Anat Cell Biol.  2023 Dec;56(4):409-414. 10.5115/acb.23.054.

Botulinum neurotoxin injection for treating plunged nose and post-rhinoplasty: anatomical perspectives of depressor septi nasi, nasalis, leveator labii superioris alaeque nasi muscle

• Yi KH
• Lee JH
• Kim SO
• Hu H
• Lee HJ
• Choi YJ
• Ahn TH
• Kim HJ

• KMID: 2548891
• DOI: http://doi.org/10.5115/acb.23.054

Abstract

Botulinum neurotoxin (BoNT) injection for the treating plunged nose, post-rhinopasty and hyaluronic filler migration is common procedures in clinical settings. However, the lack of thorough anatomical understanding makes it difficult to locate the nose region muscles. The anatomical considerations concerned with BoNT injection into the nasalis, levator labii superioris alaeque, and depressor septi nasi muscles were reviewed in this study. The injection spots have been presented for the nasalis, levator labii superioris alaeque, and depressor septi nasi muscles, with the recommended injection technique for each muscle. We have suggested the ideal injection sites in association with outer anatomical landmarks of the nose region. Moreover, these proposals would support a more accurate procedure of BoNT injection in relieving plunged nose, preventing post-rhinoplasty deviation, and migration of the hyaluronic acid filler.

Keyword

Nasalis; Levator labii superioris alaque nasi; Depressor septi nasi; Botulinum neurotoxin; Plunged nose

Figure

• 

  Fig. 1 The primary aesthetic worries plunged nose tip for many individuals. The appearance in absence of facial expression (A). The plunged nose appears when smiling (B).

• 

  Fig. 2 The schematic representation of the lateral (A) and inferior (B) views of the depressor septi nasi muscle. The purple shaded muscle is part of depressor septi nasi muscle that connects the orbicularis oris muscle.

• 

  Fig. 3 Injection point for the plunged nose, post- rhinoplasty, hyaluronic acid filler injection. The injection amount for each point for targeting transverse part of nasalis muscle (yellow dot), alar part of nasalis muscle (blue dot), and depressor septi nasi (red dot). Each points can be injected in botulinum neurotoxin units of 2, 2, and 4. ESAC, end of the supra-alar crease.

Reference

References

1. Dessy LA, Mazzocchi M, Rubino C, Mazzarello V, Spissu N, Scuderi N. 2007; An objective assessment of botulinum toxin A effect on superficial skin texture. Ann Plast Surg. 58:469–73. DOI: 10.1097/01.sap.0000244968.16977.1f. PMID: 17452827.

2. Childers MK. 2004; Targeting the neuromuscular junction in skeletal muscles. Am J Phys Med Rehabil. 83(10 Suppl):S38–44. DOI: 10.1097/01.PHM.0000141129.23219.42. PMID: 15448576.

3. Yi KH, Cong L, Bae JH, Park ES, Rha DW, Kim HJ. 2017; Neuromuscular structure of the tibialis anterior muscle for functional electrical stimulation. Surg Radiol Anat. 39:77–83. DOI: 10.1007/s00276-016-1698-6. PMID: 27206542.

4. Rha DW, Yi KH, Park ES, Park C, Kim HJ. 2016; Intramuscular nerve distribution of the hamstring muscles: Application to treating spasticity. Clin Anat. 29:746–51. DOI: 10.1002/ca.22735. PMID: 27213466.

5. Lee JJ, Yi KH, Kim HS, An MH, Seo KK, Chang-Hun H, Kim HJ. 2022; A novel needle-free microjet drug injector using Er:YAG LASER: a completely new concept of transdermal drug delivery system. Clin Anat. 35:682–5. Erratum in: Clin Anat 2022; 35:1152. DOI: 10.1002/ca.23892. PMID: 35445437.

6. Lee HJ, Lee JH, Yi KH, Kim HJ. 2022; Intramuscular innervation of the supraspinatus muscle assessed using Sihler's staining: potential application in myofascial pain syndrome. Toxins (Basel). 14:310. DOI: 10.3390/toxins14050310. PMID: 35622557. PMCID: PMC9143847. PMID: 34b169cd96874bde9b8c4748508d0448.

7. Yi KH, Lee JH, Kim GY, Yoon SW, Oh W, Kim HJ. 2022; Novel anatomical proposal for botulinum neurotoxin injection targeting lateral canthal rhytids. Toxins (Basel). 14:462. DOI: 10.3390/toxins14070462. PMID: 35878200. PMCID: PMC9316553. PMID: 46755210c7064a99b625f2d6b6dc6e0a.

