3

Integrated Management of the Thick-Skinned

Rhinoplasty Patient
Roxana Cobo, MD1 Juan Gabrie Camacho, MD2 Jorge Orrego, MD3

1 Department of Otolaryngology, Centro Médico Imbanaco, Cali, Address for correspondence Roxana Cobo, MD, Department of
Colombia Otolaryngology, Centro Médico Imbanaco, Carrera 38a #5a-100,
2 Department of Otolaryngology, Universidad Militar Nueva Granada, consultorio 231A, Cali, Colombia 760044
Bogota, Colombia (e-mail: [email protected]).
3 Department of Otolaryngology, Universidad Militar Nueva Granada,
Bogota, Colombia

Facial Plast Surg 2018;34:3–8.

Abstract Patients with thick skin are a challenge in facial plastic surgery. Rhinoplasty is still the
most frequently performed facial plastic procedure worldwide and it becomes very
difficult to obtain optimal consistent results in these patients. A systematic presurgical
Keywords skin evaluation is performed dividing skin into type I–III depending on the elasticity,
► thick skin oiliness, presence of skin alterations, size of skin pores, and laxity. Depending on the
► rhinoplasty skin type, presurgical, surgical, and postsurgical management of the epidermis and
► skin evaluation dermis is defined. Preconditioning and treating thick skin can improve postsurgical
► acne prone results and reduce postsurgical unwanted results.

The thick-skinned patient is a challenge when performing The Skin Evaluation

any facial plastic procedure. Of all procedures performed in
the face, rhinoplasty is still the most frequently performed The skin is composed of the epidermis, basement membrane,
facial plastic surgery worldwide.1 When dealing with thick and dermis. The epidermis serves as a barrier that is con-
skin, skin dyschromias, chemosis, and swelling can persist for stantly renewing itself. The basement membrane is the
months after surgery has been performed. connecting structure between the epidermis and dermis
The skin redraping capability in thick-skinned patients is and gives the skin its tight look. The dermis contains not
less and there is a higher tendency for dead space formation only the sebaceous glands but is also in charge of giving
that can later be replaced with scar tissue resulting in long-term tightness and structural support to the skin. The superficial
postsurgical edema and less than ideal cosmetic results.2–4 muscular aponeurotic system (SMAS) lies below the dermis
When specialists perform surgical procedures in the nose and is a layer of fibrous tissue that covers the muscles and
and the rest of the face, they usually focus on the surgical deeper structures of the nose and face.
procedure and on giving patients postsurgical recommenda- The thick-skinned rhinoplasty patient has always been a
tions to try and obtain the best possible result. Most pub- challenge. Efforts have been made to objectively measure the
lications concentrate on surgical techniques to try and thin skin thickness. Today, we know the skin is thicker over the
out the skin-soft tissue envelope (S-STE) without managing radix and nasal tip area and thin over the rhinion and
the skin before and after the surgical procedure. In this columella. Different measuring mechanisms have been
article, the author(s) present a formal skin evaluation pro- used, including sonograms and computed tomography
gram for the thick-skinned patient with presurgical and with varying results.5–7 Other authors have proposed differ-
postsurgical skin regimes and additional cosmetic and der- ent skin evaluations where skin texture and characteristics
matologic treatments depending on the patients’ skin type are evaluated as well as skin thickness.8,9 All of these
and thickness. quantitative methods could eventually aid the surgeon in

Issue Theme Managing the Thick Skin in Copyright © 2018 by Thieme Medical DOI https://doi.org/
Facial Plastic Surgery; Guest Editor, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0037-1617445.
Roxana Cobo, MD New York, NY 10001, USA. ISSN 0736-6825.
Tel: +1(212) 584-4662.
4 Integrated Management of the Thick-Skinned Rhinoplasty Patient Cobo et al.

Table 1 Skin evaluation

Skin elasticity (pinch test) Positive Negative

Rhinion Skin can be elevated from bone Skin cannot be elevated easily from bone
Nasal tip Skin can be moved over nasal tip Skin does not move over nasal tip
Oilyness Present Absent
Areas present Nose, other facial areas Nose, other facial areas
Skin alterations Present Absent
Acne Area affected
Telangiectasias Area affected
Hyperpigmentation Area affected
Redness Area affected
Skin pores Present Absent
Size Size, blackheads
Skin laxity Present Absent
Facial area Area affected

planning a surgical approach or in evaluating surgical or Type II: Thick skin with little elasticity. Oiliness is present.
minimally invasive procedures on the skin, but results are Mild-to-moderate acne/acne-prone skin. Open pores are
not conclusive. present.
At our clinic, the skin is evaluated taking into account skin Type III: Thick skin with no elasticity. Oiliness is present.
thickness, oiliness, elasticity, and changes or alterations in Moderate-to-severe acne is present. Moderate-to-severe/
pigmentation. A finger pinch test is performed where elas- redness can be present. Open pores are present.
ticity of the skin is evaluated at the rhinion and the nasal tip. Hyperpigmentation, telangiectasias, and other dyschro-
If the skin is oily, this is documented as well as any alterations mias can be present in any of these skin types.
in skin pigmentation, including redness, telangiectasia, acne,
and hyperpigmentation. When additional facial plastic pro-
Skin Treatment
cedures are going to be performed, laxity is evaluated in the
jowl and neck area (►Table 1). Topical Treatment
Patients are then classified according to their skin thick- After the skin is evaluated and classified, a treatment plan is
ness in three types. Thin skin is excluded from this classifica- established to fit the patients’ needs. This is not a new concept.
tion (►Fig. 1): In 1983, Klatsky was already talking about the need to manage
Type I: Thick skin but with elasticity. Oiliness is absent, no acne and the sebaceous skin presurgically and in extreme cases
acne or redness. performing joint management of skin with a dermatologist.10

