The thickness of the nasal skin has a well known important influence on the outcome of rhinoplasty. Such skin thickness can have either be a favorable or an unfavorable effect on the eventual shape of the nose. By far surgeons would much rather have thinner skin but there is no avoiding the thick-skinned rhinoplasty patient who usually has the aesthetic objectives of what can only be accomplished in a thinner-skinned nose.
The needed soft tissue contraction and shrink wrap effect that is necessary to reveal the osteocartilaginous changes in the nasal framework does not usually occur in the thick-skinned nose. Besides the thick dermis in these patients the underlying SMAS layer is also hypertrophic. This ultra thick skin coverage is often combined with weak underlying carriages to create a wide and amorphous looking tip. After surgery the lack of good contractile properties of the skin with its propensity for prolonged swelling make for a tenous and difficult postoperative course. When substantial augmentation of the nose is needed, thick skin is less problematic. But when combined with the need for structural support reduction, the worst case scenario for a satisfactory aesthetic result is created.
In the February 2018 issue of the journal Facial Plastic Surgery an article was published entitled ‘Surgical Management of the Thick-Skinned Nose’. In this paper the authors provided a comprehensive overview of all known and accepted methods for improving the outcomes of rhinoplasty surgery in the thick-skinned nose patient. The one and most well known intraoperative technique is that of SMAS debulking which can be safely performed in an open rhinoplasty with attention paid to preservation of the lateral nasal arteries near the supra-alar crease. Such SMAS excision should be limited to thick noses that are 5mms or greater in thickness. It can be safely used in both primary and revision rhinoplasty.
One other intraoperative technique I like is the use of a thin layer of gelfoam soaked in triamcinolone (Kenalog) which is applied in the supra tip area.
Immediate postoperative management includes a variety of frequently used techniques including head elevation, periorbital-nasal application of ice and intranasal steroid sprays. (fluticasone)
Beginning weeks to months after surgery, low-dose steroid injections often combined with 5-FU remains the mainstay of postoperative management of the thick nose.
In thick-skinned noses that are acne prone, presurgical control of the acne is important. But when such noses have developed postoperative flares the use of low dose Accutane for four to six months after surgery can be useful.
While there is no magical solution to ensure that the thick-skinned nose patient will have a complaint soft tissue cover, application of many of the methods described in this paper will be of benefit.
Dr. Barry Eppley
Indianapolis, Indiana