8. Lee HJ, Lee JH, Yi KH, Kim HJ. 2023; Sonoanatomy and an ultrasound scanning protocol of the intramuscular innervation pattern of the infraspinatus muscle. Reg Anesth Pain Med. 48:175–9. DOI: 10.1136/rapm-2022-103682. PMID: 36427902.

9. Kim HM, Ree YS, Park MS, Kim JS, Ahn JH, Yi KH. 2022; Clinical guideline: deoxycholic acid injection for submental fat reduction. The Aesthetics. 3:7–11. DOI: 10.46738/Aesthetics.2022.3.2.7.

10. Yi KH, Lee JH, Hu HW, Park HJ, Bae H, Lee K, Kim HJ. Novel anatomical guidelines for botulinum neurotoxin injection in the mentalis muscle: a review. Anat Cell Biol 2023 Feb 17 [Epub]. https://doi.org/10.5115/acb.22.266. DOI: 10.5115/acb.22.266. PMID: 36796830. PMCID: PMC10520866.

11. Yi KH, Lee JH, Hu HW, Choi YJ, Lee K, Lee HJ, Kim HJ. Novel anatomical proposal for botulinum neurotoxin injection targeting depressor anguli oris for treating drooping mouth corner. Anat Cell Biol 2023 Feb 21 [Epub]. https://doi.org/10.5115/acb.22.258. DOI: 10.5115/acb.22.258. PMID: 36808109. PMCID: PMC10319486.

12. Yi KH, Lee JJ, Hur HW, Bae H, Kim HJ. 2022; Hyaluronic acid filler injection for deep nasolabial folds: a novel intraoral approach. Clin Anat. 35:820–3. DOI: 10.1002/ca.23919. PMID: 35665540.

13. Yi KH, Lee JH, Lee K, Hu HW, Lee HJ, Kim HJ. 2022; Anatomical proposal for botulinum neurotoxin injection targeting the platysma muscle for treating platysmal band and jawline lifting: a review. Toxins (Basel). 14:868. DOI: 10.3390/toxins14120868. PMID: 36548765. PMCID: PMC9783622. PMID: 1fab78f1f2fb436e8f0adab9755ed1d2.

14. Yi KH, Lee HJ, Seo KK, Kim HJ. 2022; Botulinum neurotoxin injection guidelines regarding flap surgeries in breast reconstruction. J Plast Reconstr Aesthet Surg. 75:503–5. DOI: 10.1016/j.bjps.2021.09.081. PMID: 34776389.

15. Yi KH, Lee HJ, Lee JH, Seo KK, Kim HJ. 2021; Application of botulinum neurotoxin injections in TRAM flap for breast reconstruction: intramuscular neural arborization of the rectus abdominis muscle. Toxins (Basel). 13:269. DOI: 10.3390/toxins13040269. PMID: 33918558. PMCID: PMC8070362. PMID: 15169c322e5c4f158142057c4d95936b.

16. Yi KH, Lee HJ, Choi YJ, Lee K, Lee JH, Kim HJ. 2021; Anatomical guide for botulinum neurotoxin injection: application to cosmetic shoulder contouring, pain syndromes, and cervical dystonia. Clin Anat. 34:822–8. DOI: 10.1002/ca.23690. PMID: 32996645.

17. Yi KH, Lee JH, Hu HW, Kim HJ. 2022; Novel anatomical guidelines on botulinum neurotoxin injection for wrinkles in the nose region. Toxins (Basel). 14:342. DOI: 10.3390/toxins14050342. PMID: 35622589. PMCID: PMC9144745. PMID: 95ea3c07c66d4527b5265c5ec719f652.

18. Yi KH, Lee JH, Kim HM, Kim HJ. 2022; The botulinum neurotoxin for pain control after breast reconstruction: neural distribution of the pectoralis major muscle. Reg Anesth Pain Med. 47:322–6. DOI: 10.1136/rapm-2021-102653. PMID: 35039438.

19. Yi KH, Lee JH, Hu HW, Kim HJ. 2022; Anatomical proposal for botulinum neurotoxin injection for glabellar frown lines. Toxins (Basel). 14:268. DOI: 10.3390/toxins14040268. PMID: 35448877. PMCID: PMC9032255. PMID: dd131953c6e14366befdc986e94b15dd.

20. Yi KH, Lee HJ, Hur HW, Seo KK, Kim HJ. 2022; Guidelines for botulinum neurotoxin injection for facial contouring. Plast Reconstr Surg. 150:562e–71e. DOI: 10.1097/PRS.0000000000009444. PMID: 35759641.

21. Coleman KR, Carruthers J. 2006; Combination therapy with BOTOX and fillers: the new rejuvnation paradigm. Dermatol Ther. 19:177–88. DOI: 10.1111/j.1529-8019.2006.00072.x. PMID: 16784517.

