aponeurosis over the nasal dorsum, joining with the contralateral muscle. The contraction of this muscle stretches the nasal vestibule by descending the lateral crus of the alar cartilage.

The *compressor narinum minor* is a small muscle that descends from the nasal lateral cartilage to the skin over the nostrils. It is present in 57% of the population. Superficial to this muscle is the *dilator naris anterior*, whose main function is to open the nostrils. This is a fan-shaped muscle that originates in the nasal lateral cartilage and the *transverse nasalis* and inserts in the caudal border of the lateral crus of the alar cartilage and in nostrils skin. The contraction of this muscle can be felt by compressing the nasal ala between two fingers.

## **2. Botulinum toxin properties**

Clostridium Botulinum are bacteria that produce different types of toxins. Seven types have been identified, known as A, B, C, D, E, F, and G. They all produce denervation and atrophy of muscles. The most powerful is toxin A, being the elective treatment of many dystonias. Type B is also available for medical use; it has a faster but shorter effect (Myobloc ®).

We refer to our experience with toxin A commercialized by Allergan with the name BOTOX® (other products differ in pharmacodynamics and pharmacokinetics).

### **3. Toxin handling**

**◦** *Dilator naris anterior*

102 Miniinvasive Techniques in Rhinoplasty

**Figure 3.** Nasal muscles. Lateral view.

*transverse nasalis* depressor action.

tip turns down.

The *procerus* originates in the *transverse nasalis* aponeurosis, nasal bones periosteum, and nasal lateral cartilage perichondrium, and ends in glabellar skin. As an elevator it antagonizes the

The *levator labii superioris alaeque nasi* originates in the medial portion of the *orbicularis oculi* and the frontal process of the maxilla, inserting down in the nasolabial fold, nasal ala, and skin and muscles of the upper lip. It has a nasal fascicle that covers the origin of the *transverse nasalis*.

The *anomalus* originates in the frontal process of the maxilla inserting in nasal bones, nasal lateral cartilage, the *procerus*, and the *transverse nasalis*. It is present in 50% of the population.

The *alar nasalis*, also known as *dilator naris posterior*, originates in the maxilla over the lateral

The *depressor septi nasi* originates in the nasal spine of the maxilla inserting in the membranous septum and medial crus of alar cartilages. The contraction of this muscle turns downward the nasal tip. According to Zide [4], there are some superficial fibers that originate in the *orbicularis oris*, and insert in the columella, which are responsible for the elevation of the lip as the nasal

The main function is to elevate the nasal ala and open the nostrils.

incisor and inserts in the nasal ala. This muscle opens the nostrils.

Botulinum toxin is commercialized as crystallized powder that contains 100 UI per vial. Reconstitution should be done with sterile, preservative-free saline solution. The product final concentration depends on the volume used for reconstitution. For cosmetic use in the nasal area, reconstitution of the toxin is recommended to be done with 1 ml of saline solution per vial. This avoids diffusion to neighboring muscles, preventing undesired effects.

The manufacturer recommends the use within 4 HS after reconstitution, but experience has demonstrated that the reconstituted solution does not loose effectiveness if conserved in a refrigerator at 4°C.

We like to use 0.3 ml syringes with 30 G needle (Ultrafine II. Becton Dickinson-BD) for precise application. These syringes do not have dead space so no solution is lost and allows a better dosage, a fundamental aspect in the nasal area.

Botulinum toxin can be injected intramuscular, subcutaneous, or intracuticular. Anesthetic cream can be applied locally if the patient is oversensitive. Other way to reduce pain is using cold packs.

#### **4. Side effects and precautions**

In patients with neuromuscular diseases such as myasthenia gravis or amyotrophic lateral sclerosis, it is relatively contraindicated. Application should be avoided during pregnancy and lactation. Drug interaction is limited to aminoglycosides, with which a lower dose is recom‐ mended. Most secondary effects are due to toxin diffusion to neighboring muscles. This is preventable using correct doses and injection planes. There are no long-term effects described with the toxin. With repeated application the effect can diminish, probably due to antitoxin antibodies.

