Onabotulinum toxin A for drooping (ptosis) of the tip of the nose
In some people, the tip of the nose droops down with age as a result of gravity and traction from the hyperkinetic nasal septal muscle (i.e., the muscle that depresses the nasal septum). In other people, the tip of the nose is turned down from birth due to the specific structure of the skeleton. There are people in whom the tip of the nose moves noticeably up and down when talking or pursing the lips. Ona botulinum toxin A injections are a non-invasive method of elevating the tip of the nose for those patients whose tip moves actively during lowering of the upper lip and speaking. For adynamic, immobile downward-pointing nose tips, only soft tissue fillers or surgical rhinoplasty are effective.
Dynamic tip ptosis may be accompanied by excessive shortening of the lips and gingival smile, as well as a transverse line along the upper lip and philtrum. The horizontal fold of the upper lip may be enlarged in elderly patients with Aliber's dermatolysis and skin laxity. Also, this phenomenon is observed in young patients with a curving upper lip when smiling. In such patients, as a rule, a large area of \u200b\u200bthe gum is also visible when smiling or laughing.
Functional Anatomy
The paired muscle that depresses the nasal septum is often considered part of the nasal dilator muscle. It begins at the nasal spine in the center of the fossa of the front tooth, deep in the upper jaw near the orbicular muscle of the mouth and on the median cartilaginous legs. Its fibers rise up and enter the movable cartilaginous septum of the nose and the mucous membrane under the wing of the nose. The depressor septum pulls the nasal septum downward, lowers the wing of the nose, and constricts the nostril.
In some people, the entrances to the lip and ala of the nose are blocked by fibers of the muscle that lifts the upper lip and ala of the nose. Due to the diversity of anatomy and the multifunctional etiology of nasal tip descent and dynamic nasal tip retraction, injections of onabotulinum toxin A to elevate the nasal tip are not as easy to administer as they first appear.
Onabotulinumtoxin A dosage for nasal tip ptosis
To effectively treat a drooping nasal tip, ask the patient to lower the upper lip, expanding the connection between the base of the columella (septum of the nasal vestibule) and the upper lip. This lengthens the descent septum muscle, separating it from the orbicularis orbicularis muscle, allowing the needle to be inserted directly into the descent septum at the base of the columella, rather than into the fibers of the orbicularis oris muscle.
When the patient is in a sitting or reclining position, the columella should be pinched between the thumb and forefinger of the non-dominant hand, while the patient at this time forcefully pulls the upper lip down under the incisors and canines. Another technique: with the thumb of the non-dominant hand, lift the tip of the nose up and gently move it back.
Depending on the strength of the depressor septum muscle, 2-4 units of onabotulinum toxin A will be injected just above (1-2mm) the line where the columella connects to the lip. An additional 2-4 units of onabotulinum toxin A can be injected into the center of the columella and the tip of the nose if the strength of the depressor septum muscle is clearly excessive. The stronger the muscles, the higher the dose of onabotulinumtoxin A will be required. Patients in whom the depressor septum intersects with the nasal dilator muscle will need injections of 2-6 units of onabotulinum toxin A into both sides of the nasal tip to elevate the nasal tip.
Results of using onabotulinum toxin A in ptosis of the nasal tip
An injection of onabotulinum toxin A into the depressor septum muscle will relax it, lift it, and point the tip of the nose upward. A combination of injections into the columella and alae just above and away from the tip of the nose will relax the lower rim and base of the nose, providing additional lift to the tip of the nose with medial fibers of the levator labrum and ala nasi muscle. The results last for 3-4 months and a little longer with repeated procedures. Onabotulinumtoxin A should not be used to treat patients in whom the tip of the nose remains motionless during lip drooping, smiling, speaking, and lip pursing.
There is a therapeutic dosage chart for onabotulinum toxin A developed by Dr. Atamoros, which can be used to calculate the change in the height of the nasal tip and its direction.
In cases where the horizontal crease in the middle of the philtrum of the upper lip deepens when smiling, with or without downward movement of the tip of the nose, an additional 1-3 units of onabotulinum toxin A can be injected into each muscle that lifts the upper lip and ala of the nose. Injections into the muscle , depressor septum, and lateral (labial) fibers of the levator labii and ala of the nose can not only reduce the transverse line of the upper lip, but also significantly increase the vertical distance between the columella and the red border of the lips, sometimes making the upper lip of some patients more voluminous . However, in other patients, such an injection can significantly stretch the thin upper lip and the red border of the lips - in the third.
Complications of onabotulinum toxin A
Too high doses of onabotulinum toxin A cause relaxation of the decussating fibers of the alar nasalis and descent septum muscles, resulting in unsightly flaring of the nostrils. This swelling of the nostrils can be accompanied by pain and irritation of the tip of the nose, which can last for more than 2 weeks. If onabotulinumtoxin A spreads from the midpoint of the base of the nasal columella to the sides and into the central muscles that lift the upper lip, the upper lip can become elongated and thinned, smoothing the contours and depth of the philtrum. Asymmetries and changes in buccal sphincter control functionality can cause difficulty in eating, swallowing, and speaking. Injections into the muscle that lowers the nasal septum can only be performed if there is obvious mixing of the front of the nose and the tip of the nose down during the lowering of the upper lip, pursing the lips, eating, talking or smiling.
According to Prime magazine.
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