22. Fagien S, Brandt FS. 2001; Primary and adjunctive use of botulinum toxin type A (Botox) in facial aesthetic surgery: beyond the glabella. Clin Plast Surg. 28:127–48. DOI: 10.1016/S0094-1298(20)32345-2. PMID: 11248863.

23. Lee W, Ahn TH, Cheon GW, Lee MJ, Yang EJ. 2021; Comparative analysis of botulinum toxin injection after corrective rhinoplasty for deviated nose and alar asymmetry. J Cosmet Dermatol. 20:451–6. DOI: 10.1111/jocd.13523. PMID: 32557986.

24. Cerkes N. 2011; The crooked nose: principles of treatment. Aesthet Surg J. 31:241–57. DOI: 10.1177/1090820X10394167. PMID: 21317122.

25. Nettar K, Maas C. 2012; Facial filler and neurotoxin complications. Facial Plast Surg. 28:288–93. DOI: 10.1055/s-0032-1312695. PMID: 22723229.

26. Klein AW. 2003; Complications, adverse reactions, and insights with the use of botulinum toxin. Dermatol Surg. 29:549–56. discussion 556DOI: 10.1046/j.1524-4725.2003.29129.x. PMID: 12752527.

27. Hsu TS, Dover JS, Arndt KA. 2004; Effect of volume and concentration on the diffusion of botulinum exotoxin A. Arch Dermatol. 140:1351–4. DOI: 10.1001/archderm.140.11.1351. PMID: 15545544.

28. Kinnett D. 2004; Botulinum toxin A injections in children: technique and dosing issues. Am J Phys Med Rehabil. 83(10 Suppl):S59–64. DOI: 10.1097/01.PHM.0000141131.66648.E9. PMID: 15448579.

29. Lepage D, Parratte B, Tatu L, Vuiller F, Monnier G. 2005; Extra- and intramuscular nerve supply of the muscles of the anterior antebrachial compartment: applications for selective neurotomy and for botulinum toxin injection. Surg Radiol Anat. 27:420–30. DOI: 10.1007/s00276-005-0012-9. PMID: 16308665.

30. Pingel J, Nielsen MS, Lauridsen T, Rix K, Bech M, Alkjaer T, Andersen IT, Nielsen JB, Feidenhansl R. 2017; Injection of high dose botulinum-toxin A leads to impaired skeletal muscle function and damage of the fibrilar and non-fibrilar structures. Sci Rep. 7:14746. DOI: 10.1038/s41598-017-14997-3. PMID: 29116170. PMCID: PMC5677119.

31. Yi KH, Lee KL, Lee JH, Hu HW, Lee K, Seo KK, Kim HJ. 2021; Guidelines for botulinum neurotoxin injections in piriformis syndrome. Clin Anat. 34:1028–34. DOI: 10.1002/ca.23711. PMID: 33347678.

32. Yi KH, Lee JH, Lee DK, Hu HW, Seo KK, Kim HJ. 2021; Anatomical locations of the motor endplates of sartorius muscle for botulinum toxin injections in treatment of muscle spasticity. Surg Radiol Anat. 43:2025–30. DOI: 10.1007/s00276-021-02813-7. PMID: 34378107. PMCID: PMC8354843.

33. Yi KH, Lee HJ, Lee JH, Lee KL, Kim HJ. 2021; Effective botulinum neurotoxin injection in treating iliopsoas spasticity. Clin Anat. 34:431–6. DOI: 10.1002/ca.23670. PMID: 32805076.

34. Yi KH, Lee HJ, Seo KK, Kim HJ. 2022; Intramuscular neural arborization of the latissimus dorsi muscle: application of botulinum neurotoxin injection in flap reconstruction. Toxins (Basel). 14:107. DOI: 10.3390/toxins14020107. PMID: 35202134. PMCID: PMC8878018. PMID: 0c7534ebd76b4902bff96b4bfe81c6b3.

35. Yi KH, Lee JH, Hur HW, Lee HJ, Choi YJ, Kim HJ. Distribution of the intramuscular innervation of the triceps brachii: clinical importance in the treatment of spasticity with botulinum neurotoxin. Clin Anat 2023 Jan 6 [Epub]. https://doi.org/10.1002/ca.24004. DOI: 10.1002/ca.24004. PMID: 36606364.

36. Yi KH, Rha DW, Kim HJ, Hu KS. 2016; Reply. Muscle Nerve. 54:513–4. DOI: 10.1002/mus.25215. PMID: 27295324.

37. Yi KH, Rha DW, Lee SC, Cong L, Lee HJ, Lee YW, Kim HJ, Hu KS. 2016; Intramuscular nerve distribution pattern of ankle invertor muscles in human cadaver using Sihler stain. Muscle Nerve. 53:742–7. DOI: 10.1002/mus.24939. PMID: 26467315.