#### **5. Dosage and frequency**

The clinical effect of the toxin starts between the second and the fourth day, and regularly lasts for four or five months. Generally, patients that are happy with the result come back to repeat the application when the effect starts to diminish. Stronger muscles require higher doses. When working in small areas, to prevent diffusion to neighboring muscles, reconstitution with lower volumes of saline solution is recommended. As a general rule, the limit per application per session is 400 UI, doses that are only used for spastic paralysis. In the nasal region, doses never exceed 20 UI.

#### **6. Nasal application**

#### **6.1. Nasoglabellar wrinkles and bunny lines**

Over the lateral wall of the nasal bridge an important percentage of the population have diagonal lines that go toward the nasal ala. This has been the first indication of BOTOX® in the nasal area suggested by Carruthers [5].

These wrinkles or bunny lines can be primary or secondary. The secondary ones, also known as BOTOX® effect, appear after the treatment with toxin in the glablellar muscles. That is why when treating frown wrinkles it is important to advert to patients the possibility of developing compensatory nasoglabellar wrinkles. This compensatory effect develops mostly in women that already have an insinuation of these wrinkles and have an outdoor life, which generates muscle contraction by sun exposure. By blocking frown muscles some people start contracting involuntarily the *nasalis transverse*. Primary wrinkles are frequent in people that gesticulate a lot, users of heavy glasses, chronic rhinitis, and those with clear eyes that try to close the lids in response to sun or light. These muscles get hypertrophied and hyperfunctional by forced and constant contraction, provoking wrinkles in the thin skin that covers them. They are more frequent in Caucasian people, and they get accentuated when they smile, talk, or get angry. Men have a thicker skin, thus having fewer wrinkles.

In patients with previous rhinoplasty, Botulinum toxin clinical effect is less evident, probably due to anatomic changes and muscular scar provoked by surgery.

It is important to differentiate wrinkles provoked by the *transverse nasalis* (described above) from wrinkles provoked by the *procerus*. The latter are horizontal lines that appear in the nasal root when the glabellar skin is pulled down by the contraction of the *procerus*. By eliminating both these wrinkles, a juvenile and relaxed appearance is obtained in the mid face. When we do not treat simultaneously the nasoglabellar and the glabellar wrinkles, the untreated ones develop compensatory contraction, producing a strange effect on nasal image.

Tamura [6] pointed out that in 40% of patients, the nasoglabellar wrinkles can be treated with 3 UI injected in each nasal wall in the muscular body. The other 60% of the patients present different patterns of muscular contraction, needing additional 2 UI in neighboring areas. He identifies three patterns of wrinkles that appear within the first 4 weeks of application: nasoalar, nasoorbicular, and nasociliar. The nasoalar lines are produced by the contraction of the alar fibers of the *levator labii superioris* and must be treated just over the nasal ala. The nasoorbicular and the nasociliar are produced by the contraction of the *orbicularis oculi*.

We inject 2–4 UI of Botulinum toxin in the *transverse nasalis* belly where it goes over the nasal bone. Then we observe the evolution, and if necessary perform the corrections following Tamura's recommendation.

#### *6.1.1. Precaution*

**4. Side effects and precautions**

104 Miniinvasive Techniques in Rhinoplasty

**5. Dosage and frequency**

antibodies.

exceed 20 UI.

**6. Nasal application**

**6.1. Nasoglabellar wrinkles and bunny lines**

the nasal area suggested by Carruthers [5].

Men have a thicker skin, thus having fewer wrinkles.

