| BOTulInumTOxIn A | articLe
Treatment implications when injecting the nose for nasal flare 1Treat only those patients who can
onabotulinumtoxinA in the centre of or along the alar rim of each ala nasi into the dilator naris and levator alae nasi will relax the involuntary flaring of the nostrils.
effect of an onabotulinumtoxinA treatment of
nasoglabellar lines to last at least 3–4 months, or however long the glabellar frown lines remain effaced.
Complications Injecting onabotulinumtoxinA too low along the nasal sidewalls and allowing it to diffuse into the upper lip levators can produce asymmetry and even ptosis of the upper lip, including sphincter incompetence and functional difficulties. Also, if the medial palpebral orbicularis oculi is weakened as the result of the unintended diffusion of onabotulinumtoxinA, a diminution in the action of the lacrimal pump can occur, causing epiphora (excessive tearing) (13). Diplopia also can result if the medial rectus is weakened by onabotulinumtoxinA. Vigorous massage to the area after the injection of
onabotulinumtoxinA can cause it to spread and diffuse beyond the targeted area and produce the same adverse results, even if dosing is appropriate and the injection technique flawless. There is no antidote for any of these post-treatment adverse sequelae, and the patient is obligated to endure them until the effects of the onabotulinumtoxinA remain. Consultation with an ophthalmologist is advisable. The angular artery and vein sit in the nasofacial angle,
and injections placed too low along the nasal sidewall and deeply into the skin can lead to intravascular injection of the onabotulinumtoxinA or injury to one of the vessels causing either ecchymoses (vein) or haematoma (artery). There have been no reports of adverse events from intravascular injection of onabotulinumtoxinA when less than 10 u is injected.
Nasal flare There are some individuals who, either naturally or when they are under physical or emotional stress, flare their nostrils and widen their nasal aperture repeatedly as they inspire. Those who possess a broad nasal bridge with a wide nasal alar base may have well-developed muscles of the distal nose. This will allow such persons to dilate their nostrils deliberately and involuntarily.
Functional anatomy nasal flaring is the result of the involuntary contraction of the lower portion of the nasalis or the alar nasalis, also called the dilator naris, causing the alae nasi to dilate repeatedly. In some individuals, the medial alar portion of the levator labii superioris alaeque nasi, also called
there have
actively and wilfully flare their nostrils. 3Treating hyperkinetic dilator naris 2Injections of 4–10U of
with onabotulinumtoxinA can
produce an narrower nasal aperture without interfering with inspiration.
4No adverse side-effects have injection technique.
been identified with this
the levator alae nasi, pulls the lateral cartilaginous crus of the nose superiorly, displacing the circumalar furrow laterally and dilating the nostrils.
Dosing Treat the patient in the sitting or semireclined position with subcutaneous injections of 4–10 u onabotulinumtoxinA into the centre of each alae toward the alar rim along the lateral fibres of the alar nasalis. This will weaken involuntary muscle contractions of the nostrils. Such results can be useful in ethnic groups who have a characteristically broad nasal bridge and wide alae that flare easily because of a hyperkinetic alar nasalis. Only those patients who can deliberately and actively flare their nostrils are candidates for onabotulinumtoxinA injections.
Outcomes In patients who can create nasal flare wilfully, injections of onabotulinumtoxinA will decrease the frontal diameter of the nostril and give the nose a narrower appearance, without interfering with inspiration. Results can last up to 3–4 months, and sometimes longer with repeat treatments.
Complications If patients are not selected properly, injections of onabotulinumtoxinA might not be effective, and time, effort and money will have been wasted. Otherwise, these patients experience no other adverse sequelae, except those which usually occur with transcutaneous injections, including pain, oedema, erythema, and possible ecchymoses. There have been no reports of difficulty with inspiration in those patients who have been treated successfully or unsuccessfully
been no reports of difficulty with inspiration in those patients who have been treated successfully or unsuccessfully for a nasal flare.
Figure 4 Downward rotated nasal tip in a 37-year-old patient
prime-journal.com | May 2011
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IMAGE BENEDETTO
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