38. Yi KH, Lee JH, Kim HJ. 2022; Intramuscular neural distribution of the serratus anterior muscle: regarding botulinum neurotoxin injection for treating myofascial pain syndrome. Toxins (Basel). 14:271. DOI: 10.3390/toxins14040271. PMID: 35448880. PMCID: PMC9033065. PMID: c4ef8fa6e12442a990c0be9185a526e5.

39. Rohrich RJ, Huynh B, Muzaffar AR, Adams WP Jr, Robinson JB Jr. 2000; Importance of the depressor septi nasi muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg. 105:376–83. discussion 384–8. DOI: 10.1097/00006534-200001000-00061. PMID: 10627007.

40. Cigna E, Sorvillo V, Stefanizzi G, Fino P, Tarallo M. 2013; The use of botulinum toxin in the treatment of plunging nose: cosmetic results and a functional serendipity. Clin Ter. 164:e107–13.

41. Kim JW, Choi YJ, Lee HJ, Yi KH, Kim HJ, Hu KS. 2015; Anatomic study of the dorsalis pedis artery, first metatarsal artery, and second metatarsal bone for mandibular reconstruction. J Oral Maxillofac Surg. 73:1627–36. DOI: 10.1016/j.joms.2015.02.007. PMID: 25930957.

42. Yi KH, Lee KL, Lee JH, Hu HW, Kim HJ. 2022; Guidance to trigger point injection for treating myofascial pain syndrome: intramuscular neural distribution of the quadratus lumborum. Clin Anat. 35:1100–6. DOI: 10.1002/ca.23918. PMID: 35655442.

43. Yi KH, Choi YJ, Cong L, Lee KL, Hu KS, Kim HJ. 2020; Effective botulinum toxin injection guide for treatment of cervical dystonia. Clin Anat. 33:192–8. DOI: 10.1002/ca.23430. PMID: 31301235.

44. Yi KH, Kim HJ. 2021; Is variation in posterior tibial veins a risk factor for deep-vein thrombosis? Clin Anat. 34:829–34. DOI: 10.1002/ca.23691. PMID: 32996214.

45. Yi KH, Lee JJ, Hur HW, Kim HJ. 2021; Anatomical consideration of deep calf veins: application to catheter-directed thrombolysis. Surg Radiol Anat. 43:2071–6. DOI: 10.1007/s00276-021-02821-7. PMID: 34432130. PMCID: PMC8385696.

46. Yi KH, Lee HJ, Choi YJ, Lee JH, Hu KS, Kim HJ. 2020; Intramuscular neural distribution of rhomboid muscles: evaluation for botulinum toxin injection using modified Sihler's method. Toxins (Basel). 12:289. DOI: 10.3390/toxins12050289. PMID: 32375284. PMCID: PMC7291336. PMID: 2a43e00b63b34292bd34bcaa4ce50d09.

47. Daniel RK, Glasz T, Molnar G, Palhazi P, Saban Y, Journel B. 2013; The lower nasal base: an anatomical study. Aesthet Surg J. 33:222–32. Erratum in: Aesthet Surg J 2013;33:619. DOI: 10.1177/1090820X12472695. PMID: 23335645.

48. Sundaram H, Signorini M, Liew S, Trindade de Almeida AR, Wu Y, Vieira Braz A, Fagien S, Goodman GJ, Monheit G, Raspaldo H. 2016; Global aesthetics consensus: botulinum toxin type A--evidence-based review, emerging concepts, and consensus recommendations for aesthetic use, including updates on complications. Plast Reconstr Surg. 137:518e–29e. DOI: 10.1097/01.prs.0000475758.63709.23. PMID: 26910696. PMCID: PMC5242214.

49. De Souza Pinto EB, Da Rocha RP, Filho WQ, Neto ES, Zacharias KG, Amâncio A, Braz de Camargo A. 1998; Anatomy of the median part of the septum depressor muscle in aesthetic surgery. Aesthetic Plast Surg. 22:111–5. DOI: 10.1007/s002669900175. PMID: 9502842.

50. Benlier E, Top H, Aygit AC. 2005; A new approach to smiling deformity: cutting of the superior part of the orbicularis oris. Aesthetic Plast Surg. 29:373–7. discussion 378DOI: 10.1007/s00266-004-0137-y. PMID: 16151663.

51. Preceruti P. 2001; Importance of the depressor septi nasal muscle in rhinoplasty: anatomic study and clinical application. Plast Reconstr Surg. 107:1081–2. DOI: 10.1097/00006534-200104010-00036. PMID: 11277123.