In patients with neuromuscular diseases such as myasthenia gravis or amyotrophic lateral sclerosis, it is relatively contraindicated. Application should be avoided during pregnancy and lactation. Drug interaction is limited to aminoglycosides, with which a lower dose is recom‐ mended. Most secondary effects are due to toxin diffusion to neighboring muscles. This is preventable using correct doses and injection planes. There are no long-term effects described with the toxin. With repeated application the effect can diminish, probably due to antitoxin

The clinical effect of the toxin starts between the second and the fourth day, and regularly lasts for four or five months. Generally, patients that are happy with the result come back to repeat the application when the effect starts to diminish. Stronger muscles require higher doses. When working in small areas, to prevent diffusion to neighboring muscles, reconstitution with lower volumes of saline solution is recommended. As a general rule, the limit per application per session is 400 UI, doses that are only used for spastic paralysis. In the nasal region, doses never

Over the lateral wall of the nasal bridge an important percentage of the population have diagonal lines that go toward the nasal ala. This has been the first indication of BOTOX® in

These wrinkles or bunny lines can be primary or secondary. The secondary ones, also known as BOTOX® effect, appear after the treatment with toxin in the glablellar muscles. That is why when treating frown wrinkles it is important to advert to patients the possibility of developing compensatory nasoglabellar wrinkles. This compensatory effect develops mostly in women that already have an insinuation of these wrinkles and have an outdoor life, which generates muscle contraction by sun exposure. By blocking frown muscles some people start contracting involuntarily the *nasalis transverse*. Primary wrinkles are frequent in people that gesticulate a lot, users of heavy glasses, chronic rhinitis, and those with clear eyes that try to close the lids in response to sun or light. These muscles get hypertrophied and hyperfunctional by forced and constant contraction, provoking wrinkles in the thin skin that covers them. They are more frequent in Caucasian people, and they get accentuated when they smile, talk, or get angry.

It is important to inject above the nasofacial groove to prevent diffusion of toxin to the *levator labii superioris*, causing lip ptosis and lip asymmetry. This can cause incompetence of the labial sphincter, creating problems to eat and talk.

Less frequent, but not less important complication is toxin diffusion to the *orbicularis oculi*, diminishing the pump effect over the lacrimal sac causing tearing. Diffusion to the *medial rectus* of the eye has been described, causing blurred vision.

It is important to avoid injecting the product in the angular artery, which can cause thrombosis and blindness.

To prevent these complications that are mainly caused by diffusion to neighboring muscles, and for which there is no antidote, it is preferable to avoid any kind of massage in the area after applying the toxin.

#### **6.2. Nasal tip ptosis**

As people age, the nasal tip tends to turn downward partially by the gravity forces and partially caused by the hyperkinetic action of the *depressor septi nasi* muscle over the caudal portion of the nasal septum. When this occurs, appearance turns senile, evil, and witch-like.

The importance of the *depresor septi nasi* in rhinoplasty has been remarked upon many years ago. Wright [7] in 1976 noted that a hyperactive muscle contributed to the tip ptosis, and that this phenomenon could be diagnosed by the "smile test." In 1983, Ham [8] reported that the *depressor septi nasi* was responsible for the tension in nasal tip and dorsum, and he recom‐ mended this muscle transection to solve the problem. Cachay-Velazquez [9, 10] described in 1992 the "rhino-gingivo-labial syndrome of the smile." He points out the importance of dynamic examining of face, which can reveal aesthetic imperfections, not so evident at rest. The rhino-gingivo-labial syndrome of the smile includes:


The author attributes this syndrome to the *depressor septi nasi* hypertrophy. For the correction he proposes excision of the *depressor septi nasi*, and a partial excision of *orbicularis oris* and *nasalis* muscles through a stab incision. There are no cases of nasal obstruction in the clinical experi‐ ence of the author, contrary to what Converse [11] revealed about the importance of conserving this muscle.

De Souza Pinto [12] reported his technique called "dynamic rhinoplasty." He uses a Z-plasty based on the labial bridle and combines relaxation of the medial fascicle of the *depresor septi nasi*, with horizontal or vertical plication of the intermediate fascicle, depending on the length of the superior lip.

The nasal tip ptosis generally coincides with a short superior lip, entity described by Rohrich [13] as the functional unity of the inferior third of the nose. The *depressor septi nasi* and the *levator labii superioris alaeque nasi* are responsible for the muscular forces affecting this area in the dynamic and static models. The *depressor septi nasi* is sometimes considered as part of the *dilator naris*, muscle that originates in the incisor fossa of the maxilla, just below the *orbicularis oris*, and in the mucosa of the superior lip. The *depressor septi nasi* pulls down the nasal septum and ala stretching the nostrils. The interdigitation of this muscle with *dilator naris*is present in a small percentage of the population. In these cases, a paradoxical opening of the nostrils is provoked when these muscles contract together.

