| BOTulInumTOxIn A | articLe
Treatment implications when injecting nasoglabellar lines 1Squinting will reveal the presence or absence of
nasoglabellar lines and they should be elicited before treating glabellar frown lines with onabotulinumtoxinA.
2Nasoglabellar lines are present naturally in some 3When nasoglabellar lines are produced as the result
individuals when they squint.
after an onabotulinumtoxinA treatment, they are referred to as the ‘BOTOX sign’.
4Treat vertical nasoglabellar frown lines (i.e. those
produced by the contraction of the transverse nasalis) along with horizontal glabellar frown lines (i.e. those produced by thåe contraction of the procerus) during the same treatment session.
lines should be treated along with glabellar frown lines with injections of onabotulinumtoxinA at the same treatment session. If the nasoglabellar lines are not treated, the patient is likely to blame the physician and onabotulinumtoxinA for their presence after treatment. If the transverse nasalis does not overtly exhibit wrinkling and is not treated in conjunction with the glabellar frown lines, and when the nasoglabellar lines become evident after the patient’s glabellar frown lines are treated with onabotulinumtoxinA (i.e. displays the ‘BOTOx sign’), then the nasoglabellar lines should be identified and treated during the obligatory follow-up visit 2–3 weeks after onabotulinumtoxinA treatment (Figure 2).
Dosing With the patient in the upright sitting or semireclined position, nasoglabellar lines can be relaxed by injecting 2–5 u of onabotulinumtoxinA subcutaneously or intramuscularly into the lateral walls of the nasal bridge, just inferior to the nasal radix, and anterior and superior to the nasofacial angle. This technique should position the needle well above the angular vessels and upper lip levators (8–11). The soft tissue is extremely thin and vascular in this area and advancing the needle tip a few millimetres goes a long way. It is important to avoid injecting too low along the nasal sidewalls and into the nasofacial sulcus. The dose of onabotulinumtoxinA depends on the
overall depth and location of the lines and strength of the transverse nasalis. A dose of 3–5 u of onabotulinumtoxinA injected on each side of the nasal bridge may be necessary. An additional 2–4 u may be required before the least amount of nasoglabellar wrinkling is totally eliminated, especially in patients who spend most of their day outdoors, and whose nasalis is hypertrophic and hyperkinetic from constant squinting.
Outcomes Eliminating nasoglabellar lines along with glabellar frown lines gives the individual a relaxed, youthful appearance. Tamura et al (12) found that they were able to successfully treat approximately 40% of their patients
prime-journal.com | May 2011
5Injections too low and deeply into the
nasofacial sulcus may result in ecchymoses,
haematoma, upper lip ptosis and asymmetry, or even upper lip incompetence and functional difficulties of the sphincteric action of the mouth.
of compensatory contraction of the transverse nasalis 6Additional units may be needed along the lateral aspect of the nasal radix and the
proximal and distal nasal bridge in different injection patterns to efface all the nasoglabellar lines in some patients.
7Patients with inelastic, lax skin who squint
that cannot be completely reduced by onabotulinumtoxinA injections.
with nasoglabellar lines by injecting them with 3u of onabotulinumtoxinA on either side of the nasal side wall into the belly of the transverse nasalis. The other 60% of patients in the study had persistent bunny lines that exhibited different linear patterns along the proximal and distal nasal bridge. They found that in order to further diminish these persistent bunny lines, an additional 2u of onabotulinumtoxinA needed to be injected at different sites along either side of the nasal bridge according to the three patterns they identified. They named the recalcitrant bunny lines according to their anatomic location as the nasoalar rhytides, naso-orbicular rhytides, and nasociliary rhytides. The additional onabotulinumtoxinA treatments were given during the first follow-up visit, 4 weeks after the initial treatment with onabotulinumtoxinA (12). Patients who recruit cheek and submalar skin and
elevate it toward the nasal radix, forming corrugations of skin along the lateral aspect of the proximal nose, will not be helped by onabotulinumtoxinA injections. Only those rhytides that are formed by the contraction of the transverse nasalis will be diminished by injections of onabotulinumtoxinA. usually, one can expect the
excessively may produce nasoglabellar lines
Figure 3 A 49-year-old patient frowning before and 3 weeks after a treatment with onabotulinumtoxinA of both the glabella and nasoglabellar lines. Note the diminished nasoglabellar ‘bunny lines’
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