Fig. 1 Skin types. (A) Type I: Thick nonoily, elastic skin. No acne or redness present. (B) Type II: Thick skin, some elasticity present. Skin is oily,
pores are open, and mild-to-moderate acne is present. (C) Type III: thick inelastic skin. Very oily, moderate-to-severe acne is present, pores are
open, and redness is present with skin color changes.

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 Integrated Management of the Thick-Skinned Rhinoplasty Patient Cobo et al. 5

All skin types benefit from a perioperative skin program, Patients are put on a low-dose treatment (0.25–0.4 mg/
but it becomes crucial in patients with thick skin. The final kg/day) unless higher doses are stipulated by a dermatolo-
objective of treatment is to re-establish normal skin condi- gist. Studies have shown that low-dose schemes are just as
tions (if possible) and to diminish the skin’s inflammatory effective in the treatment of acne as conventional dosing
response. A series of steps have been established and are (0.5–1 mg/kg/day).15 Low-dose schemes have better toler-
given to the patient depending on their initial diagnosis. ance of treatment, have less side effects, and relapse rates are
Ideally, all skin programs should be started several weeks not increased. With isotretinoin use, most patients are free of
before surgery. If this is not possible, they should be started acne after approximately 16 weeks of treatment.
with the initial consultation and followed until the patient is Isotretinoin is stopped 1 week before surgery and
operated upon. Skin regimes should be followed postopera- restarted 2 to 3 weeks after the surgical procedure.13 No
tively for at least 6 months after surgery. evidence supports delaying skin surgery, dermabrasion, or
The steps used in thick-skinned patients are the following: superficial chemical peels.14 In patients who are candidates
cleansing, exfoliation, and control of oil and sebum produc- for isotretinoin use but have not started the program and
tion of the skin. Treatment should be targeted not only to the want surgery performed first, the program is begun 2 weeks
epidermis but also aimed at the dermis where the sebum and after surgery has been performed and nasal tapes have been
glands proliferate.8,9 removed.
All patients on isotretinoin must be followed closely.
Epidermis Routine laboratory tests including pregnancy tests, serum
The surface of the skin can be treated with cleansing agents, lipid profiles, and liver function tests must be performed and
exfoliants and topical medications. Cleansing agents can con- repeated on a monthly basis. Pregnancy is an absolute
tain salicylic acid (type I) or benzoyl peroxide (types II and III), contraindication for this medication (in men and women).14
which will control oil production, promote exfoliation, unclog
pores, and decrease trapped sebum. Additional topical treat- Surgical Management
ment with topical antioxidants, retinoids (tretinoin), and When evaluating the S-STE in the thick-skinned patient, it
benzoyl peroxide and judicious use of sunblock during day- becomes important to define if the thickness is in the dermis
time will help to finally stabilize the epidermis. or in the subcutaneous plane to see what can be impacted
surgically. The surgical objective with the thick-skinned
Dermis patient is to try and push out the underlying skeletal struc-
Most patients with thick skin have oily skin to some degree. tures of the nose thinning the S-STE and creating some
Types II and III definitely have oily skin and this should be definition of the nasal tip. Sometimes overbuilding the nasal
treated if possible. Controlling oil production will help tip can result in overprojected nasal tips which should be
diminish size of sebaceous glands and will help reduce avoided. Thus, a balance needs to be found in these patients.
inflammation and swelling. Surgical techniques can be performed on the S-STE and on
Oil control of the skin should ideally be pretreated with the underlying structures of the nose.
scrubs and use of salicylic acids, retinoids, α-hydroxy acids,
and when needed, benzoyl peroxide. The objective is to Skin-Soft Tissue Envelope
create an acute inflammatory response with exfoliation. Dissection is performed using an open rhinoplasty approach
This will help unclog pores and regenerate new cells. Initially, and flap is elevated under the SMAS. When necessary, SMAS
skin will be red and will exfoliate but with continued use it debulking over the nasal supratip area can be performed
will even out and pores will be less apparent. Ideally, treat- always respecting the subdermal plexus.16 When necessary,
ment should be started at least 4 to 6 weeks before surgery, additional excision of the fatty tissue between the domes can
stopped 1 week before the surgery is scheduled, and be removed creating more definition of the underlying
restarted 10 to 15 days postsurgery when tapes are removed. structures of the nose.
In acne-prone patients, a change in diet can be beneficial.
This is especially true in adolescents in whom acne flare-ups Creating a Rigid Underlying Skeletal Framework
are seen more frequently. There is some evidence that the A strong skeletal frame is needed to be able to support the
Western diet can have an impact on acne production.11,12 Even weight of a thick S-STE. Structural grafting techniques are
though more studies are recommended, it is helpful to have employed reinforcing the pedestal, middle third of nose, and
acne-prone patients change their diets and avoid hyperglyce- nasal tip17,18 (►Fig. 2). In primary rhinoplasty patients,
mic carbohydrates, milk and milk derivatives, and saturated grafts are obtained from the patient’s nasal septum. In
fats. We also recommend having a food diary and avoiding revision patients, it is frequent to harvest costal cartilage
foods that patients feel exacerbate their acne production. to be able to obtain the necessary support of the skeletal
framework.
Thick-Skinned and Acne-Prone Patients
In type III patients or patients with moderate-to-severe acne, Elimination of the Dead Space in Supratip Area
cystic acne, or sebaceous hyperplasia, in addition to topical In patients with a thick S-STE, it is not uncommon to find that
treatments, oral isotretinoin is recommended.13,14 Patients on this flap is very inelastic and does not redrape easily over the
isotretinoin should be managed conjointly with a dermatologist. underlying skeletal framework of the nose. Once all surgical