Due to anatomical variations described above and the multifactorial etiology of the nasal tip ptosis, BOTOX® application will have positive results only when the main cause of the defect is the muscular action. To evaluate the muscular strength it is important to observe the functional unity of the inferior third of the nose during forced smile. With this observation, we can predict which patients will have a good result with toxin. To perform the procedure we have to pull down the patient's upper lip over the teeth in order to open the nasolabial angle. In this way we elongate the muscle, making easier the identification of the muscle insertion in the base of the columella, where the needle should be introduced to inject 2–4 UI in the subcutaneous to avoid diffusion to the *orbicularis oris* (Fig. 4). If we are in the presence of a strong muscle, additional 2 UI can be used in the mid columella. In patients with interdi‐ gitation of the *depressor septi nasi* and the *dilator naris*, additional 4–5 UI are recommended in the nasal ala dorsum, inside the *dilator naris,* in order to obtain a better tip projection.

**Figure 4.** Application in the depressor septi nasi.

*depressor septi nasi* was responsible for the tension in nasal tip and dorsum, and he recom‐ mended this muscle transection to solve the problem. Cachay-Velazquez [9, 10] described in 1992 the "rhino-gingivo-labial syndrome of the smile." He points out the importance of dynamic examining of face, which can reveal aesthetic imperfections, not so evident at rest.

The author attributes this syndrome to the *depressor septi nasi* hypertrophy. For the correction he proposes excision of the *depressor septi nasi*, and a partial excision of *orbicularis oris* and *nasalis* muscles through a stab incision. There are no cases of nasal obstruction in the clinical experi‐ ence of the author, contrary to what Converse [11] revealed about the importance of conserving

De Souza Pinto [12] reported his technique called "dynamic rhinoplasty." He uses a Z-plasty based on the labial bridle and combines relaxation of the medial fascicle of the *depresor septi nasi*, with horizontal or vertical plication of the intermediate fascicle, depending on the length

The nasal tip ptosis generally coincides with a short superior lip, entity described by Rohrich [13] as the functional unity of the inferior third of the nose. The *depressor septi nasi* and the *levator labii superioris alaeque nasi* are responsible for the muscular forces affecting this area in the dynamic and static models. The *depressor septi nasi* is sometimes considered as part of the *dilator naris*, muscle that originates in the incisor fossa of the maxilla, just below the *orbicularis oris*, and in the mucosa of the superior lip. The *depressor septi nasi* pulls down the nasal septum and ala stretching the nostrils. The interdigitation of this muscle with *dilator naris*is present in a small percentage of the population. In these cases, a paradoxical opening of the nostrils is

Due to anatomical variations described above and the multifactorial etiology of the nasal tip ptosis, BOTOX® application will have positive results only when the main cause of the defect is the muscular action. To evaluate the muscular strength it is important to observe the functional unity of the inferior third of the nose during forced smile. With this observation, we can predict which patients will have a good result with toxin. To perform the procedure we have to pull down the patient's upper lip over the teeth in order to open the nasolabial angle. In this way we elongate the muscle, making easier the identification of the muscle insertion in the base of the columella, where the needle should be introduced to inject 2–4 UI in the subcutaneous to avoid diffusion to the *orbicularis oris* (Fig. 4). If we are in the presence of a strong muscle, additional 2 UI can be used in the mid columella. In patients with interdi‐ gitation of the *depressor septi nasi* and the *dilator naris*, additional 4–5 UI are recommended in

the nasal ala dorsum, inside the *dilator naris,* in order to obtain a better tip projection.

The rhino-gingivo-labial syndrome of the smile includes:

**•** Elevation and shortening of the superior lip

provoked when these muscles contract together.

