The Clinical Problem ( Fig. 21.1 )
Increased nose self-awareness translates into increased patient concern and increased demand for relatively small changes in nasal contour. Medical rhinoplasty is especially well suited to many of these patients. The pretreatment consultation should include a psychological assessment. Patients with body dysmorphic disorder (BDD) need special consideration.
Prior to treatment, it is helpful to demonstrate any asymmetries to the patient. The risk of bruising is reduced by asking the patient to avoid aspirin and other nonsteroidal antiinflammatory drugs for 14 days prior to treatment.
Botulinum Toxin
Multi-mini Botulinum Toxin
The technique of precision placement of multiple minidose injections of botulinum toxin (BTX) i.e., more injections, each of a much lower dose, has been described as multi-mini BTX (M-M BTX). In M-M BTX, the target muscles are carefully observed and palpated; the points of maximum movement are identified and injected. Compared with standard BTX protocols advocated by manufacturers, M-M BTX has the advantages of being more controlled and predictable in its action, more natural in its effects, more economical in the quantities of BTX used, and possibly marginally longer in its duration of action (patients are typically booked for their next treatment 5.5 months after the last one).
Nasal Muscle Function and Anatomy
The muscles of the nose serve to open and close the nostrils, also known as the nares. Hence, there are dilator muscles and constrictor muscles. The main function of the dilators is to ensure that the nostrils do not become sucked flat on inspiration, especially on deep inspiration. Indeed, the commencement of deep inspiration is immediately preceded by dilation of the nostrils. The dilators are more developed in certain ethnic groups, and this is apparent as flared nostrils and/or arched nasal side walls. In all races and ethnic groups, flaring of the nostrils is a manifestation of anger.
The function of the contractor muscles is less clear, but it has been noted that some free divers can teach themselves to close their nares when submerged. Presumably, the increased external barometric pressure of the deep water assists with this.
The surface anatomy of the nose is outlined in Fig. 21.2 . The principal nostril dilators and nasal tip depressors are listed in Box 21.1 .
Increasing the Nasofrontal Angle
At the sellion, the procerus muscle and other soft tissues that lie anterior to the nasal bone are drawn posteriorly by the medial fibers of the orbicularis oculi. Relaxation of this drawing back of the sellion allows the procerus and other soft tissues to prolapse anteriorly by 1 mm, which serves to lessen the depth of the sellion and widen the bridge of the nose. To do this, BTX is injected laterally to the sellion, over the most anterior part of the lateral facing aspect of the nasal bone (0.25 neurotoxin units [ntu] each side; Fig. 21.3 ).
Bunny Lines
The nasalis pars transversa is partly responsible for so-called bunny lines. The patient is asked to make a bunny nose (i.e., wrinkle the nose). The nasalis pars transversa is injected subdermally with BTX, 0.5 ntu ( Fig. 21.4 ).
Reducing Nostril Flare
Nostril flare and the high arched nostril are in large part due to contraction of the dilator naris anterior and dilator naris posterior ( Fig. 21.5 ). To treat the dilator naris anterior, the skin, 7 to 9 mm superior to the top of the arch of the free edge of the nostril, is observed. The patient is asked to flare the nostrils. The point of maximum movement usually lies 7 mm superior to the free edge of the nostril, at a point just anterior to the top of the arch. At this site, BTX, 0.5 ntu, is injected.