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6 Integrated Management of the Thick-Skinned Rhinoplasty Patient Cobo et al.

Fig. 2 Structural approach to the nasal tip. A strong skeletal framework is necessary to push out the S-STE and create more definition in the nasal
tip. Surgical techniques include the use of structural grafts to increase projection and create definition. The structural grafts more commonly
used are (A) septal extension graft: reinforces the pedestal; (B) shield graft: improves definition and increases projection of the nasal tip; (C) alar
strut graft: increases support to the lateral crura; (D) alar rim grafts: increase support and improves shape of the alar sidewall. Top row are the
images of the grafts that are shown already placed in position in the bottom row.

techniques are performed on this framework, it becomes way down to the supratip break and fixed in place with
necessary to eliminate as much as possible any dead space micropore tapes and thermoplastic splints. On day 8, cast
that can be created. It also becomes necessary to create a nice and tapes are removed. Skin is cleansed and cosmetically
supratip break that usually will not be obtained sponta- treated with topical agents to decrease swelling, erythema,
neously because of the inelasticity of the skin. Many techni- and oil production. A piece of Gelfoam is placed again over
ques have been described to obtain a supratip break and dorsum and the nose is taped for an additional 8 days. The
eliminate dead space. Techniques like the alar crural span- Gelfoam over the dorsum serves as a splint to exert gentle
ning suture or the septocolumellar suture can be used to pressure over the skin and eliminate swelling and dead space
place the tip in a proper position and create a supratip formation. No additional taping is performed as this was
break.17,18 When the transcolumellar incision is closed, a found to increase skin oil and acne formation in thick-
piece of Gelfoam (Pfizer Inc.) is placed over the dorsum all the skinned patients (►Figs. 3–5).

Fig. 3 Eight days postsurgical images (A–C) of patient who underwent rhinoplasty, submental liposuction, and Bichat fat pad resection. Patient
was on preconditioning of skin with topical treatment. Prior to surgery, a facial was performed with lymphatic drainage of face. Note very slight
edema and minimal bruising.

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 Integrated Management of the Thick-Skinned Rhinoplasty Patient Cobo et al. 7

Fig. 4 Pre- and 8 months postsurgical image of type II thick-skinned patient who underwent primary rhinoplasty. Structuring was done with placement of
bilateral spreader grafts, septal extension graft, alar crural strut grafts, and alar rim grafts. (A–D) Presurgical images and (E–H) postsurgical images.

Fig. 5 Pre- and 3 years postsurgical images of type III cystic acne male patient who underwent primary rhinoplasty. Reinforcement of middle third of nose
was done with spanning sutures. A long strut was used to reinforce the pedestal and tip work included suturing techniques to refine the nasal tip and
placement of a long shield graft plus bilateral alar rim grafts to structure the nasal tip. Skin preconditioning was not performed because patient came from
out of town. A presurgical facial with lymphatic drainage was done the day before surgery and patient was placed postsurgically on oral isotretinoin therapy
at a dose of 1 mg/kg which he received during 6 months without interruption. (A–D) Presurgical views and (E–H) postsurgical views.

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8 Integrated Management of the Thick-Skinned Rhinoplasty Patient Cobo et al.

Fig. 6 Nasal massage. Massage is performed by interwining hands and applying firm pressure on lateral nasal sidewalls using bilateral index
fingers. Skin should be flattened out over nasal dorsum while exerting soft continuous pressure on lateral bony sidewalls during 10–15 seconds.
If massage is done properly, skin should be white over nasal dorsum (arrow).

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Patients should always use some skin regime after surgery Kitahara T. Ethnic differences in the structural properties of facial
targeted toward control of oil and sebum production. Use of skin. J Dermatol Sci 2009;53(02):135–139
sunblock is a must and patients should avoid activities that 4 Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast
Reconstr Surg 2000;105(03):1140–1151, discussion 1152–1153
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