**•** Increased exposure oral mucosa

**•** Nasal tip ptosis

106 Miniinvasive Techniques in Rhinoplasty

this muscle.

of the superior lip.

Peres Atamoros [14] created a therapeutic protocol that allows measuring of the tip elevation when using BOTOX®. He establishes that for a soft elevation, 2 UI must be injected in each *dilator naris* and 2 UI in the *depressor septi nasi* (total of 6 UI). For a medium elevation, 4 UI should be injected in each point (total of 12 UI). Finally, for a strong elevation 6 UI should be injected in each point (total of 18 UI).

In some patients, the use of BOTOX® increases the distance between the columellar base and the vermilion border, creating the appearance of a fuller and voluminous lip. It can also correct the gingival smile. If the toxin diffuses laterally in the base of the columella, it can affect the *levator labii superioris* and the *orbicularis oris*, provoking an unaesthetic elongation of the superior lip, filtrum flattening, and labial sphincter incompetence when talking and drinking.

The use of high doses in the nasal tip can produce an exaggerated opening of the nostrils and a strong elevation of the tip, leaving an unattractive appearance in the frontal view. The clinical effect in this area usually lasts for a shorter time than other parts of the face. The first days after the injection, the patient can experience pain in the nasal tip.

In order to obtain satisfactory results in nasal tip ptosis correction, it is important to understand the mechanism of the downward rotation of the tip when smiling. This mechanism depends on a functional unity with three components:


BOTOX® application does not replace surgery in patients with static nasal tip ptosis, but it is useful in dynamic ptosis and in other defects caused by a hypertrophic or hyperactive *depressor septi nasi*, and with patients that do not desire a rhinoplasty. Besides, BOTOX® can be used temporarily in patients that are evaluating a surgical procedure. The application of toxin is a great combination with other minimal invasive procedures as bioplasty, fillers, and nasal rein. It is possible to obtain a reduction of the dynamic nasal tip ptosis, a correction on the shortening of the superior lip, and apparent absence of philtrum by using BOTOX® (Allergan Inc. Irvine, California).

When the *depressor septi nasi* contracts the nasal tip descends, making more evident the nasal tip ptosis. According with the interdigitation of this muscle with the *orbicularis oris*, it is classified in three subtypes:


The *levator labii superioris alaeque nasi* originates in the frontal process of the maxilla and inserts down in skin of the nasal ala and superior lip. Its action is to elevate the superior lip and nasal ala. When contracting, together with the *depressor septi nasi* they descend the nasal tip while ascending the nasal ala and superior lip, thus opening the nostrils. Their contraction also produces a horizontal wrinkle, which divides the philtrum, and oral mucosa exposure. Until the discovery of the Botulinum toxin, acting over these muscles was only possible through surgical procedures. Now we can, applying 5 UI in the *depressor septi nasi* and 3 UI in each *levator labii superioris alaeque nasi,* attenuate this muscle's action, diminishing tip ptosis during smile, leaving the alar insertion in a neutral position. Also, the nasal angle opens to 110–115°. Satisfaction index in patients is very high and we have not observed serious secondary effects as labial sphincter incompetence or problems with talking.

With Botulinum toxin we can:


In patients where the nasal tip ptosis is mainly due to aging, the result of BOTOX® is not as good as in young people where the muscular hypertrophy plays a major role. Precaution should be taken with patients with long lips and little vermilion, since there is significant risk of lip ptosis after the procedure.

#### **6.3. Nasal flutter**

Some people, naturally or under stress (emotional or physical), present wide movements of nasal flutter that enlarge the nostrils. This nasal flutter can be very embarrassing. Generally, people with short and flat nasal bridge with wide nasal ala present more active nasal muscles, which allow them to voluntarily move the nasal ala. The widened nostrils can take different forms expressing in the face moods such as anger, fear, worry, fatigue, reprobation, or stress.

The nasal flutter is the result of involuntary and repeated contraction of the inferior portion of the *alar nasalis* muscle, also known as *dilator naris posterior*. This muscle originates in the maxilla over the lateral incisive, is medial to the *transverse nasalis* in the nasolabial sulcus, travels through the nasal ala, and inserts in the caudal portion of the alar cartilage and skin of the nostrils. The medial fibers can join the *depressor septi nasi*. Its main action is to move the nasal ala laterally and downward, opening the nostrils and preventing the ala collapse during inspiration.

The side of the columella and the septum turns visible when the nostrils open exaggeratedly. This unaesthetic appearance gets accentuated with the contraction of the *depressor septi nasi*. In people with wide nasal base and ability to move the nasal ala, a stretching effect is seen in nostrils after applying BOTOX® in the *dilator naris posterior*. The injection of 5–10 UI, bilaterally, in the area of greater contraction of the *dilator naris posterior* (over the nasal ala), has diminished the nasal flutter for 3–4 months (Fig. 5). We have not experienced secondary effects after the use of toxin in this area.

**Figure 5.** Application in the levator labii superioris alaeque nasi.

#### **6.4. Botox® in nasal dorsum hyperhidrosis**

temporarily in patients that are evaluating a surgical procedure. The application of toxin is a great combination with other minimal invasive procedures as bioplasty, fillers, and nasal rein. It is possible to obtain a reduction of the dynamic nasal tip ptosis, a correction on the shortening of the superior lip, and apparent absence of philtrum by using BOTOX® (Allergan Inc. Irvine,

When the *depressor septi nasi* contracts the nasal tip descends, making more evident the nasal tip ptosis. According with the interdigitation of this muscle with the *orbicularis oris*, it is

The *levator labii superioris alaeque nasi* originates in the frontal process of the maxilla and inserts down in skin of the nasal ala and superior lip. Its action is to elevate the superior lip and nasal ala. When contracting, together with the *depressor septi nasi* they descend the nasal tip while ascending the nasal ala and superior lip, thus opening the nostrils. Their contraction also produces a horizontal wrinkle, which divides the philtrum, and oral mucosa exposure. Until the discovery of the Botulinum toxin, acting over these muscles was only possible through surgical procedures. Now we can, applying 5 UI in the *depressor septi nasi* and 3 UI in each *levator labii superioris alaeque nasi,* attenuate this muscle's action, diminishing tip ptosis during smile, leaving the alar insertion in a neutral position. Also, the nasal angle opens to 110–115°. Satisfaction index in patients is very high and we have not observed serious secondary effects

In patients where the nasal tip ptosis is mainly due to aging, the result of BOTOX® is not as good as in young people where the muscular hypertrophy plays a major role. Precaution should be taken with patients with long lips and little vermilion, since there is significant risk

Some people, naturally or under stress (emotional or physical), present wide movements of nasal flutter that enlarge the nostrils. This nasal flutter can be very embarrassing. Generally, people with short and flat nasal bridge with wide nasal ala present more active nasal muscles,

**2.** Type II: inserted in the periosteum and partially in the *orbicularis oris* (22%)

California).

classified in three subtypes:

108 Miniinvasive Techniques in Rhinoplasty

With Botulinum toxin we can:

**2.** Elongate the superior lip

of lip ptosis after the procedure.

**6.3. Nasal flutter**

**1.** Type I: totally inserted in the *orbicularis oris* (62%)

as labial sphincter incompetence or problems with talking.

**4.** Keep the rotation:projection proportion during movement

**5.** Preserve the motor and sensitive innervation of the superior lip

**1.** Correct the balance between the tip and the lip

**3.** Create the appearance of superior lip fullness

**3.** Type III: rudimentary muscle or absent

Excessive sweating of the face generally affects areas as forehead, cheeks, scalp, lips, nasal dorsum, and ala. This is less frequent than axillary or hands and feet sweating but is highly detrimental for social and occupational life because it is extremely exposed to sight. Botulinum toxin blocks the liberation of acetylcholine in synapses that regulate the production of eccrine glands. The incidence of this disorder in the population is not known, but statistically it is more frequent in man and tends to worsen with aging. The permanent sweat impedes the correct application of creams, makeup, and sun block. And sometimes it makes glasses slide over the wet surface producing local irritation.

**Figure 6.** Application in nasal dorsum for hyperhidrosis

In some women, local sweating can appear in the premenopause together with the heat waves that characterize this period. Usually, these symptoms disappear spontaneously. Other stimuli for facial sweating are: caffeine, physical activity, stress, seasoned food, and heat.

A precise diagnosis of the area of sweating can be made through the test of Minor (iodinated alcohol and starch).

To treat this disorder, injections must be intracuticular, producing skin whitening and papules, in order to act over glands and not over muscles. This is a painful procedure, so we recommend the use of anesthetic cream, or if the patient is oversensitive, a local nerve blocking for the nasal area. The dose is 1–2 UI per injection, with 1 cm space between them, until covering the whole area of hyperhidrosis (Figs. 6 and 7). It is important to conserve symmetry while working, in order to avoid asymmetry that can affect the muscles. The patient is called back at day 10 after injection to evaluate the results, and if any area is still sweating, it is corrected. The effects in general last for seven months.

#### **6.5. Botox® in the treatment of multiple eccrine hidrocystoma**

Eccrine hidrocystomas is a cystic lesion of sweat gland ducts described by Andrew Ross Robinson in 1983. Incidence is higher in women. Multiple eccrine hidrocystoma are papulecystic lesions of elevated surface with a blue coloration that is seen through a transparent dome, easily confused with blackheads. It is common to find them in the facial area surrounding the eyes, forehead, nose, and superior lip. The etiology is a defect in transpiration or insensible perspiration. If ruptured or spontaneously broken, a clear and transparent liquid drains. It is presented in literature as an infrequent disease, but we think that is because of ignorance and misdiagnose with blackhead. This condition worsens with transpiration and environmental humidity, thus enlarging in summer and reducing in winter.

**Figure 7.** Application in nasal dorsum for hyperhidrosis pseudo-blackhead.

Based on our experience with botulinum toxin type A for the use of focal hyperhidrosis and the amount of bibliography about the effect of Botulinum toxin in parasympathetic fibers, we started using it in this disorder as well [15]. The application is similar to what is described above for hyperhidrosis. Results are excellent with complete reconstitution of the areas treated.

### **Author details**

glands. The incidence of this disorder in the population is not known, but statistically it is more frequent in man and tends to worsen with aging. The permanent sweat impedes the correct application of creams, makeup, and sun block. And sometimes it makes glasses slide over the

In some women, local sweating can appear in the premenopause together with the heat waves that characterize this period. Usually, these symptoms disappear spontaneously. Other stimuli

A precise diagnosis of the area of sweating can be made through the test of Minor (iodinated

To treat this disorder, injections must be intracuticular, producing skin whitening and papules, in order to act over glands and not over muscles. This is a painful procedure, so we recommend the use of anesthetic cream, or if the patient is oversensitive, a local nerve blocking for the nasal area. The dose is 1–2 UI per injection, with 1 cm space between them, until covering the whole area of hyperhidrosis (Figs. 6 and 7). It is important to conserve symmetry while working, in order to avoid asymmetry that can affect the muscles. The patient is called back at day 10 after injection to evaluate the results, and if any area is still sweating, it is corrected. The effects in

Eccrine hidrocystomas is a cystic lesion of sweat gland ducts described by Andrew Ross Robinson in 1983. Incidence is higher in women. Multiple eccrine hidrocystoma are papule-

for facial sweating are: caffeine, physical activity, stress, seasoned food, and heat.

**6.5. Botox® in the treatment of multiple eccrine hidrocystoma**

wet surface producing local irritation.

110 Miniinvasive Techniques in Rhinoplasty

**Figure 6.** Application in nasal dorsum for hyperhidrosis

alcohol and starch).

general last for seven months.

Diego Schavelzon1\*, Guillermo Blugerman1 , Gabriel Wexler2 and Lorena Martinez1


2 Universidad Nacional del Nordeste, Argentina

#### **Conflict of interest**

The authors declare no conflict of interest.

Informed consent was obtained from the patients included in the chapter.

#### **References**

